Association between hospital overcrowding-related stress and self-reported medical errors among nurses in government healthcare facilities

Abstract

Background

Hospital overcrowding is a patient-safety concern in resource-constrained health systems, where limited bed capacity, staffing shortages, high patient acuity, and weak organizational support increase pressure on nurses. Although international evidence links crowded clinical environments with nurse stress, workload pressure, burnout, and patient-safety risks, limited evidence from Palestine has examined overcrowding-related stress as a distinct factor associated with self-reported medical errors among nurses.

Objective

This study aimed to examine the association between hospital overcrowding-related stress and self-reported medical errors among nurses working in government healthcare facilities in the West Bank, Palestine.

Methods

A descriptive cross-sectional study was conducted between January and March 2025 among nurses working in five West Bank government hospitals. Of 220 distributed questionnaires, 213 were completed and analyzed, yielding a response rate of 96.8%. Data were collected using a structured self-administered questionnaire assessing sociodemographic characteristics, overcrowding-related stress, and self-reported medical errors. Data were analyzed using descriptive statistics, correlation analysis, and binary logistic regression, with significance set at p < 0.05.

Results

The mean age was 31.07 years (SD = 7.77). Most participants were male (68.1%), married (59.2%), held a bachelor’s degree in nursing (65.7%), and had 6–10 years of experience (31.9%). Very extreme overcrowding-related stress was reported by 49.3%, followed by extreme stress (27.7%), moderate stress (19.7%), and no stress (3.3%). The mean stress-category score was 3.23 (SD = 0.88). Overcrowding-related stress was weakly but significantly associated with self-reported medical errors (r = 0.326, p < 0.001), explaining 10.6% of the variance. In adjusted regression, marital status and years of experience were significant predictors, although confidence intervals were wide.

Conclusion

Overcrowding-related stress was common and weakly but significantly associated with self-reported medical errors. Findings support staffing review, workload management, early-career nurse support, and non-punitive error reporting.

Keywords

hospital overcrowding occupational stress medical errors nurses patient safety Palestine

Introduction

Hospital overcrowding is a persistent patient-safety concern in health systems where service demand exceeds available bed capacity, staffing levels, and operational resources. Rather than representing only a high number of patients, overcrowding reflects a system-level imbalance between patient flow, clinical acuity, infrastructure, and workforce capacity. In overcrowded units, nurses often provide care under conditions of increased task density, frequent interruptions, reduced recovery time between clinical demands, and limited access to essential resources. These conditions are particularly important in emergency departments, intensive care units, medical wards, and surgical wards, where timely assessment, medication administration, monitoring, and communication are central to safe care delivery.^1,2

Overcrowding-related stress should be distinguished from general occupational stress, workload, burnout, and cognitive overload. In this study, overcrowding-related stress refers to nurses’ perceived psychological and work-related strain arising specifically from crowded clinical environments, including high patient volume, increased patient-to-nurse demands, limited physical space, interruptions, and pressure to deliver care within constrained time and resource conditions. Workload refers more broadly to the quantity and complexity of assigned tasks, burnout reflects a longer-term syndrome of emotional exhaustion and reduced professional efficacy, and cognitive overload refers to the excessive mental processing demands that may interfere with attention and decision-making. Clarifying these distinctions is essential because overcrowding may operate as a contextual stressor that interacts with workload, staffing adequacy, and organizational support, rather than being identical to them.^3,4

International evidence suggests that overcrowded hospital environments are associated with poorer care processes, reduced workflow efficiency, delayed treatment, and increased pressure on healthcare professionals.^1,2 However, much of the available evidence is cross-sectional or observational, which limits causal interpretation. Studies from different healthcare systems have reported associations between high workload, workplace stress, burnout, and patient-safety outcomes, including self-reported errors and lower safety culture among nurses.^3,5,6 For example, research among nurses in high-acuity settings has shown that occupational stress is associated with diminished concentration, emotional exhaustion, and perceived reductions in care quality.^5,7 Similarly, studies addressing medical errors have emphasized that error occurrence and reporting are shaped not only by individual performance but also by organizational conditions, staffing adequacy, communication patterns, and safety culture.^8,9 Therefore, the relationship between overcrowding-related stress and medical errors should be understood as an association within a complex system rather than as a direct causal pathway.

The Job Demand–Control Model provides a useful theoretical lens for understanding this relationship. According to this model, psychological strain is more likely when job demands are high and workers have limited control over how work is organized or performed.¹⁰ In overcrowded hospital settings, nurses may experience high demands through increased patient volume, time pressure, competing tasks, and urgent clinical decisions, while their control may be constrained by limited staffing, bed shortages, and insufficient resources. The Transactional Model of Stress and Coping further suggests that stress depends on how individuals appraise environmental demands and the coping resources available to manage them.¹¹ From this perspective, overcrowding may be associated with greater perceived stress when nurses judge clinical demands as exceeding their available resources, support, or coping capacity. These frameworks support examination of overcrowding-related stress as a potential factor associated with self-reported medical errors, while recognizing that cross-sectional data cannot determine temporal or causal direction.

Evidence from regional and low-resource settings remains important because the meaning and consequences of overcrowding may differ according to health-system capacity, staffing models, reporting culture, and political or economic instability. Studies from Middle Eastern and other resource-constrained contexts have reported that nurses and healthcare workers frequently experience high workload, stress, and system pressures that may affect perceived patient safety and quality of care.^5,7,12 In Palestine, government hospitals operate within a uniquely constrained environment shaped by chronic resource limitations, population growth, movement restrictions, recurrent crises, and increasing service demand. Existing Palestinian healthcare literature has highlighted emergency-care pressures and barriers faced by healthcare providers, particularly during periods of instability, but empirical evidence specifically examining overcrowding-related stress and self-reported medical errors among nurses remains limited.^12,13 This represents an important gap because nurses are continuously present at the bedside and are directly involved in medication administration, monitoring, communication, and early detection of clinical deterioration.¹⁴

The present study addresses this gap by examining the association between hospital overcrowding-related stress and self-reported medical errors among nurses working in government hospitals in the West Bank, Palestine. The study also explores whether selected demographic and professional characteristics, including marital status and years of nursing experience, are associated with self-reported stress-related medical errors. It was hypothesized that higher levels of overcrowding-related stress would be positively associated with higher levels of self-reported medical errors. Because the study uses a cross-sectional design, the findings are interpreted as associations and not as evidence of causation.

Methods

Study design

A descriptive cross-sectional study was conducted to examine the association between hospital overcrowding-related stress and self-reported medical errors among nurses working in government healthcare facilities in the West Bank, Palestine. A cross-sectional design was considered appropriate because the study aimed to measure variables at one point in time and identify statistical associations rather than determine causality. The reporting of this study was guided by the Strengthening the Reporting of Observational Studies in Epidemiology statement.¹³

Study setting

The study was conducted in five major government hospitals in the West Bank, Palestine. These hospitals provide inpatient and emergency services across high-demand clinical areas, including emergency departments, intensive care units, medical wards, and surgical wards. The hospitals varied in bed capacity, with approximate capacities ranging from 71 to 120 beds. Overcrowding was defined operationally as a condition in which patient demand exceeded available bed capacity, staffing resources, or usual clinical workflow capacity during the study period.

Hospital occupancy data were obtained from hospital administrative records during the data collection period. Occupancy rates were reviewed to describe the level of overcrowding in participating hospitals. In some hospitals, occupancy reached up to 155% during the study period, indicating that patient numbers exceeded the intended operational capacity. Because overcrowding can fluctuate by day, shift, and clinical unit, the occupancy figure was treated as a contextual indicator of hospital crowding rather than as an individual-level exposure variable.

Study population and eligibility criteria

The target population included registered nurses working in direct patient-care roles in government hospitals in the West Bank. Nurses were eligible to participate if they were full-time registered nurses, worked in inpatient or high-demand clinical units, and had at least one year of clinical experience in their current hospital or unit. The one-year threshold was used to ensure that participants had sufficient exposure to the clinical workflow, patient volume, and organizational conditions of their units.

Nurses were excluded if they worked in administrative positions, outpatient clinics, private hospitals, or non-direct patient-care roles. Nurses with less than one year of experience were also excluded because their limited exposure to overcrowding-related clinical conditions could affect the consistency of responses.

Sampling technique and sample size

A simple random sampling method was used. Lists of eligible nurses were obtained from the nursing administration in each participating hospital. Eligible nurses were assigned identification numbers, and participants were selected using a computer-generated random selection process. This procedure was used to reduce selection bias and improve representativeness of nurses working in government hospitals.

The sample size was estimated based on the expected association between overcrowding-related stress and self-reported medical errors. Assuming a small-to-moderate expected correlation of approximately 0.30, a two-sided significance level of 0.05, and statistical power of 80%, the minimum required sample was approximately 84 participants.¹⁴ The sample size was increased to allow subgroup analysis and logistic regression modelling, and an additional allowance was made for non-response. Therefore, 220 questionnaires were distributed. Of these, 213 were completed and included in the final analysis, yielding a response rate of 96.8%.

Data collection instrument

Data were collected using a structured, self-administered questionnaire written in English. The questionnaire consisted of three sections.

The first section assessed sociodemographic and professional characteristics, including age, gender, marital status, educational level, clinical unit, and years of nursing experience.

The second section assessed overcrowding-related stress. In this study, overcrowding-related stress referred to nurses’ perceived psychological and work-related strain arising from high patient volume, limited resources, increased patient-to-nurse demands, frequent interruptions, time pressure, and restricted clinical space. Items assessing overcrowding-related stress were rated using a four-point Likert-type response format ranging from 1 to 4, with higher scores indicating greater perceived overcrowding-related stress. Likert-type scales are commonly used in survey research to measure respondents’ attitudes, perceptions, and subjective experiences across ordered response categories.^15,16

The third section assessed self-reported medical errors. Medical errors were defined as nurse-reported errors or near-errors related to clinical care, including medication-related errors, delayed care, missed monitoring, documentation errors, or communication-related errors. The medical error outcome was analyzed as a self-reported outcome. For regression analysis, the outcome was coded as a binary variable according to whether the participant reported the occurrence of stress-related medical errors. The coding procedure and cut-off point were determined before analysis and applied consistently across all participants.

The total overcrowding-related stress score was calculated by summing item scores and converting the score into a percentage. Stress levels were categorized descriptively as follows: less than 25% = no stress, 25%–50% = moderate stress, 51%–75% = extreme stress, and more than 75% = very extreme stress. These categories were used only for descriptive interpretation. The continuous stress score was retained for correlation analysis to avoid unnecessary loss of information.

Validity and reliability of the instrument

The questionnaire was reviewed by a panel of five experts in nursing, patient safety, and hospital management to assess content relevance, clarity, wording, and appropriateness for the Palestinian hospital context. Expert feedback was used to revise unclear items and improve the structure of the questionnaire.

A pilot test was conducted with approximately 10% of the target sample. Nurses who participated in the pilot test were excluded from the final analysis. The pilot test assessed clarity, completion time, feasibility, and internal consistency. The overcrowding-related stress scale demonstrated good internal consistency, with a Cronbach’s alpha of 0.88.

If the questionnaire was adapted from a previously validated tool, the original validation source should be cited here. If no previous validation source is available, the questionnaire should be described as researcher-developed or adapted for this study, and the absence of full psychometric validation, including exploratory factor analysis and test–retest reliability, should be acknowledged in the limitations section.

Data collection procedure

Data were collected between January 3 and March 5, 2025. After obtaining administrative permission from each participating hospital, the principal investigator coordinated with nursing managers to identify eligible nurses. Questionnaires were distributed during appropriate times that did not interfere with clinical duties, such as shift breaks or staff meetings.

Participants received an explanation of the study purpose, voluntary participation, confidentiality, and their right to withdraw without penalty. Written informed consent was obtained before participation. Completed questionnaires were returned in sealed envelopes to maintain privacy and reduce response bias.

Study variables

The main independent variable was overcrowding-related stress, measured as a continuous score and categorized descriptively into stress levels. The main dependent variable was self-reported medical errors. For logistic regression, self-reported medical errors were coded as a dichotomous outcome.

Sociodemographic and professional variables included age, gender, marital status, educational level, and years of nursing experience. These variables were included because previous evidence suggests that professional experience, workload adaptation, and personal circumstances may be associated with stress perception and error reporting among healthcare professionals.

Data analysis

Data were analyzed using IBM SPSS Statistics version 24. Data were first checked for completeness, coding accuracy, missing values, and outliers. Descriptive statistics were used to summarize participant characteristics. Frequencies and percentages were used for categorical variables, while means and standard deviations were used for continuous variables when normally distributed.

The normality of continuous variables was assessed using distributional checks, including skewness, kurtosis, and graphical inspection. The association between overcrowding-related stress and self-reported medical errors was examined using Pearson’s correlation coefficient when assumptions were met. If normality or linearity assumptions were violated, Spearman’s rank correlation was used as a non-parametric alternative. Correlation strength was interpreted cautiously, with recognition that statistical significance does not necessarily indicate a strong practical effect.

Binary logistic regression was used to examine sociodemographic and professional predictors of self-reported medical errors. Crude odds ratios and adjusted odds ratios with 95% confidence intervals were calculated. Independent variables were entered into the adjusted model based on theoretical relevance and bivariate findings. Multicollinearity was assessed using variance inflation factor and tolerance values. Model fit was evaluated using the Hosmer–Lemeshow goodness-of-fit test, classification accuracy, and pseudo-R² statistics, including Cox and Snell R² and Nagelkerke R².¹⁷ Statistical significance was set at p < 0.05.

Ethical considerations

Ethical approval was obtained from the relevant university ethics committee and the Ministry of Health Institutional Review Board. The same ethics approval number should be reported consistently in the title page, Methods section, and all submission documents. Participation was voluntary, and written informed consent was obtained from all participants. No personal identifiers were collected. Data were stored securely and were accessible only to the research team. Participants were informed that they could withdraw from the study at any time without consequences.

Results

A total of 220 questionnaires were distributed to eligible nurses working in five government hospitals in the West Bank. Seven questionnaires were incomplete and excluded from the final analysis. Therefore, 213 questionnaires were analyzed, yielding a response rate of 96.8%.

The sociodemographic and professional characteristics of the participants are presented in Table 1. The mean age of the participants was 31.07 years (SD = 7.77). Most participants were aged 20–30 years (43.2%), male (68.1%), married (59.2%), and held a bachelor’s degree in nursing (65.7%). Regarding professional experience, the largest proportion of nurses had 6–10 years of experience (31.9%).

Table 1.

Sociodemographic and professional characteristics of participants.

Variable	Category	n	%
Age, years	Mean ± SD	31.07 ± 7.77	—
	20–30	92	43.2
	31–40	73	34.3
	41–50	34	16.0
	>50	14	6.6
Gender	Male	145	68.1
	Female	68	31.9
Marital status	Single	58	27.2
	Married	126	59.2
	Divorced/widowed	29	13.6
Educational level	Diploma	44	20.7
	Bachelor’s degree in nursing	140	65.7
	Master’s degree or higher	29	13.6
Years of nursing experience	1–5	61	28.6
	6–10	68	31.9
	11–15	48	22.5
	>15	36	16.9

Note. Percentages were recalculated using the final analyzed sample of N = 213. SD = standard deviation.

Overcrowding-related stress levels

The distribution of overcrowding-related stress levels is shown in Table 2. Nearly half of the participants reported very extreme overcrowding-related stress (49.3%), followed by extreme stress (27.7%) and moderate stress (19.7%). Only 3.3% of participants reported no overcrowding-related stress. The mean stress-category score was 3.23 (SD = 0.88), indicating that the overall level of reported overcrowding-related stress was high.

Table 2.

Distribution of overcrowding-related stress levels among participants (N = 213).

Overcrowding-relatedstress level	n	%
Very extreme stress >75%	105	49.3
Extreme stress 51%–75%	59	27.7
Moderate stress 25%–50%	42	19.7
No stress <25%	7	3.3
Stress-category score, Mean ± SD	3.23 ± 0.88	—

Note. The stress-category score was calculated from the four ordered stress categories, where higher scores indicate higher overcrowding-related stress. The previously reported value of 2.35 ± 3.84 was removed because an SD of 3.84 is not possible for a four-point scale.

Association Between Overcrowding-Related Stress and Self-Reported Medical Errors

The correlation between overcrowding-related stress and self-reported medical errors is presented in Table 3. Overcrowding-related stress was weakly but statistically significantly associated with self-reported medical errors (r = 0.326, p < 0.001). The coefficient of determination indicated that overcrowding-related stress explained approximately 10.6% of the variance in self-reported medical errors.

Table 3.

Correlation between overcrowding-related stress and self-reported medical errors (N = 213).

Variables	Correlation coefficient	r²	p value
Overcrowding-related stress and self-reported medical errors	0.326	0.106	<0.001

Note. r = Pearson correlation coefficient. r²= coefficient of determination. Statistical significance was set at p < 0.05. The relationship was interpreted as weak despite statistical significance.

Factors Associated With Self-Reported Medical Errors

Binary logistic regression was conducted to examine sociodemographic and professional factors associated with self-reported medical errors. The adjusted regression findings are presented in Table 4. After adjustment, marital status and years of nursing experience were statistically associated with self-reported medical errors. Single nurses and married nurses had significantly higher odds of reporting medical errors compared with the reference category. Nurses with 1–5 years and 6–10 years of experience also had significantly higher odds of reporting medical errors compared with nurses with more than 15 years of experience. Age, gender, and educational level were not statistically significant predictors.

Table 4.

Adjusted logistic regression analysis of factors associated with self-reported medical errors (N = 213).

Variable	Category	β	SE	Wald	AOR	95% CI for AOR	p value
Age, years	20–30	-3.793	2.186	3.010	0.02	0.00–1.63	0.083
	31–40	-4.121	2.107	3.825	0.02	0.00–1.01	0.051
	41–50	-1.270	1.862	0.465	0.28	0.01–10.80	0.495
	>50	Ref	—	—	1.00	—	—
Gender	Male	-0.048	0.462	0.011	0.95	0.39–2.36	0.918
	Female	Ref	—	—	1.00	—	—
Marital status	Single	3.119	1.360	5.261	22.62	1.57–325.25	0.022
	Married	3.218	1.340	5.770	24.98	1.81–345.30	0.016
	Divorced	2.898	1.354	5.560	18.14	1.28–257.71	0.061
	Widowed	Ref	—	—	1.00	—	—
Educational level	Diploma	1.849	0.956	3.735	6.35	0.98–41.38	0.053
	Bachelor’s degree in nursing	1.323	0.900	2.162	3.75	0.64–21.91	0.141
	Master’s degree in nursing	2.012	0.876	2.454	7.48	1.34–41.64	0.602
	Doctorate in nursing	Ref	—	—	1.00	—	—
Years of nursing experience	1–5	3.053	1.404	4.730	21.18	1.35–331.90	0.022
	6–10	3.812	1.302	8.574	45.24	3.53–580.52	0.016
	11–15	2.105	1.063	3.921	8.21	1.02–65.92	0.061
	>15	Ref	—	—	1.00	—	—

Note. AOR = adjusted odds ratio; CI = confidence interval; Ref = reference category; SE = standard error. AORs and 95% CIs were calculated from the reported β and SE values. Because some confidence intervals are very wide, the findings should be interpreted cautiously.

Discussion

This study examined the association between hospital overcrowding-related stress and self-reported medical errors among nurses working in government hospitals in the West Bank, Palestine. Three main findings emerged. First, a high proportion of nurses reported extreme or very extreme overcrowding-related stress, suggesting that overcrowding represents a substantial perceived occupational strain in the participating hospitals. Second, overcrowding-related stress was weakly but statistically significantly associated with self-reported medical errors (r = 0.326, p < 0.001), explaining approximately 10.6% of the variance in reported errors. Third, marital status and years of nursing experience were statistically associated with self-reported medical errors in the adjusted regression analysis, although these findings should be interpreted cautiously because of the wide confidence intervals and the cross-sectional design.

The high level of overcrowding-related stress reported by nurses is consistent with international evidence showing that overcrowded clinical environments place substantial pressure on frontline healthcare workers. Overcrowding is not only a matter of high patient numbers; it reflects a broader imbalance between patient flow, staffing, physical space, bed availability, and organizational capacity.^1,2 A recent study from Saudi Arabia found that emergency department nurses perceived overcrowding as a major contributor to workload pressure, delayed care, staff exhaustion, and perceived threats to patient safety.¹⁸ These findings are relevant to the present study because both contexts involve high-demand hospital environments where nurses are required to sustain safe care under constrained operational conditions. However, the present study measured perceived overcrowding-related stress rather than real-time occupancy, staffing ratios, or patient acuity. Therefore, the findings should be interpreted as nurses’ subjective assessment of overcrowding-related strain rather than objective measurement of overcrowding exposure.

The significant association between overcrowding-related stress and self-reported medical errors should be interpreted carefully. Although the relationship was statistically significant, the correlation was weak, and overcrowding-related stress explained only 10.6% of the variance in self-reported errors. This indicates that overcrowding-related stress may be one contributing factor within a broader patient-safety system, but it is not sufficient to explain medical errors independently. Recent systematic review evidence supports this cautious interpretation. Li et al.,³ in a large systematic review and meta-analysis, found that nurse burnout was associated with poorer patient safety, lower quality of care, and reduced patient satisfaction, but the authors emphasized that these relationships are shaped by multiple organizational and workforce factors. Similarly, patient-safety literature indicates that errors are usually associated with complex interactions among workload, fatigue, communication, safety culture, staffing, and reporting systems rather than a single isolated factor.^8,9

The finding also aligns with evidence linking high workload and time pressure with patient-safety risks. A recent emergency nursing workload study demonstrated that emergency department nursing tasks involve considerable mental and temporal demands, highlighting the importance of identifying workload thresholds that may affect safety and performance.¹⁹ In addition, a rapid review on safe work-hour limits in nursing reported that extended work hours and overtime were associated with increased risks of medication errors and occupational injuries.²⁰ These findings strengthen the interpretation that overcrowding-related stress may be related to error vulnerability through workload intensity, fatigue, interruptions, and reduced attentional capacity. Nevertheless, because the present study was cross-sectional, it cannot determine whether overcrowding-related stress preceded medical errors, whether nurses who reported errors perceived higher stress, or whether both were influenced by unmeasured organizational factors.

The results can be understood through the Job Demand–Control Model and the Transactional Model of Stress and Coping. According to the Job Demand–Control Model, psychological strain is more likely when job demands are high and workers have limited control over how work is organized.¹⁰ In overcrowded hospital units, nurses may experience high demands through increased patient volume, time pressure, competing clinical priorities, and frequent interruptions, while having limited control over staffing, patient flow, or resource availability. The Transactional Model of Stress and Coping further suggests that stress arises when individuals appraise environmental demands as exceeding available coping resources.¹¹ In this study, overcrowding-related stress may reflect nurses’ perception that patient-care demands exceeded the available time, support, staffing, or resources needed to provide safe care. However, these theoretical interpretations remain explanatory rather than causal because the study design does not establish temporality.

Years of nursing experience were statistically associated with self-reported medical errors. Nurses with fewer years of experience had higher odds of reporting medical errors compared with nurses with more than 15 years of experience. This finding is plausible because early-career nurses may still be developing clinical prioritization, situational awareness, confidence, and coping strategies in high-pressure environments. International evidence has shown that stress and high workload are particularly challenging in emergency and critical care settings, where clinical decisions often need to be made rapidly and under conditions of uncertainty.^5,7,19 However, the very wide confidence intervals observed in the regression model suggest statistical imprecision, possibly due to small subgroup sizes. Therefore, this finding should be interpreted as a potential association that requires confirmation in larger samples with more stable regression estimates.

Marital status was also statistically associated with self-reported medical errors in the adjusted model. Single and married nurses showed higher odds of reporting medical errors compared with the reference group. This result should be interpreted with caution for several reasons. First, the confidence intervals were wide, indicating unstable estimates. Second, marital status may not directly explain error reporting; rather, it may represent unmeasured social, family, financial, emotional, or work–life balance factors. Third, the study did not measure social support, family responsibilities, psychological distress, or work–family conflict. Therefore, no strong conclusion can be drawn regarding marital status. Future studies should examine whether social support, work–life conflict, coping capacity, and psychological well-being moderate the relationship between overcrowding-related stress and self-reported medical errors.

The Palestinian context gives additional importance to these findings. Government hospitals in the West Bank operate under persistent resource constraints, high public-sector demand, limited bed capacity, and recurrent political and healthcare disruptions. Previous Palestinian healthcare research has documented barriers faced by healthcare providers during emergency conditions and periods of instability.¹² The present study contributes to this literature by focusing specifically on nurses’ perceived overcrowding-related stress and self-reported medical errors in government hospitals. However, the findings should not be interpreted as evidence that overcrowding is the root cause of medical errors. Rather, they suggest that overcrowding-related stress is statistically associated with error reporting and should be considered alongside staffing adequacy, safety culture, leadership, communication, patient acuity, and reporting systems.

Several practical implications can be drawn from the findings, but these should remain proportionate to the evidence. In the short term, hospital administrators should strengthen non-punitive error reporting systems, improve shift-level communication, and provide structured support for early-career nurses assigned to high-demand units. In the medium term, hospitals should review staffing allocation, workload distribution, patient-flow procedures, and bed-management systems in units where overcrowding is frequently reported. In the longer term, policymakers may consider developing national guidance on safe staffing, occupancy monitoring, escalation procedures during patient surges, and workforce retention. These recommendations are supported by broader evidence showing that nurse burnout, workload, and time pressure are associated with patient-safety outcomes, although intervention studies are still needed to determine which strategies are most effective in the Palestinian context.^3,19,20

This study has several limitations. First, the cross-sectional design prevents conclusions about causality or temporal direction. Second, medical errors were measured through self-report, which may be affected by recall bias, social desirability bias, and fear of blame or disciplinary consequences. This is especially important because medical errors are sensitive events and may be underreported when staff perceive reporting systems as punitive.⁸ Third, the study measured perceived overcrowding-related stress but did not independently measure objective nurse-to-patient ratios, patient acuity, shift length, overtime, real-time occupancy, leadership style, or institutional safety culture. Fourth, although the questionnaire demonstrated acceptable internal consistency, the absence of full psychometric validation, including exploratory factor analysis and test–retest reliability, limits confidence in the measurement structure. Finally, the wide confidence intervals in the logistic regression model indicate statistical imprecision; therefore, findings related to marital status and years of experience should be interpreted cautiously.²¹

In summary, this study found that overcrowding-related stress was common among nurses in West Bank government hospitals and was weakly but significantly associated with self-reported medical errors. The modest effect size indicates that overcrowding-related stress is only one component of a broader patient-safety issue. The findings support the need for organizational attention to staffing adequacy, workload pressure, supportive supervision, early-career nurse support, and non-punitive reporting systems. Future research should use longitudinal, mixed-methods, or multi-site designs to examine how overcrowding, workload, fatigue, safety culture, and error reporting interact over time.

Strengths and implications

The findings suggest that hospital administrators should prioritize practical strategies to reduce overcrowding-related workload pressure, especially in high-demand units. Short-term actions may include improving shift handover, strengthening non-punitive error reporting, and providing closer supervision for early-career nurses. At the policy level, safe staffing guidance, occupancy monitoring, and surge-capacity planning are needed. Future studies should use longitudinal or mixed-method designs and include objective indicators such as nurse-to-patient ratios, bed occupancy, overtime, and official incident reports.

This study addresses an important patient-safety issue in Palestinian government hospitals. It included nurses from five government hospitals and achieved a high response rate. Another strength is its focus on overcrowding-related stress as a specific work-environment factor rather than general occupational stress.

Limitations

The cross-sectional design prevents causal interpretation. Medical errors were self-reported, which may lead to recall bias, social desirability bias, and underreporting because nurses may fear blame or disciplinary action. The study did not measure objective indicators such as patient acuity, nurse-to-patient ratios, shift length, or official error reports. In addition, the questionnaire had limited psychometric validation, and some regression estimates had wide confidence intervals. Therefore, the findings should be interpreted cautiously.

Conclusion

Overcrowding-related stress was common among nurses in West Bank government hospitals and was weakly but significantly associated with self-reported medical errors. The modest correlation indicates that overcrowding-related stress is only one factor within a broader patient-safety system. Improving staffing, workload management, supportive supervision, and non-punitive reporting systems may help strengthen patient safety.

Supplemental material

Supplemental material - Association between hospital overcrowding-related stress and self-reported medical errors among nurses in government healthcare facilities

Supplemental material for Association between hospital overcrowding-related stress and self-reported medical errors among nurses in government healthcare facilities by Khalaf Awwad, Mohammad Qtait and Nesreen Alqaissi in Sage Open Medicine.

Supplemental material

Supplemental material - Association between hospital overcrowding-related stress and self-reported medical errors among nurses in government healthcare facilities

Footnotes

Acknowledgements

I want to express my deepest gratitude to all those who contributed to completing this study. My sincere thanks go to the nurses who participated in this research, offering their valuable time and insights despite their demanding schedules.

ORCID iD

Mohammad Qtait

Ethical considerations

Ethical approval was obtained from the Palestine Polytechnic University (Reference: KCE.2024.12) and the Ministry of Health Institutional Review Board (RESC/2025-1). Participation was voluntary, and written informed consent was obtained from all participants. Confidentiality was ensured through anonymous data handling, and participants were assured of their right to withdraw from the study at any stage without consequences. Data were stored securely and used solely for research purposes. Palestinian Ministry of Health with reference number UHOL 1092 (No:140).

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental material

Supplemental material for this article is available online.

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