Levels of Quality of Work Life and Clinical Empathy Among Nurses in Palestine During the War: A Cross-Sectional Study of Predictors

Abstract

Background

Quality of work life has emerged as one of the primary determinants of nurse's satisfaction, retention, and well-being within the profession, while empathy refers to responding to patient's feelings in a compassionate and caring manner.

Objective

This study aimed to assess the quality of work life and clinical empathy levels among nurses in Palestine and to identify the predictive factors of quality of work life.

Methods

A descriptive cross-sectional design was used, involving 250 nurses working in governmental and nongovernmental hospitals, selected using a convenience sampling technique. Data were collected through an internet-based questionnaire from February to April 2025 which included validated tools for measuring quality of work life and empathy, demonstrating very good reliability (α = 0.88 and 0.82, respectively).

Results

Nurses reported a mean overall quality of work life (QWL) score of 3.30 ± 0.47. Among QWL domains, Stress at work recorded the highest mean score (3.62 ± 0.72), while general well-being and the home–work interface demonstrated comparatively lower scores. The mean empathy score was 33.55 ± 5.56 (range 0–64). Multiple linear regression analysis revealed that empathy was the strongest positive predictor of QWL (β = .370, p < .001). Divorced or widowed marital status was positively associated with QWL (β = .172, p = .004), whereas working nonstandard shifts (β = −.127, p = .044), higher educational level (β = −.144, p = .020), older age (β = −.148, p = .049), and employment in certain departments (β = −.175, p = .010) were negatively associated with QWL.

Conclusion

Empathy plays a significant and meaningful role in enhancing nurses’ quality of work life, functioning as a key psychosocial resource within challenging healthcare environments. Organizational strategies that promote stable work scheduling, professional role alignment, and empathy-oriented development may contribute to improving occupational well-being and sustaining high-quality patient care.

Keywords

quality of work life empathy nurses cross-sectional study Palestine

Introduction

The nursing profession is essential because it has been integrated into every healthcare system worldwide and plays a vital role in the care, treatment, and recovery of patients (Hojat et al., 2011). However, nursing professionals often face significant work stressors, including long shifts, high workloads, emotional strain, and exposure to traumatic situations, which can affect their well-being and job performance (Khamisa et al., 2025). Quality of work life (QWL) has emerged as one of the primary determinants of nurses’ level of satisfaction, retention, and well-being within the profession. QWL captures multiple components, including adequate remuneration, competent safety standards, employment, advancement opportunities, and the balance between professional and personal life (Fonseca et al., 2025). In the present study, QWL is adopted as the main conceptual framework guiding the assessment of nurses’ occupational well-being and the selection of study variables. For nurses, attaining optimal QWL is crucial not only for their wellness but also for the best possible level of patient care to be delivered.

Clinical empathy is a healthcare provider's understanding of, sharing in, and responding to a patient's feelings in a compassionate and caring manner (Hojat et al., 2011). In nursing, empathy, which is considered one of the factors affecting nurses’ QWL, is essential because it promotes communication, enhances the relationship between nurses and patients, and helps in patient recovery (Al-Kalaldeh et al., 2020; Del Canale et al., 2012). However, work-related stressors tend to deplete empathy levels and cause emotional strain, flattening, or burnout (Moudatsou et al., 2020). The relationship between QWL and clinical empathy is striking because it seems that nurses who achieve work-life balance tend to respond more empathetically to their patients. From a conceptual perspective, empathy represents a key individual resource within the QWL framework that may shape how nurses perceive and cope with their work environment.

Internationally, literature has shown that poor QWL among nurses contributes to decreased job satisfaction, increased burnout, and high turnover rates. For example, a study in the United States indicated that more than 60% of nurses experienced moderate-to-severe burnout, attributing it largely to QWL factors (Dyrbye et al., 2017). In the Middle East, studies have pointed out similar issues, where nurses cited low job satisfaction as a result of poor working conditions, excessive patient loads, and a lack of organizational support (Alzoubi et al., 2024; Quesada-Puga et al., 2024).

Locally, studies have shown that Palestinian nurses are subjected to high levels of stress and emotional exhaustion due to ongoing political violence, poor economic conditions, and problems within the healthcare system (Amro et al., 2020; Asherah & Amro, 2024). Studies have also shown that over 50% of Palestinian nurses report job dissatisfaction and poor well-being, and inadequate QWL is a major factor influencing their professional life (Amro et al., 2020; Nassar et al., 2024). There seems to be consensus regarding the impact of QWL on nursing outcomes and performance. However, few previous studies have investigated clinical empathy in this relationship among nurses, especially in the context of Palestine.

In addition, the recurrent cycles of armed conflict and the current wartime context have placed Palestinian nurses under extraordinary psychological and professional pressure, characterized by increased workload, exposure to trauma, ethical dilemmas, and constant threats to personal safety (Zabin et al., 2025). In such settings, nurses are not only caregivers but also frontline responders to mass casualties and human suffering, which may profoundly affect both their quality of work life and their capacity for empathetic care.

Evidence from other recent war and conflict settings supports this concern. Studies conducted among nurses in Ukraine, Syria, and conflict-affected regions have shown that, despite extreme adversity, nurses often maintain high professional commitment and empathy, while reporting compromised quality of work life and elevated moral distress (Caggianelli et al., 2025; Lazieh et al., 2025; Zasiekina & Martyniuk, 2025).

Despite the multitude of research addressing QWL and its repercussions on nurses’ job satisfaction and patient care, little attention has been paid to the influence of clinical empathy on this relationship, particularly in Palestine. This neglect becomes glaring in light of the burdens that Palestinian nurses bear politically, economically, and even at the resource level. In a wartime environment, where healthcare systems operate under extreme strain and moral distress is frequent, understanding how empathy interacts with nurses’ work life becomes especially critical for sustaining both workforce resilience and quality of patient care.

Ignoring these issues might plunge the healthcare system into persistent problems of high turnover rates among nurses, low patient satisfaction, and the overall degradation of healthcare services. By investigating QWL and clinical empathy, this study aimed to bridge a significant knowledge gap and provide insights into how improving nurses’ QWL can foster greater empathy, leading to better patient care and professional fulfillment. Therefore, the primary objective of this study was to assess the levels of quality of work life and empathy among nurses in Palestine. The secondary objective was to identify the predictive factors associated with quality of work life.

Review of Literature

Research on nurses’ QWL shows that this construct continues to predict their professional well-being, retention, and care delivery quality. A 2024 study conducted in Saudi Arabia demonstrated that primary care nurses maintained a moderate QWL score, but their compassion fatigue levels showed strong negative connections to their QWL (Al-Otaibi & Kerari, 2025). A study conducted in 2024 established that nurses who experience poor QWL tend to develop burnout and PTSD symptoms when they work under stressful conditions (Manzari et al., 2024).

The research indicates that operating-room nurses who perform surface acting to hide their emotions experience lower work-related QWL, but deep acting and authentic emotional expression lead to better QWL (Li et al., 2025). The research demonstrates that QWL consists of multiple factors, including workload, emotional demands, autonomy, remuneration, safety, and personal-professional life balance, and these factors become more critical in high-pressure environments such as war-afflicted or crisis healthcare settings.

On the clinical empathy side, the current research shows that nurses’ clinical empathy affects both their work performance and the quality of their work life. A 2024 study demonstrated that nurse-reported clinical empathy levels have decreased over the last ten years, while facing mounting work-related challenges (Shaw et al., 2024). Moreover, Scheepers et al. (2023) demonstrated that nurses who receive adequate job resources, including autonomy, social support, and meaningful work tasks, develop better work engagement and deliver individualized patient care. Finally, although direct studies linking empathy as a predictor of QWL are still emerging, a 2025 study in emergency nursing found that QWL influenced job satisfaction and that clinical empathy played a mediating role between QWL and job satisfaction (Sepahvand et al., 2025). The research indicates that better QWL conditions in stressful environments, such as war zones or unstable healthcare systems, allow nurses to preserve their empathy, which leads to improved professional satisfaction and enhanced patient care quality.

Methods

Research Design

A descriptive cross-sectional design was used to assess the QWL and clinical empathy among nurses in Palestine. This manuscript was prepared and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement for cross-sectional studies (Von Elm et al., 2014).

Setting and Population

The target population included all nurses in the West Bank, Palestine, with full- and part-time contracts with at least three months of nursing experience working in governmental and nongovernmental hospitals. Healthcare providers who were not nurses or nursing students were excluded.

Sample Size and Method

A convenience sampling method was employed to recruit participants, and was calculated using the following formula for proportion-based sample size calculation:

n = Z^{2} . P . (1 - P) / e^{2}

where n is the required sample size, Z is the Z-value (1.96 for 95% confidence), p is the estimated proportion of the population (maximum variability of 0.5), and e is the margin of error (0.05 for 5%). The required sample size for a study with an unknown population, at a 95% confidence level and 5% margin of error, was approximately 384 participants. The final sample size was 250. A response rate of 65% was achieved. This is attributable to several factors: contextual constraints arising from wartime conditions, elevated patient loads among nurses, staff shortages, emotional fatigue, and restricted Internet access, all of which diminished nurses’ willingness or capacity to engage in a voluntary online questionnaire.

Instrument

An internet-based questionnaire was used as the data collection method, which included the following sections: First section: demographic variables of the nurses, such as age, gender, level of education, level of experience, working department, and shift status. Second section: The QWL scale used in this study was adopted from a previously published and psychometrically validated English-language instrument developed by Easton and Van Laar (2012). The original validation study reported excellent internal consistency reliability, with a Cronbach's alpha of 0.91 for the total scale, and acceptable reliability coefficients across its subdomains. It consists of 24 items rated on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree), and all items were taken from established tools to ensure reliability and relevance. The subheadings of the QWL scale are as follows: Job and Career Satisfaction (six items), with a Cronbach's alpha of .86, Control at Work (three items) with Cronbach alpha of .81, General Well-Being (six items) with Cronbach alpha of .89, home-work interface (three items) with Cronbach alpha of .82, Stress at Work (two items) with Cronbach alpha of .81, Working Conditions (three items) with Cronbach alpha of .75, and Satisfaction of Overall Quality of Working Life (one item). Items 7, 9, and 19 were reverse-coded prior to analysis and item 24 (“satisfaction of overall quality of working life”) is assessed and reported separately. A higher mean score indicates a higher quality of work life. Third section: The Toronto Empathy Scale, consisting of 16 items on a 5-point Likert scale was adopted from the original study (Spreng et al., 2009). The original instrument demonstrated very good internal consistency, with a reported Cronbach's alpha of 0.85, supporting its reliability as a unidimensional measure of empathy. Items responses were scored according to the following scale for positively worded Items 1, 3, 5, 6, 8, 9, 13, 16. Never = 0, Rarely = 1, Sometimes = 2, Often = 3, Always = 4. The following negatively worded items are reverse scored: 2, 4, 7, 10, 11, 12, 14, 15. The total score ranges from 0 to 64, with higher scores indicating greater empathy.

Pilot Test

A pilot test was conducted prior to the primary data collection with 38 nurses from two hospitals who were not included in the main study sample. The purpose of the pilot test was to evaluate the clarity and comprehensibility of the questionnaire items, estimate the average completion time, and assess the relevance of the instruments in the local context. Based on feedback from pilot participants, minor modifications were made to the wording and layout to improve clarity. The average time required to complete the questionnaire was approximately 15 min.

Validity and Reliability

The questionnaire was reviewed by three experts in scientific research to assess its face validity, focusing on its applicability, readability, and feasibility. Cronbach's alpha was computed to evaluate the internal consistency reliability of the entire questionnaire, yielding the following results for the two validated instruments included in the study: QWL: α = 0.88, and Empathy: α = 0.82.

These data demonstrated substantial internal consistency across all scales, affirming the trustworthiness of the instruments employed in the Palestinian setting. The final questionnaire, revised according to the pilot research findings, was sent to the primary study population.

Data Collection

Data were gathered via a standardized, self-administered online questionnaire developed using Google Forms from February to April 2025. This strategy was selected to enable participation in a secure, accessible, and time-efficient manner, particularly given the volatile sociopolitical circumstances of Palestine.

The survey link was sent via professional WhatsApp groups and private Facebook groups used by nursing employees. The study team selected these platforms based on their past knowledge of usage within the target group and established professional communication networks. The invitation to participate was exclusively extended to authenticated nurse personnel employed in governmental and nongovernmental settings.

The Google Form was set up to permit only one answer per email account to prevent repeated submissions. A compulsory informed consent statement was incorporated into the initial survey page. Participants were informed of the study's objective, the voluntary aspect of their involvement, and the confidentiality of their responses. Advancing the questionnaire after reviewing the consent statement was considered evidence of their consent to participate.

The finalized survey data were securely stored in encrypted files accessible to the lead investigators. The research staff oversaw the submission process to guarantee response quality, monitor completion rates, and address participant inquiries swiftly, as necessary.

Data Analysis

The collected data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 27. Descriptive and inferential statistics were employed. Descriptive statistics, including frequencies, percentages, means, standard deviations, minimums, and maximums, were used to summarize sociodemographic characteristics and main study variables.

Inferential analyses included independent samples t-tests and one-way analysis of variance (ANOVA) to examine differences in quality of work life across categorical variables. Assumptions of normality were assessed using the Kolmogorov–Smirnov and Shapiro–Wilk tests, which indicated that the data were normally distributed (p ≥ .05). Multiple linear regression analysis was conducted to identify predictors of quality of work life. Nominal variables were dummy coded prior to inclusion in the regression model, and variance inflation factor (VIF) values were examined to assess multicollinearity. Statistical significance was set at p < .05.

Ethical Consideration

Ethical approval for the study was obtained from the Ethical Committee of Modern University College (Approval No. MUC012/2025). Informed consent was provided to all participants prior to their enrollment in the study, and participants were informed that their participation was voluntary on the first page of the questionnaire. Confidentiality while gathering data was ensured. Additionally, the participants were assured that all personal information would be protected, secured, and kept confidential. The study adhered to the ethical standards outlined in the Declaration of Helsinki regarding the rights, protection, and well-being of the research participants.

Results

Sociodemographic Variables of the Participants

Among the 250 participants, the majority were female (71.2%) and primarily belonged to the early adult age group (76.0%). Most held a bachelor's degree (70.8%), whereas a smaller portion had a diploma (20.8%) or higher education (8.4%). In terms of work experience, nearly half had 2–5 years of experience (47.6%), followed by those with over 5 years (28.4%), and those with one year or less (24.0%). The majority of the participants worked in nongovernmental hospitals (68.0%) and were single (63.2%). Most participants worked nonstandard shifts (64.4%). Regarding department, the largest groups worked in emergency (34.8%) and other departments such as operation, orthopedics, and pediatrics (35.6%), followed by ICU/CCU (15.6%), and medical-surgical units (14.0%), as seen in Table 1.

Table 1.

Frequency and Percentages of the Sociodemographic Variables Among Participants (n = 250).

Variables		n	%
Age (years)	Mean: 29.8, SD: 2.7, Min: 23, Max: 49
Years of experience (years)	Mean: 4.3, SD: 1.3, Min: 1, Max: 10
Gender	Male	72	28.8%
	Female	178	71.2%
Level of Education	Diploma	52	20.8%
	Bachelor's degree	177	70.8%
	Higher education (master's or PhD)	21	8.4%
Type of Hospital	Governmental	80	32.0%
	Nongovernmental	170	68.0%
Marital Status	Single	158	63.2%
	Married	85	34.0%
	Divorced or widowed	7	2.8%
Work Shift	Standard shift (Fixed A)	89	35.6%
	Nonstandard shift (A, B, or C)	161	64.4%
Department	Medical and surgical	35	14.0%
	ICU or CCU	39	15.6%
	Emergency	87	34.8%
	Other (operations, orthopedics, and pediatrics)	89	35.6%

Note: n = frequency.

Quality of Work Life and Clinical Empathy

The overall QWL score among nurses showed a mean of 3.30 ± 0.47. Among the QWL domains, the highest mean score was observed in the SAW domain (3.62 ± 0.72), followed by JCS (3.44 ± 0.68), while the GWB domain showed a mean of 3.10 ± 0.38. Regarding clinical empathy, the mean total score was 33.55 ± 5.56, as seen in Table 2.

Table 2.

Mean Score of Quality of Work Life Domains and Clinical Empathy Among Participants (n = 250).

Domain	Min	Max	Mean	SD	Range	Percentage Mean
JCS (six items)	1.50	5.00	3.44	0.68	3.50	68.8%
CAW (three items)	1.67	5.00	3.30	0.77	3.33	66.0%
GWB (six items)	2.00	4.17	3.10	0.38	2.17	62.0%
HWI (three items)	1.00	5.00	3.12	0.82	4.00	62.4%
SAW (two items)	1.50	5.00	3.62	0.72	3.50	72.4%
WCS (three items)	1.00	5.00	3.25	0.78	4.00	65.0%
Satisfaction with overall Quality of Work Life (one item)	1.00	5.00	3.27	1.00	4.00	65.4%
Quality of Work Life (23 items)	2.03	4.64	3.30	0.474	2.61	66.0%
Clinical Empathy Mean Sum Score (16 items)	14.00	50.00	33.55	5.56	36.00	52.4%

Note. GWB: General Well-being; HWI: Home-Work Interface; JCS: Job-Career Satisfaction; CAW: Control at Work; WCS: Working Conditions; SAW: Stress at Work; SD: Std. Deviation.

Association Factors That Affect Both QWL and Empathy

The analysis revealed several significant differences in QWL across participant characteristics. Significant differences in QWL were observed based on years of experience (p = .035), marital status (p = .007), and work shift (p = .022). According to the Tukey post hoc test, participants with 2–5 years of experience reported the highest QWL scores compared to those with ≤1 year or more than 5 years of experience (p = .033). According to the Tukey post hoc test, divorced or widowed participants demonstrated higher QWL scores than single or married individuals (p = .043). Additionally, those working fixed standard shifts reported significantly higher QWL compared to those working nonstandard rotating shifts. No statistically significant differences in QWL were found based on gender, age group, level of education, type of hospital, or department.

Regarding empathy, department was the only factor showing a statistically significant difference (p = .044). According to the Tukey post hoc test, participants working in medical and surgical departments reported higher empathy scores compared to those working in other critical departments such as ICU, CCU, and emergency (p = .014). No significant differences in empathy were observed based on gender, age group, educational level, years of experience, type of hospital, marital status, or work shift. As seen in Table 3.

Table 3.

Association Factors That Affect Both QWL and Empathy (n = 250).

Variables		n	QWL			Empathy
Variables		n	Mean	SD	p-value	Mean	SD	p-value
Gender	Male	72	3.28	0.51	.293	32.97	6.39	.651
Gender	Female	178	3.31	0.46	.293	33.79	5.20	.651
Age Group(years)	23–29	190	3.32	0.49	.535	33.40	5.60	.090
	30–39	46	3.25	0.44		33.24	5.59
	40–49	14	3.23	0.32		36.71	4.29
Level of Education	Diploma	52	3.42	0.49	.066	33.25	6.90	.091
	Bachelor's Degree	177	3.28	0.47		33.34	5.14
	Higher Education (Master or PhD)	21	3.16	0.42		36.10	4.96
Years of Experience	≤ 1 year	60	3.21	0.50	.035>*	32.83	5.80	.516
	2–5 years	119	3.38	0.46		33.78	5.47
	>5 years	71	3.25	0.46		33.79	5.57
Type of Hospital	Governmental	80	3.28	0.44	.170	32.85	5.34	.690
	Nongovernmental	170	3.31	0.49	.170	33.89	5.66	.690
Marital Status	Single	158	3.32	0.47	.007>*	33.39	5.34	.820
	Married	85	3.22	0.47		33.85	5.86
	Divorced or widowed	7	3.78	0.50		33.86	7.63
Work Shift	Standard shift (Fixed A)	89	3.39	0.46	.022*	34.29	5.90	.120
	Nonstandard shift (A, B, or C)	161	3.25	0.48	.022*	33.15	5.35	.120
Department	Medical and surgical	35	3.39	0.49	.316	35.06	4.70	.044*
	ICU or CCU	39	3.31	0.52		33.90	5.08
	Emergency	87	3.33	0.45		32.28	5.75
	Other (operation, orthopedics, and pediatric)	89	3.23	0.47		34.07	5.74

Note. Independent t-test and One-Way ANOVA; M: mean score; SD: standard deviation.

*p < .05.

Factors Associated With Nurses’ Quality of Work Life

A multiple linear regression analysis was conducted to examine predictors of quality of work life. The overall model was statistically significant and explained 23.6% of the variance in QWL (R = .485, R² = .236, Adjusted R² = .197). Empathy emerged as the strongest predictor of QWL (β = .370, p < .001), indicating that higher empathy was associated with better perceived quality of work life. Divorced or widowed participants reported significantly higher QWL compared to single participants (β = .172, p = .004), whereas working nonstandard shifts was associated with lower QWL (β = −.127, p = .044). Participants working in other departments reported lower QWL compared to those in emergency departments (β = −.175, p = .010). Age (β = −.148, p = .049) and level of education (β = −.144, p = .020) were also significant predictors, with higher age and education associated with slightly lower QWL. No significant multicollinearity was detected (all VIF < 2). As seen in Table 4.

Table 4.

Multiple Linear Regression Predicting Quality of Work Life Among Nurses (n = 250).

Predictor	B	SE	Β	t	P	95% CI	VIF
(Constant)	2.667	0.211	—	12.608	<.001	2.250, 3.083	—
Female	0.019	0.065	0.018	0.294	.769	−0.109, 0.147	1.192
Age	−0.124	0.063	−0.148	−1.975	.049*	−0.247, 0.000	1.730
Level of Education	−0.130	0.056	−0.144	−2.336	.020*	−0.239, −0.020	1.176
Years of Experience	0.087	0.045	0.132	1.916	.057	−0.002, 0.176	1.475
Nongovernmental Hospital	−0.051	0.063	−0.050	−0.812	.418	−0.174, 0.072	1.174
Married	−0.109	0.068	−0.109	−1.600	.111	−0.243, 0.025	1.438
Divorced/Widowed	0.495	0.168	0.172	2.943	.004*	0.164, 0.827	1.064
Nonstandard Shift	−0.126	0.062	−0.127	−2.027	.044*	−0.248, −0.004	1.216
Medical and Surgical	−0.064	0.088	−0.047	−0.727	.468	−0.238, 0.110	1.298
ICU/CCU	−0.003	0.085	−0.002	−0.038	.970	−0.172, 0.165	1.327
Other Departments	−0.173	0.067	−0.175	−2.582	.010*	−0.305, −0.041	1.423
Empathy Total Score	0.032	0.005	0.370	6.267	<.001*	0.022, 0.041	1.078

Note. R = .485, R² = .236, adjusted R² = .197, SE = 0.426.

* p < .05.

Discussion

QWL

The present study found that nurses reported a mean overall QWL score of 3.30 ± 0.47 (66.0% of the maximum possible score). The highest scoring domain was SAW (M = 3.62 ± 0.72), suggesting that participants perceived work-related stress as generally manageable, whereas the lowest scoring domains were GWB (M = 3.10 ± 0.38) and HWI (M = 3.12 ± 0.82), indicating relative challenges in psychological well-being and work–life balance.

These findings suggest that while nurses demonstrate reasonable levels of job satisfaction and coping with workplace stress, broader psychosocial and work–life integration aspects remain areas of concern. This is particularly important in a profession that is emotionally and physically demanding such as nursing.

The predominance of moderately favorable mean scores across QWL domains aligns with previous studies conducted in the Middle East, which have consistently reported moderate levels of job satisfaction among nurses due to systemic challenges, such as limited resources, poor organizational support, and excessive workloads (Alzoubi et al., 2024; Quesada-Puga et al., 2024). In Palestine, nurses are often exposed to additional stressors stemming from political instability, economic hardship, and structural issues in the healthcare system, all of which have been shown to negatively impact their QWL (Al-Kalaldeh et al., 2020; Nassar et al., 2024).

The relatively high mean score in the Stress at Work domain may reflect adaptive coping mechanisms developed by nurses working in high-pressure environments, particularly within conflict-affected healthcare systems. However, the comparatively lower scores in General Well-Being and Home–Work Interface suggest that personal and family-related strain may persist despite professional resilience.

In the current wartime context, these systemic challenges are further intensified by increased patient volumes, exposure to trauma, moral distress, and threats to personal safety, which may constrain nurses’ perceptions of their work-life quality even when professional commitment remains high (Qtait et al., 2025). This contextual pressure may help explain why QWL scores, although above the scale midpoint, did not approach the upper range of the scale.

From an international perspective, similar patterns have been reported in conflict-affected and high-pressure healthcare systems, where nurses frequently report compromised QWL despite maintaining professional commitment and care quality (Lazieh et al., 2025; Zasiekina & Martyniuk, 2025). These converging findings suggest that moderate but stable QWL levels may represent an adaptive equilibrium in adverse clinical environments rather than an indication of optimal work conditions.

Clinical Empathy

Nurses in the present study reported a mean empathy score of 33.55 ± 5.56 (range 14–50 out of a possible 0–64), corresponding to 52.4% of the maximum score. This indicates a moderate level of affective empathy rather than uniformly high empathic engagement. Empathy is a fundamental component of nursing practice, facilitating therapeutic communication, strengthening nurse–patient relationships, and improving clinical outcomes (Al-Kalaldeh et al., 2020; Suraya et al., 2024). The observed empathy levels may reflect strong professional values and cultural norms emphasizing compassion and caregiving within Palestinian society.

Contrary to some previous research, empathy in this study was not significantly associated with gender, marital status, educational level, hospital type, or work shift. The only significant difference was observed across departments, where nurses working in medical and surgical units reported higher empathy scores compared to other departments. This may be explained by greater continuity of care and prolonged patient interaction in these settings, fostering deeper relational engagement (Wilkinson et al., 2017).

Despite operating within a high-stress and conflict-affected environment, nurses maintained stable levels of empathic engagement. However, the moderate rather than high empathy scores suggest that contextual strain may still exert subtle pressure on emotional resources. While empathy appears relatively resilient, it is not immune to cumulative occupational stress (Moudatsou et al., 2020; Wilkinson et al., 2017). Therefore, structured empathy training, reflective practice, and emotional support programs remain essential for sustaining compassionate care in demanding healthcare systems.

Association Factors and Predictors of QWL

The regression analysis revealed that empathy was the strongest predictor of QWL (β = .370, p < .001), and the overall model explained 23.6% of the variance in QWL (Adjusted R² = .197). This finding indicates that QWL is not solely determined by structural or organizational conditions but is strongly influenced by individual psychosocial attributes.

Nurses with higher empathy levels may derive greater intrinsic meaning and emotional satisfaction from patient interactions, which enhances their perception of work-life quality (Moudatsou et al., 2020). In this context, empathy may function as a psychological resource that buffers occupational strain and promotes professional fulfillment.

Working nonstandard shifts was associated with lower QWL (β = −.127, p = .044), highlighting the disruptive impact of rotating schedules on occupational well-being. Irregular shifts may impair sleep patterns, reduce family time, and increase fatigue, thereby diminishing perceived work-life quality (Booker et al., 2018).

Departmental differences were also observed, with nurses working in departments other than emergency reporting lower QWL (β = −.175, p = .010). This may reflect variations in workload intensity, clinical exposure, or team dynamics across units.

Age and higher educational level were negatively associated with QWL. Older nurses may experience cumulative occupational strain or role fatigue, while highly educated nurses may encounter unmet career expectations or limited advancement opportunities within resource-constrained systems. Such mismatches between qualifications and professional roles have been linked to dissatisfaction and reduced occupational well-being in previous research (De Vries et al., 2023).

Divorced or widowed participants reported significantly higher QWL (β = .172, p = .004). This finding should be interpreted cautiously given the small sample size in this category; however, it may reflect reduced family-related role conflict or greater autonomy in managing professional demands. Overall, these findings suggest that QWL among nurses emerges from a dynamic interaction between individual psychological resources, such as empathy, and organizational factors, including work schedule and clinical environment. Interventions aimed at improving QWL should therefore adopt a dual approach, targeting both institutional working conditions and the development of emotional and professional competencies.

It is noteworthy that some variables that demonstrated significant associations with QWL in bivariate analyses did not remain significant in the multivariate regression model. This shift suggests that their initial associations may have been influenced by confounding factors or shared variance with stronger predictors, particularly empathy and work-related variables. Multivariate analysis allows for the simultaneous adjustment of multiple factors, thereby identifying independent predictors of QWL. The emergence of age and educational level as significant predictors only after adjustment further underscores the complexity of occupational well-being and the interplay between personal and organizational characteristics. These findings reinforce the importance of interpreting bivariate results cautiously and prioritizing adjusted models when identifying determinants of professional quality of life.

Perspectives for Clinical and Assistive Practices

From a clinical and assistive practice perspective, the present findings underscore that QWL and empathy are not peripheral constructs, but central determinants of workforce sustainability and care quality. The significant association between empathy and QWL identified in this study suggests that emotional competencies function as protective psychological resources that enhance nurses’ occupational well-being.

In conflict-affected settings, preserving nurses’ QWL is particularly critical for maintaining safe clinical performance, continuity of care, and patient trust. The negative association between nonstandard shift work and QWL further highlights the importance of stable scheduling and workload regulation as structural determinants of occupational well-being. Similarly, departmental variations in QWL indicate that contextual workplace factors influence professional satisfaction and resilience.

Interventions aimed at strengthening emotional resilience and empathic engagement may indirectly improve QWL, given the strong predictive role of empathy in the present model. Structured supervision, reflective practice programs, and empathy-oriented training initiatives may enhance both emotional sustainability and patient-centered care delivery. International evidence suggests that organizational strategies promoting psychological safety, leadership support, and professional recognition are effective in improving nurses’ well-being and clinical functioning (Labrague, 2021).

Taken together, these findings support a dual-level intervention framework, combining structural workplace reforms with psychosocial capacity-building strategies to sustain both QWL and empathic practice in high-pressure healthcare environments.

Strengths and Limitations

This study is strengthened by its relatively large sample size, use of standardized instruments, and application of multivariate regression to identify independent predictors of quality of work life. The inclusion of nurses from different departments, hospital types, and work shifts enhances the internal validity of the findings. However, the cross-sectional design limits causal interpretation of the observed associations. In addition, the reliance on convenience sampling may have introduced selection bias, as well as combined with 250 participants with 65% response rate limited the generalizability. Nurses who participated may differ from nonrespondents in important characteristics such as empathy, coping ability, or psychological resilience, particularly under wartime conditions. This self-selection may limit the generalizability of the findings to the wider Palestinian nursing population. In addition, the final sample size was smaller than the initially calculated target, which may have limited the statistical power to detect very small effects; therefore, weak associations should be interpreted with caution. Moreover, the relatively small number of divorced or widowed participants may have affected the stability of the regression coefficient for this subgroup, and this finding should be interpreted carefully.

Implications for Practice

The present findings have important implications for nursing practice and management. Given that empathy emerged as a significant positive predictor of quality of work life, nurse managers should integrate empathy-enhancement strategies, such as communication skills training and reflective practice, into continuing professional development programs. The lower QWL observed among nurses working nonstandard shifts underscores the need for more stable and supportive scheduling policies to reduce work-related strain and burnout. Targeted organizational support should also be directed toward nurses with higher educational attainment, who reported lower QWL, to optimize role utilization, career progression, and job satisfaction. Additionally, given the observed association between department type and QWL, managers should assess unit-specific work environments to identify contextual stressors and implement tailored support strategies. In addition, fostering supportive work environments that consider personal factors such as marital status and years of experience may enhance nurses’ well-being, retention, and overall quality of patient care.

Conclusion

This study highlights the close relationship between quality of work life and empathy as key dimensions of nurses’ professional experience. The findings emphasize the importance of addressing both organizational conditions and psychosocial competencies in efforts to promote nurses’ well-being and effective practice. Workplace policies that support stable work organization and integrate empathy-oriented professional development may contribute to improving occupational satisfaction and sustaining high-quality patient care. Although causal inferences cannot be drawn from the cross-sectional design, this study adds to the growing evidence base guiding future longitudinal and intervention research in this area, particularly within conflict-affected healthcare systems.

Supplemental Material

sj-docx-1-son-10.1177_23779608261436787 - Supplemental material for Levels of Quality of Work Life and Clinical Empathy Among Nurses in Palestine During the War: A Cross-Sectional Study of Predictors

Supplemental material, sj-docx-1-son-10.1177_23779608261436787 for Levels of Quality of Work Life and Clinical Empathy Among Nurses in Palestine During the War: A Cross-Sectional Study of Predictors by Nawaf Amro, Mohammad Qtait, Bayan Mansour, Ne’ma Shaltaf, Malak Sharabati, Hanan Jaber and Nadine Shawish in SAGE Open Nursing

Supplemental Material

sj-docx-2-son-10.1177_23779608261436787 - Supplemental material for Levels of Quality of Work Life and Clinical Empathy Among Nurses in Palestine During the War: A Cross-Sectional Study of Predictors

Supplemental material, sj-docx-2-son-10.1177_23779608261436787 for Levels of Quality of Work Life and Clinical Empathy Among Nurses in Palestine During the War: A Cross-Sectional Study of Predictors by Nawaf Amro, Mohammad Qtait, Bayan Mansour, Ne’ma Shaltaf, Malak Sharabati, Hanan Jaber and Nadine Shawish in SAGE Open Nursing

Footnotes

ORCID iDs

Nawaf Amro

Mohammad Qtait

Bayan Mansour

Ne’ma Shaltaf

Malak Sharabati

Hanan Jaber

Nadine Shawish

Ethics Approval and Consent to Participate

Ethical approval for this study was obtained from the Ethical Committee of Modern University College (Approval No. MUC012/2025). Informed electronic consent was obtained from all participants prior to participation. All participants were aged 18 years or older. Participation was voluntary, confidentiality was ensured, and the study was conducted in accordance with the Declaration of Helsinki.

Study Approval Number

MUC012/2025

Authors’ Contributions

NA and MQ: conceptualized the study, performed data analysis and interpretation, wrote the initial draft, and contributed to revisions. NA and MQ conceptualized the study and critically revised the entire manuscript for important intellectual content. BM, NS, MS, HJ, and NS were responsible for data collection and entry, followed by ethical approval, building the figure, and contributed to the writing of the manuscript as well.

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.

Availability of Data and Materials

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Supplemental Material

Supplemental material for this article is available online.

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