Abstract
Introduction
Nurses in conflict zones face unique ethical challenges distinct from stable environments. The West Bank, under prolonged military occupation and structural violence, presents a critical context to examine how nurses sustain ethical practice. Despite growing awareness of moral distress, the lived experiences of nurses in such settings remain underexplored through qualitative, phenomenologically-informed approaches.
Objectives
This study aimed to explore the lived experiences of moral distress and resilience among nurses in West Bank governmental hospitals and to identify key ethical challenges, coping mechanisms, and institutional support needs.
Methods
A qualitative design using Interpretive Phenomenological Analysis was implemented with 21 purposively sampled nurses from three hospitals. Data collection involved semi-structured, in-depth Arabic interviews (60–120 minutes), transcribed, translated (forward-backward method), and analyzed iteratively. Data saturation was achieved after the 18th interview. Exclusion criteria included nurses who were not currently employed in a direct patient care role, those with less than one year of experience in the setting, and non-Arabic-speaking staff. Reporting followed COREQ guidelines.
Results
Analysis yielded three superordinate themes: (1) “The Double Burden”, moral distress from political barriers and chronic resource scarcity; (2) “Our Shared Strength”, reliance on peer, family, cultural (Sumud), and religious support; (3) “The Structural Void”, absence of formal institutional support (e.g., debriefing, psychological services).
Conclusions
Palestinian nurses demonstrate extraordinary resilience through informal networks, but this reveals a systemic failure, as their distress is structural. There is an urgent need for contextually-adapted institutional support programs to preserve workforce well-being and uphold care integrity.
Keywords
Introduction
Moral distress, defined as the experience of knowing the ethically appropriate action yet being constrained from taking it, is a central concern in nursing practice globally (Epstein & Hamric, 2009; Jameton, 1984). Closely related is the concept of moral resilience, which refers to the capacity to maintain or restore one’s integrity in the face of moral complexity, distress, or adversity (Clark et al., 2021; Rushton et al., 2015). While both concepts are interconnected; moral resilience representing an adaptive response to moral distress, they are conceptually distinct: moral distress denotes the suffering caused by ethical constraint, whereas moral resilience captures the nurse’s capacity to respond to and recover from such suffering. Both are examined in this study to provide a holistic understanding of nurses’ ethical experience.
Healthcare professionals experience moral distress when they know the right action but face constraints that prevent it, a phenomenon linked to burnout, compassion fatigue, and attrition (Cooke et al., 2022; Epstein & Hamric, 2009). While studied extensively in stable, high-resource systems, there is significantly less understanding of moral distress in contexts of prolonged conflict, structural violence, and scarcity (Alqaissi et al., 2025; Fumis et al., 2017; Shamia et al., 2015). This gap is critical, as millions of nurses practice in such environments.
Review of Literature
The concept of moral distress has evolved from focusing on clinical dilemmas to include moral injury, profound suffering following events that betray deeply held moral beliefs (Rabin et al., 2023; Williamson et al., 2020). Nurses working under conditions of chronic stress and inadequate resources may experience cumulative moral distress leading to burnout and reduced capacity for ethical practice (Cooke et al., 2022). Research has also demonstrated that nurses in conflict-affected settings carry heightened risks of both psychological trauma and moral injury. These risks stem from repeated exposure to violence, chronic resource scarcity, and constrained decision-making (Shamia et al., 2015). Research in active conflict zones documents extreme pressures on healthcare workers (Hamaideh, 2014; Sadhaan et al., 2022).
The Palestinian West Bank, in particular, represents a distinct “chronic crisis” shaped by protracted military occupation, creating structural violence that systematically constrains health access and forces healthcare workers to confront ethical dilemmas rooted in political, rather than clinical, barriers (Galtung, 1969; Giacaman et al., 2009; WHO, 2020). This “geography of constraint” leads to care rationing and repeated exposure to politically inflicted trauma (ALMasri & Rimawi, 2022; Hammami, 2015; Qtait et al., 2025).
Despite this, there remains a significant gap in qualitative, phenomenologically-informed studies exploring the lived experiences of Palestinian nurses specifically, a gap this study directly addresses.
Resilience literature highlights social-ecological factors like peer support and cultural values such as Sumud (steadfastness) in collectivist societies (García-Martín et al., 2021; Hammami, 2015; Rushton et al., 2015). Coping in nursing has been conceptualized broadly to include problem-focused strategies (such as active problem-solving and seeking information), emotion-focused strategies (such as peer debriefing and spiritual practice), and meaning-focused strategies (such as cultural identity and vocational calling) (Folkman & Moskowitz, 2004). In the West Bank context, these coping dimensions manifest through informal peer support networks, family solidarity, religious faith, and the cultural principle of Sumud—all of which are explored as central themes in this study. However, reliance on informal coping risks privatizing distress and masking systemic failure (Bourdieu, 1998; ICN, 2021), underscoring the need for formal institutional support.
The West Bank Context
Since 1967, the West Bank has been under Israeli military occupation, which structures healthcare delivery through a complex system of checkpoints, barriers, and permits (Giacaman et al., 2009). This causes life-threatening delays for patients and restricts movement for staff and supplies. Governmental hospitals, the focus of this study, are chronically underfunded, facing shortages of medicines, equipment, and staff (WHO, 2020). Nurses operate at the intersection of macro-political violence and micro-level resource constraints within a sustained crisis (Hammami, 2015). The three hospitals selected for this study span distinct geographical zones of the West Bank: northern, central, and southern, each with unique political and operational characteristics that shape nursing experience differently. The northern zone is characterized by frequent military incursions and dense checkpoint networks; the central zone serves as a major urban referral hub managing high patient volume; and the southern zone faces acute constraints from settlement expansion and movement restrictions. Understanding how these distinct regional pressures may differentially contribute to moral distress was a guiding rationale for the geographical spread of this study.
Study Aim and Research Questions
The aim of this study was to explore, interpret, and understand the lived experiences of moral distress, coping, and institutional support among nurses in three West Bank governmental hospitals, using an interpretive phenomenological approach. It was guided by three research questions: 1. What are the primary sources and manifestations of moral distress experienced by nurses in these settings? 2. What personal, interpersonal, and cultural resources do nurses draw upon to cope? 3. How do nurses perceive institutional support for moral well-being, and what formal structures are present or absent?
Methods
Study Design
This study was conducted using Interpretive Phenomenological Analysis (IPA), a qualitative methodology firmly rooted in phenomenology, hermeneutics, and idiography (Smith, 2024; Smith et al., 2009). IPA is particularly suited to research questions that seek to understand how individuals make sense of their significant lived experiences. It moves beyond mere description of an experience to a nuanced interpretation of the meanings participants attribute to that experience. Given the study’s focus on the personal, often profound, experiences of moral distress and resilience in a unique context, IPA provided the necessary philosophical and methodological framework to engage deeply with participants’ narratives and uncover the essence of their lived reality.
Research Team and Reflexivity
The research team consisted of three members. The primary researcher is a PhD-prepared nurse with extensive training in qualitative methods, phenomenology, and nursing ethics, and with prior clinical experience in the region. Two co-investigators, one with expertise in phenomenological research and another in global health and conflict studies, provided supervision and analytical support. While the primary researcher had professional familiarity with the Palestinian healthcare landscape, no prior personal relationships existed with any participants. To manage potential biases and the “insider/outsider” dynamic, the team engaged in continuous reflexivity. This involved maintaining detailed reflective journals to document assumptions and emotional responses, holding regular peer debriefing sessions to challenge interpretations, and explicitly practicing bracketing, the conscious effort to set aside preconceptions to better hear the participant’s world (see Supplementary Material S2 for excerpts). This rigorous reflexive practice was integral to ensuring the trustworthiness of the analysis.
Setting and Participants
The study was conducted across three major governmental hospitals in the West Bank, selected to provide geographical and contextual diversity:
A purposive sampling strategy with maximum variation was used to recruit participants. Inclusion criteria mandated that participants be: (1) registered nurses; (2) employed full-time in a direct patient care role at one of the three study hospitals; (3) have a minimum of one year of experience in that setting; and (4) Arabic-speaking, as all interviews were conducted in Arabic to ensure linguistic and cultural authenticity. Exclusion criteria were as follows: nurses currently on administrative or non-clinical assignments, nurses with less than one year of experience in the current setting, and individuals who were unable to communicate in Arabic. The goal was to capture a wide range of perspectives across clinical departments, years of experience, and gender. Recruitment continued until data saturation was reached, the point at which new interviews yielded no significant new themes or insights into the research questions. This occurred after 18 interviews, but a final sample of 21 nurses (seven from each hospital) was secured to confirm that no new themes emerged and to ensure robust representation across the varied hospital contexts.
Regarding language expectations: Arabic is the primary language of nursing practice across all three regions studied. Nurses in West Bank governmental hospitals are expected to communicate with patients, colleagues, and administrators in Arabic; no additional language requirement is formally mandated in these settings. This confirms that the Arabic-language inclusion criterion did not inadvertently exclude eligible participants, as Arabic proficiency is a professional norm in these hospitals.
Ethical Considerations
Ethical approval for this study was granted by the Institutional Review Board (IRB) of Ibn Sina College for Health Professions, Nablus University (Reference #: Nrs. May 2024/8), the Palestinian Ministry of Health Research Ethics Committee, and the institutional review boards at each participating hospital. The study was conducted in strict accordance with the principles outlined in the Declaration of Helsinki.. The research team obtained written, informed consent from every participant. A detailed participant information sheet, explaining the study’s purpose, procedures, risks, benefits, and rights (including the right to withdraw at any time without consequence), was provided at least 48 hours prior to the interview. Confidentiality was guaranteed through the use of pseudonyms (e.g., P1, P2), the removal of all identifying details from transcripts, and secure, encrypted storage of all digital data (audio files, transcripts). In reporting findings, extreme care was taken to use non-identifying quotations and to avoid any details that could compromise participant anonymity.
Data Collection
Data were generated through semi-structured, in-depth interviews. An interview guide was developed based on a comprehensive literature review and consultation with experts in nursing ethics and qualitative methodology (see Supplementary Material S2 for the full guide). The guide contained open-ended, exploratory questions designed to elicit rich narrative accounts, such as: “Can you describe a typical day at work and the kind of ethical challenges you encounter?” “Tell me about a specific time when you felt you could not provide the care you believed a patient needed. What was the situation, and what was the constraint?” “How do you and your colleagues support one another during or after particularly difficult shifts?” “What does the hospital administration do, if anything, to support staff who are dealing with moral or emotional distress?” “How does the broader political situation and the movement restrictions affect your daily work and your sense of professional duty?”
All interviews were conducted face-to-face in Arabic by the primary researcher to ensure linguistic and cultural fluency. They took place in private rooms within the hospitals (e.g., unused offices, conference rooms) at times convenient for the participants, often before or after their shifts. Interviews ranged in length from 60 to 120 minutes, with an average duration of 85 minutes. With explicit consent, every interview was audio-recorded using a digital recorder. Concurrently, the researcher took field notes to capture contextual observations, non-verbal cues (e.g., pauses, sighs, emotional expressions), and preliminary analytical thoughts, which later enriched the data analysis.
Translation Procedures
Given that data collection occurred in Arabic and analysis was conducted bilingually, a rigorous translation protocol was essential for maintaining the integrity of the data. All audio recordings were transcribed verbatim in Arabic by a research assistant fluent in both languages. These Arabic transcripts were then translated into English by a member of the research team who is a bilingual nursing educator, ensuring familiarity with clinical and ethical terminology. To preserve semantic, conceptual, and emotional nuance, a forward-backward translation approach was employed: a second independent bilingual expert back-translated a randomly selected sample of the English transcripts into Arabic. The original Arabic and the back-translated version were compared, and any discrepancies in meaning were discussed and resolved by the research team until consensus was reached. This process ensured that the English-language data used for analysis remained faithful to participants’ original expressions and intended meanings.
Data Analysis
Data analysis adhered to the systematic, iterative steps of Interpretive Phenomenological Analysis (IPA) as outlined by Smith et al. (2009). This process began with Immersion and Initial Reading, involving repeated reading of each transcript to deeply familiarize the researcher with each participant’s narrative. Following this, Initial Noting entailed a line-by-line exploratory analysis of the first transcript, where detailed marginal notes were made, including descriptive, linguistic, and conceptual comments. These notes were then synthesized into concise, phrase-like statements during Developing Emergent Themes, capturing the psychological essence of each participant’s experience. Searching for Connections Across Emergent Themes involved clustering these themes into related groups to form a coherent structure for each case. This entire process was then Repeated for Each Subsequent Transcript, ensuring each participant’s account was treated on its own terms. Finally, by Looking for Patterns Across Cases, the emergent themes from all 21 participants were analyzed together to identify convergences, divergences, and overarching superordinate themes, while also noting unique perspectives. While MAXQDA (VERBI Software, 2022; https://www.maxqda.com) was used to organize transcripts, codes, and memos, the essential interpretive work, deep textual engagement and hermeneutic meaning-making, was performed manually by the researcher, in alignment with IPA’s philosophical foundations.
Rigor and Trustworthiness
The study’s rigor was established through a commitment to Lincoln and Guba’s (1985) trustworthiness criteria. Credibility was ensured via prolonged engagement (three months in the field), member checking of thematic summaries with six participants, peer debriefing, and triangulation of interview transcripts, field notes, and reflective journals. Transferability was supported by thick, contextual description and maximum variation purposive sampling. Dependability was maintained through a detailed audit trail and standardized procedures, while confirmability was enhanced through reflexive journaling and a clear, logical trail of evidence linking raw data to themes.
Reporting Guidelines
To ensure comprehensive and transparent reporting, this study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ), a 32-item checklist designed for interviews and focus groups (Tong et al., 2007). A completed COREQ checklist is provided as Supplementary Material S1.
Results
Participant Demographics
Descriptive Characteristics of Study Participants (N=21)
Note. BSN = Bachelor of Science in Nursing; MSN = Master of Science in Nursing.
Superordinate Themes and Subthemes
Theme 1: The Double Burden: Navigating Clinical Duty Amidst Systemic and Political Barriers
This theme encapsulates the fundamental reality described by all participants: the experience of moral distress was not born from a single source but from the relentless, compounding pressure of two intertwined systems of constraint, the political-military occupation and the chronic scarcity of the public health system. This “double burden” created a distinct and profound form of ethical suffering.
Subtheme 1.1: The Geography of Care: Movement Restrictions as Ethical Agony
Participants consistently described a profound sense of helplessness and ethical violation rooted in the spatial politics of occupation. The “geography of care” was not abstract; it was a daily determinant of life and death. Nurses were forced to be bystanders as patients deteriorated due to delays entirely outside clinical control.
“The absolute worst part of this job is the waiting. You stabilize a patient who needs emergency surgery or a specialist in another city. You call for the ambulance transfer; you prepare the paperwork. And then you wait. You watch the monitor, you watch the clock, and you know the ambulance is sitting at a checkpoint. The care your patient needs is a 30-minute drive away, but it might as well be on another continent. You are trained to act, to intervene, but here, your hands are tied by geography and soldiers.” (P4, Emergency Nurse, 15 years experience)
“I will never forget him. A myocardial infarction. Young. We needed the cardiologist from Ramallah to come for a catheterization. We were ready. He was held at Huwara checkpoint. For two hours, they held him. My patient died. The doctor arrived to a body. That day, I didn’t just lose a patient; I felt my profession was made a mockery of. The technology, the skill—it was all rendered meaningless by a checkpoint.” (P11, ICU Nurse, 9 years experience)
It is important to note that while checkpoint delays represented a major contributing factor to adverse patient outcomes described by participants, the multifactorial nature of mortality in conflict settings must be acknowledged. Factors including the patient’s clinical severity, pre-existing resource limitations, and broader structural constraints all interact. Participants’ narratives emphasized the moral weight of these delays rather than attributing causality solely to any single factor.
Subtheme 1.2: Chronic Scarcity: Rationing as Standard Practice
Resource limitations were not framed as occasional crises but as the permanent backdrop against which all care was delivered. This “chronic scarcity” forced nurses into a state of continuous ethical triage, making painful decisions about medication allocation, staff attention, and care priorities that directly conflicted with their professional ethos of equitable, patient-centered care.
“It’s not a matter of ‘if’ we run out, but ‘what’ we run out of this week. Basic antibiotics, pain medication, even IV fluids. You become a gatekeeper, not a nurse. You look at two patients: one might have a family who can afford to buy the drug outside, the other does not. That shouldn’t be my calculation. That’s a policy failure, but it lands on me, every shift.” (P3, Internal Medicine Nurse, 8 years experience)
“The danger isn’t just the shortage itself; it’s what it does to you over time. You start to normalize the unacceptable. You lower your own internal standard because ‘that’s just how it is here.’ The moral erosion is slow, quiet, and very real. You adapt to what is possible, not what is right.” (P5, Surgical Nurse, 25 years experience)
Subtheme 1.3: The Weight of Trauma: Recurrent Exposure to Political Violence
For nurses in emergency and critical care departments, the “double burden” included the psychological and moral weight of repeatedly treating victims of political violence. This was distinct from trauma in other settings; it was systemic, predictable in its recurrence, and imbued with a profound sense of futility and political injustice.
“We patch them up. A 16-year-old with a chest full of birdshot. A father caught in crossfire. We do the surgery, we manage the pain, we send them to the ward. And we know, with a horrible certainty, that next week or next month, we will see another one just like them. We are treating symptoms of a disease we cannot cure. It creates a specific kind of exhaustion—a moral exhaustion.” (P10, Emergency Nurse, 22 years experience)
“There is no professional distance here. I am not just their nurse. I am Palestinian. I cross the same checkpoints. I fear for my children in the same way. When I wash the blood from a young man’s face, I see my brother, my neighbor. The vulnerability is shared. It’s personal, and that makes the professional burden infinitely heavier.” (P6, Pediatric Nurse, 4 years experience)
Theme 2: Our Shared Strength: Peer and Community Support as Foundational, Yet Recognized as Limited, Coping
In the face of the “double burden,” participants described a robust ecosystem of informal support that was universally identified as the primary reason they could continue their work. This theme highlights the agency and resilience of nurses, while also capturing their sophisticated awareness of the limits of these organic strategies.
Subtheme 2.1: The Unit as Family: Immediate, Informal Peer Debriefing
The nursing unit was consistently described as a surrogate family. This peer network provided immediate, understanding, and non-judgmental support that was available in the moment of crisis, in stark contrast to any formal, scheduled intervention.
“After a terrible code, a death that felt unjust, a shift where everything went wrong... we don’t just go home. We can’t. We gather in the break room. We make tea. We sit in silence sometimes. We talk it out. We say, ‘You did everything you could.’ We cry together. That shared understanding, that unspoken bond—it’s what gets us through the door the next day.” (P8, ICU Nurse, 12 years experience)
“My colleagues are my rock. They understand without me having to explain the checkpoint, the shortage, the feeling of helplessness. The support is in a glance, a hand on the shoulder. It’s practical too—covering a assignment when you’re overwhelmed. This unit is my second family, truly.” (P12, Emergency Nurse, 16 years experience)
However, participants also voiced a critical caveat:
“But we have to be honest. We are all carrying the same heavy stones. Sometimes, I worry that when we ‘debrief’ like this, we are just passing the trauma around in a circle. We’re comforting each other, but are we processing it? Are we healing, or just sharing the burden until we are all equally weighed down?” (P16, ICU Nurse, 19 years experience)
Subtheme 2.2: Familial and Cultural Resilience: Drawing Strength From Sumud
Resilience was deeply rooted in the social and cultural fabric. Family members, living the same political reality, provided unique understanding and validation. The Palestinian cultural concept of Sumud (steadfastness, perseverance, rootedness) was repeatedly invoked not as passive suffering, but as an active, dignified form of resistance and meaning-making.
“At home, I don’t need to justify my fatigue or my anger. My husband, my parents—they live it. When I say I watched an ambulance be delayed, they nod. They know. Their support isn’t pity; it’s solidarity. They see my work as part of our Sumud—our way of staying, of caring for our people, of refusing to be broken.” (P1, Internal Medicine Nurse, 5 years experience)
“Sumud is not just about enduring. For me, as a nurse, it is an active principle. To provide compassionate, professional care in a system designed to humiliate and constrain—that is resistance. It is insisting on humanity. My work is my Sumud.” (P11, ICU Nurse, 9 years experience)
Subtheme 2.3: Spiritual Fortitude: Religious Faith as a Framework for Meaning
For many participants, religious faith (predominantly Islam, with some Christian references) provided a vital framework for making sense of suffering, practicing patience, and relinquishing control over outcomes that were truly beyond their influence.
“My faith is my anchor. In prayer, I find a moment of peace amidst the chaos. It reminds me that I am an instrument, doing my duty, and that ultimate outcomes are in God’s hands. This belief helps me to do my best and then, critically, to let go of the things I cannot change. It prevents the helplessness from consuming me.” (P3, Internal Medicine Nurse, 8 years experience)
“The concept of Sabr (patience) in Islam is deeply meaningful. It’s not passive waiting; it’s active, enduring patience with faith and hope. When I face a situation where a patient suffers due to a checkpoint, I practice Sabr. I continue to do my clinical duty with care, and I cultivate patience in my heart, trusting in a wisdom larger than this political moment.” (P9, Surgical Nurse, 10 years experience)
Theme 3: The Structural Void: The Critical Absence of Formal Institutional Frameworks for Moral Well-Being
Paradoxically set against the strength of Theme 2, this theme represents a powerful and consistent critique of the healthcare institutions themselves. Participants identified a stark and dangerous gap: the almost complete lack of systematic, institutional-level support designed to address the moral and psychological dimensions of their work.
Subtheme 3.1: Reliance on Individual Managers: Variable Support Dependent on Personal Compassion
Support for moral distress was described as a lottery, contingent entirely on the personal empathy and style of one’s direct supervisor or head nurse, rather than on established institutional policy.
“I am very lucky. My head nurse is an angel. After a difficult loss, she will pull each of us aside, check in, really listen. But I have friends in other departments whose managers see that as a weakness or a waste of time. They are told to ‘be strong’ and move on. Your access to basic humanity shouldn’t depend on winning the manager lottery.” (P5, ICU Nurse, 25 years experience)
“It’s a fundamental injustice. Support for the moral injury we experience should be a right of the job, like gloves or a salary. It shouldn’t be a personal favor you get if your boss happens to be a kind person.” (P12, Emergency Nurse, 16 years experience)
Subtheme 3.2: The Absence of Formal Debriefing: No Structured Psychological Support
Across all three hospitals and all departments, participants reported a total absence of formal, structured mechanisms for psychological or ethical processing after critical incidents.
“A mass casualty event, three deaths in one shift, a particularly traumatic injury in a child—after these, there is nothing. No one comes. No psychologist, no counselor, no structured debrief. The message is clear: ‘Clean up, restock, and be ready for the next shift.’ Our informal huddles are vital, but they are not a substitute for professional, facilitated psychological first aid.” (P17, Emergency Nurse, 22 years experience)
“Look at our context! We are a society experiencing collective, ongoing trauma. And the people on the front lines of that trauma in the hospitals—the nurses and doctors—we have zero mental health support from our employer. No Employee Assistance Program, no confidential counseling, nothing. It’s a glaring, dangerous omission.” (P2, Pediatric Nurse, 18 years experience)
Subtheme 3.3: A Cry for Recognition: The Desire for Formal, Contextually-Aware Support
Participants did not merely lament the void; they articulated clear, sophisticated, and compelling visions for what meaningful support would look like. Their calls went beyond generic wellness programs to demand recognition of the unique political nature of their distress.
“We don’t want sympathy or empty praise. We want recognition. Recognition that nursing under military occupation, with chronic political violence and designed scarcity, is a distinct professional experience with distinct psychological risks. The Ministry of Health needs to invest in our mental and moral well-being with the same seriousness it (tries to) invest in MRI machines.” (P11, ICU Nurse, 9 years experience)
“We need real solutions. Trained peer-support facilitators from among us who understand the context. Mandatory, protected-time ethical debriefs after critical events, not about clinical errors but about the moral pain. Access to therapists who understand occupation trauma. These things exist in other countries’ health systems. Why are we, who arguably need them more, deemed unworthy of them?” (P15, Emergency Nurse, 19 years experience)
Discussion
The findings of this study paint a complex and compelling portrait of the moral landscape inhabited by nurses in West Bank governmental hospitals. The identified themes, The Double Burden, Our Shared Strength, and The Structural Void, interlock to form a powerful narrative about sustaining care under profound and sustained constraint. This discussion interprets these findings within the broader literature on moral distress, resilience, and health systems in conflict, while also highlighting their unique contributions.
The Double Burden as Structural Moral Injury
The “double burden” experienced by participants, the synergistic pressure of political-military barriers and chronic resource scarcity, represents a potent manifestation of structural violence (Farmer, 2004; Galtung, 1969). For these nurses, structural violence is not an abstract theory but a lived reality where checkpoint delays contribute to adverse outcomes, permit denials equate to diagnostic delays, and budget shortfalls force daily ethical triage. This moves the experience of moral distress beyond the traditional frameworks of intra-institutional or interprofessional conflict (Epstein & Hamric, 2009) into the realm of politically-inflicted ethical suffering.
This aligns with and extends the emerging concept of moral injury in healthcare (Rabin et al., 2023; Williamson et al., 2020). While moral injury often focuses on individual acts or omissions, the findings suggest that in contexts of protracted political conflict, the injury can be collective and systemic. The “betrayal of what’s right” is perpetrated not by a colleague or a hospital policy, but by overarching political and economic structures that make ethical nursing practice, as internationally defined, functionally impossible. The profound powerlessness expressed by participants echoes the core of moral injury: the chasm between one’s moral code and the reality one is forced to inhabit. It should be noted, however, that adverse patient outcomes in these settings are multifactorial, arising from the interplay of clinical severity, resource limitations, and structural barriers. Participants’ accounts reflect the moral weight of these constraints rather than attributing mortality to any single cause.
Furthermore, the concept of “rationing as standard practice” refines our understanding of resource-based moral distress. It is not an occasional triage during a disaster but a chronic, low-grade condition that permeates every clinical decision, leading to what Participant P5 aptly called “moral erosion.” This chronicity distinguishes it from the acute resource dilemmas often described in the literature from high-income countries (Ulrich et al., 2010).
Moral Distress, Moral Injury, and Moral Erosion in Context
A central contribution of this study is its illumination of the specific contours of moral distress as experienced in a prolonged conflict setting. Moral distress, as theorized by Jameton (1984) and elaborated by Epstein and Hamric (2009), arises from the gap between what a nurse knows is ethically correct and what they are able to do. In the West Bank context, this gap is not primarily generated by institutional hierarchy or interprofessional disagreement, but by a politically-constructed environment of constraint. This distinction is critical: nurses in this study did not describe uncertainty about what the right action was. They described clarity about the right action paired with structural impossibility of carrying it out, a particularly acute form of moral distress. Participants also described what can be understood as moral erosion (P5), a gradual normalization of ethical compromise that, over time, dulls one’s moral sensitivity. This trajectory, from acute moral distress to chronic moral erosion, has important implications for nurse education and institutional support, as it represents a cumulative process that requires sustained, proactive intervention rather than acute response alone. The findings also speak to psychological trauma as an inseparable dimension of moral distress in this context. The recurrent exposure to politically inflicted suffering, treating victims of violence, witnessing preventable deaths, bearing witness to systemic injustice, constitutes a form of vicarious and direct traumatization that compounds the moral dimension of nurses’ suffering. Understanding these experiences as simultaneously moral and psychological in nature strengthens the case for integrated support responses.
The Paradox of Informal Resilience: Strength and Systemic Failure
Theme 2, “Our Shared Strength,” powerfully demonstrates the agency, creativity, and deep social cohesion of Palestinian nurses. Their reliance on peer-as-family support, cultural Sumud, and religious faith provides a rich, context-specific model of resilience that aligns with social-ecological theories emphasizing community and cultural resources (García-Martín et al., 2021; Ungar, 2018). This finding challenges deficit-based narratives about healthcare in crisis settings, highlighting immense strength and adaptability.
However, the critical insight from this theme is participants’ own reflexive awareness of its limitations. The metaphor of “pooling trauma” rather than processing it is analytically profound. It suggests that while peer support is essential for immediate survival and solidarity, it may be insufficient for long-term psychological recovery and may even risk creating a culture where distress is normalized and internalized rather than resolved. This critique aligns with warnings about the “privatization of risk” in neoliberal systems (Bourdieu, 1998), where systemic problems are offloaded onto individuals and their informal networks. The nurses’ sophisticated understanding that their coping mechanisms are a necessary but inadequate response to systemic failure underscores the urgency of Theme 3.
The Structural Void: A Call for Institutional Moral Accountability
The near-universal description of a “Structural Void” represents the study’s most damning and actionable finding. The complete absence of formal debriefing, psychological services, ethics consultation, and standardized managerial support constitutes what can be termed a systemic abandonment of the nursing workforce’s moral well-being. This goes beyond a simple lack of resources; it reflects a failure of institutional imagination and responsibility.
International guidance, such as from the International Council of Nurses (ICN, 2021) and the World Health Organization (WHO, 2022), increasingly stresses the obligation of health systems to provide psychosocial support for workers in high-stress environments. Models like Critical Incident Stress Management (CISM), Schwartz Rounds for ethical reflection, and embedded mental health services are evidence-based interventions (Lown & Manning, 2010; Maben et al., 2021). That none of these were present, even in nascent form, highlights a critical gap between global standards and local reality in this context.
Participants’ “cry for recognition” is particularly significant. They are not asking for passive victim support but for active, contextually-competent institutional partnership. They demand that their unique challenges, shaped by occupation, be formally acknowledged and addressed with tailored resources, such as politically-aware counseling and ethical debriefing that explicitly names structural violence. This moves the discourse from “faculty wellness” to “structural support for moral practice,” a more robust and justice-oriented framework.
Strengths and Limitations
This study has several notable strengths. First, the use of Interpretive Phenomenological Analysis (IPA) allowed for deep, nuanced exploration of nurses’ lived experiences, capturing the emotional and moral complexity of practicing under prolonged political conflict—an approach rarely applied to this population. Second, the sample of 21 nurses across three geographically diverse hospitals (northern, central, and southern West Bank) provided rich variation in political and operational contexts, enhancing the transferability of findings. Third, rigorous methodological procedures—including forward-backward translation, member checking, peer debriefing, and reflexive journaling—strengthened the credibility and confirmability of the analysis. Fourth, the inclusion of nurses from multiple clinical specialties (Emergency, ICU, Surgery, Internal Medicine, Pediatrics) ensured a broad spectrum of perspectives on moral distress and coping. Fifth, data saturation was achieved and confirmed, and the average interview duration of 85 minutes yielded exceptionally rich narrative data. Finally, the study addresses a critical gap in the literature by centering Palestinian nurses’ voices, a population largely absent from existing moral distress research.
Several limitations must also be acknowledged. First, as a qualitative study at a single point in time, it captures experiences within a specific socio-political moment. The dynamics of occupation and resource availability are fluid; a longitudinal design could reveal how moral distress and coping evolve. Second, the focus on governmental hospitals in the West Bank means findings may not be directly transferable to nurses in the Gaza Strip, East Jerusalem, or the private/NGO sector in the West Bank, where contexts differ significantly. Third, while gender was a sampling variable, the study did not undertake a dedicated gendered analysis, which could reveal important differences in experiences of distress, coping, and institutional treatment. Fourth, despite rigorous assurances of confidentiality, the sensitive nature of the topic may have influenced some participants’ willingness to share certain experiences, though the depth and critique in the data suggest a high degree of candor. Fifth, the translation process, however careful, may have subtly altered some linguistic and cultural nuances. Sixth, the researcher’s professional familiarity with the Palestinian healthcare landscape, while valuable for contextual interpretation, may have introduced unavoidable interpretive biases despite rigorous bracketing and reflexivity practices. Finally, the absence of formal institutional support structures in the study setting meant that participants had no alternative coping framework to compare against their experiences of informal resilience.
Implications for Practice
The findings of this study carry several important implications for nursing practice, healthcare administration, policy development, and nursing education, particularly in conflict-affected and resource-limited settings.
For Clinical Nursing Practice
First, nurses working in conflict zones should be formally trained in ethical reasoning and moral resilience strategies as part of their core clinical competencies. Currently, Palestinian nurses rely on informal peer support, but this is insufficient for processing the cumulative moral distress caused by structural violence. Second, nurses should be empowered to participate in unit-level ethical debriefing sessions following critical incidents, similar to clinical morbidity and mortality reviews but focused on moral rather than technical failures. Third, nurses themselves must advocate for protected time and space to engage in collective reflection, as the current expectation to “clean up, restock, and be ready for the next shift” normalizes psychological suffering and accelerates moral erosion. Fourth, experienced nurses should be trained as peer support facilitators who can recognize signs of moral distress and moral injury in colleagues and provide culturally competent, context-aware initial interventions.
For Hospital and Health System Administrators
Hospital administrators have an ethical obligation to recognize moral distress as an occupational hazard, not a personal failing. The complete absence of formal psychological support documented in this study constitutes a systemic failure. Administrators should immediately implement three low-cost, high-impact interventions: (1) mandatory, protected-time group debriefing sessions facilitated by trained peer supporters following mass casualty events or critical incidents; (2) designation of unit-based “moral wellness” champions who receive basic training in psychological first aid and ethical distress recognition; and (3) establishment of a confidential referral pathway to mental health professionals who understand occupation-related trauma. These interventions require minimal financial investment but signal institutional recognition of nurses’ moral suffering. Furthermore, administrators must integrate measures of moral distress and well-being into routine quality improvement and staff retention monitoring, treating them with the same seriousness as infection rates or medication errors.
For Ministry of Health and National Policy Makers
At the policy level, the Ministry of Health should develop a national framework for psychosocial support of healthcare workers in all public hospitals, with specific adaptations for facilities in politically volatile regions. This framework should include: (1) mandated ethical debriefing protocols; (2) sustainable funding for embedded mental health services; (3) training standards for peer support facilitators; and (4) accountability mechanisms to ensure implementation. Additionally, the Ministry should formally document and report care disruptions caused by political barriers (e.g., checkpoint delays, permit denials) as part of health system surveillance, transforming individual moral distress into evidence for structural advocacy. Without such systemic recognition, nurses will continue to bear the psychological costs of political failures alone.
For Nursing Education and Professional Development
Nursing curricula in conflict-affected regions must be reformed to prepare students for the specific ethical challenges they will face. Pre-licensure education should include modules on moral distress, moral injury, structural violence, and culturally grounded coping strategies such as Sumud (steadfastness) as an active professional value. Simulation-based training should incorporate scenarios involving resource rationing, political barriers to care, and ethical decision-making under constraint. Continuing education programs should offer workshops on moral resilience, self-care strategies, and peer support skills. Professional nursing associations in the region should develop context-specific ethical guidelines that explicitly address the realities of practicing under military occupation, moving beyond generic codes of ethics that assume stable, resource-rich environments.
For International Health Partners and Donors
International organizations and donors funding health system strengthening in conflict zones must expand their focus beyond infrastructure and medical supplies to include investment in the psychological and moral well-being of the healthcare workforce. Donors should require that funded projects allocate a minimum percentage of budgets (e.g., 5–10%) to staff support interventions, including peer support programs, mental health services, and ethical debriefing structures. Furthermore, international partners should support regional research networks to evaluate the effectiveness of context-specific support interventions, generating evidence that can inform practice in other conflict-affected settings globally, including Syria, Yemen, Ukraine, and Sudan.
For Researchers
Future research should address the gaps identified in this study. Longitudinal studies are urgently needed to track how moral distress and coping evolve over time in response to changing political and resource conditions. Comparative studies should examine moral distress across different conflict-affected settings (e.g., West Bank vs. Gaza vs. refugee camp contexts) and across different health sectors (governmental vs. NGO vs. private). Dedicated gendered analyses are essential to understand whether female and male nurses experience, express, and cope with moral distress differently, and whether institutional responses are equitable. Intervention studies should evaluate the feasibility, acceptability, and effectiveness of peer support programs, ethical debriefing protocols, and culturally adapted mental health services. Finally, participatory action research that involves nurses as co-researchers could empower the profession while generating locally relevant solutions.
Conclusion
This phenomenological study has illuminated the profound and textured reality of nursing in West Bank governmental hospitals. Nurses in this context carry a “Double Burden” of clinical responsibility compounded by political and resource constraints, which fosters a distinct form of moral distress akin to structural moral injury. The study also reveals how moral distress, moral injury, and psychological trauma are deeply intertwined in this setting, compounding one another over time and necessitating integrated institutional responses. In response, nurses have cultivated remarkable “Shared Strength” through peer, familial, cultural, and spiritual resources, demonstrating immense resilience and commitment. Yet, this very reliance on informal coping starkly reveals the “Structural Void”, a debilitating absence of formal institutional support that constitutes a systemic failure to uphold those who uphold care.
The findings compellingly argue that supporting nurses in such environments cannot rest solely on fostering individual resilience. It requires bold institutional action and systemic accountability. The recommendations outlined, from peer support programs to ethical debriefing and confidential mental health services, are not luxuries but essential investments in the sustainability of the healthcare workforce and the integrity of patient care. They represent a shift from expecting nurses to endlessly adapt to broken systems, toward building systems that actively support their moral and psychological well-being.
For Palestinian health authorities and the international community, the message is clear: the strength of a health system is measured not only by its infrastructure and medicines but by the well-being of its frontline caregivers. Upholding care under constraint requires first and foremost upholding the carers. The nurses in this study, through their steadfastness and their critiques, have shown the way. It is now the responsibility of institutions to listen and to act.
Supplemental Material
Supplemental Material - Upholding Care Under Constraint: Moral Distress, Psychological Trauma, and Resilience Among Nurses in West Bank Hospitals
Supplemental Material for Upholding Care Under Constraint: Moral Distress, Psychological Trauma, and Resilience Among Nurses in West Bank Hospitals by Ibrahim Aqtam, MSN, PhD, Mustafa Shouli, MSN, PhD in Sage Open Nursing
Supplemental Material
Supplemental Material - Upholding Care Under Constraint: Moral Distress, Psychological Trauma, and Resilience Among Nurses in West Bank Hospitals
Supplemental Material for Upholding Care Under Constraint: Moral Distress, Psychological Trauma, and Resilience Among Nurses in West Bank Hospitals by Ibrahim Aqtam, MSN, PhD, Mustafa Shouli, MSN, PhD in Sage Open Nursing
Footnotes
Acknowledgments
The authors extend profound gratitude to the 21 nurses who shared their experiences for this research, as well as to the nursing directors and administrative staff at Rafidia Hospital (Nablus), Palestine Medical Complex (Ramallah), and Alia Hospital (Hebron) for facilitating access. We thank the Palestinian Ministry of Health Research Ethics Committee for their oversight, and Nablus University for Vocational and Technical Education and the Dean of Applied Scientific Research for their cooperation and financial support. We are grateful to our external IPA methodology consultant and peer debriefers for strengthening the rigor of this work. Finally, we acknowledge all Palestinian nurses who continue to provide compassionate care under occupation and constraint; this research is dedicated to honoring your resilience while advocating for the systematic support you deserve.
Ethical Considerations
This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Institutional Review Board (IRB) of Ibn Sina College for Health Professions, Nablus University for Vocational and Technical Education (Reference #: Nrs. May 2024/8) on May 05, 2024.
Consent to Participate
Written informed consent was obtained from all individual participants included in the study prior to any study procedures. Participants were informed of their right to withdraw at any time without affecting their employment or professional standing.
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.
Data Availability Statement
The qualitative data generated and analyzed during this study are not publicly available due to the sensitive nature of the transcripts and to protect participant confidentiality. De-identified data may be made available from the corresponding author, Ibrahim Aqtam, upon reasonable request and with permission from the Nablus University for Vocational and Technical Education Institutional Review Board.
Supplemental Material
Supplemental material for this article is available online.
References
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