Systemic violence as an occupational hazard: Moral injury and nursing practice

Abstract

This paper examines how sustained armed conflict operates as a primary occupational hazard that produces moral injury among nurses. It moves beyond burnout and moral distress frameworks to propose a justice-centered approach to nurse well-being in conflict settings. This discursive paper employs a critical interpretive synthesis (CIS) of peer-reviewed studies and humanitarian reports from 2020 to 2024, comparing documented conditions in Gaza with prevailing nursing well-being models. Sixty-eight sources were analyzed through iterative comparison of situational evidence and conceptual scholarship. Gaza served as a critical case to test the explanatory limits of dominant frameworks. Three systemic hazards shape nursing practice in Gaza: severe resource deprivation, direct violence against healthcare workers and facilities, and the collapse of health and civic infrastructure. Under these conditions, moral injury emerges as the dominant occupational harm. Nurses are compelled by external political and military forces to act in ways that violate core professional duties. Resilience and coping approaches fail where harm originates outside healthcare systems and where internal reform is not possible. In settings where healthcare is systematically targeted, political violence becomes a primary occupational hazard. A justice-centered framework is required, centered on protection of healthcare under international humanitarian law, accountability for violations, and global professional solidarity as core elements of nurse well-being. Occupational health becomes inseparable from protection, accountability, and justice. Models that assume stable healthcare systems cannot explain nurse suffering in conflict zones. Nursing policy and practice must expand occupational health frameworks to address structural and political conditions. Practical responses include protection mechanisms, documentation of violations, and evacuation pathways for healthcare workers under attack.