Educating Behind Barriers: A Qualitative Study of Nursing Education Adaptations to Geographic and Systemic Constraints in the West Bank

Abstract

Aim

To explore the lived experiences of nursing educators and students in the West Bank regarding the impact of geographic fragmentation and movement restrictions on nursing education.

Design

A qualitative descriptive study.

Methods

In-depth semi-structured interviews with 15 nursing faculty and three focus group discussions with 18 final-year students from three universities. Thematic Analysis was used, with credibility ensured through prolonged engagement, member checking, and peer debriefing.

Results

Three superordinate themes emerged: (1) The Checkpoint as a Pedagogical Disruptor, where movement restrictions create chronic unpredictability and fragment clinical learning; (2) Pedagogical Sumud, highlighting strategic improvisation using simulation, community-based training, and technology; and (3) The Systemic Bind, describing tension between institutional support and political/resource constraints.

Conclusion

Findings conceptualize a “crisis-responsive pedagogy” sustained through local ingenuity. Recommendations include: (1) developing standardized protocols for crisis-responsive pedagogy in accreditation standards; (2) allocating dedicated funding for simulation infrastructure in conflict-affected regions; and (3) establishing formal psychological support for educators and students under protracted adversity.

Keywords

qualitative research thematic analysis lived experience structural violence resilience pedagogy global health education nursing education Palestine west bank

Introduction

The Global Imperative for Resilient Nursing Education

Nursing education serves as the cornerstone of health system resilience and the achievement of Sustainable Development Goal 3 (World Health Organization ([WHO], 2020). The quality and adaptability of educational programs directly shape nursing workforce competence and population health outcomes, particularly in crisis-affected settings (Frenk et al., 2010). Globally, nursing education faces challenges including inadequate clinical placements, insufficient faculty, and the need to integrate technology effectively (Brownie et al., 2018). These challenges are dramatically intensified in contexts characterized by political instability, conflict, and systematic barriers to mobility (Ager et al., 2012), where structural violence, the harm inflicted by political and economic structures, shapes every aspect of daily life (Farmer, 2004). Understanding how nursing education systems adapt within such contexts is therefore not only of local relevance but carries implications for global health workforce development.

Review of Literature

The predominant body of research on nursing education originates from stable, high-income contexts (Khamis et al., 2020), leaving a significant gap in understanding how institutions function under protracted conflict, geographic fragmentation, and chronic resource scarcity (Rahim et al., 2016). Existing literature on health professions education in conflict settings has largely documented deficits rather than illuminating conceptual frameworks for adaptive innovation (Dveirin & Adams, 2021). This study responds to calls for contextually-grounded qualitative research (Bleakley et al., 2022) by offering a theoretically-grounded analysis of adaptation processes in the West Bank, generating insights applicable to other fragile settings.

The Distinct Context of Nursing Education in the West Bank

Since 1967, the Palestinian territories have existed under Israeli military occupation, creating an educational landscape characterized by movement restrictions, checkpoint systems, the separation barrier, and administrative fragmentation into Areas A, B, and C (B’Tselem, 2022). Nursing programs operate within this “no war, no peace” reality, a protracted normalized crisis (Hammami, 2015), where students and faculty must routinely navigate checkpoints to reach campuses and clinical sites, facing unpredictable delays, closures, and permit denials (PCBS, 2023). This study was conducted across three geographically and politically distinct public universities representing the Northern, Central, and Southern West Bank, each facing distinct but overlapping movement and access constraints.

Aim and Research Questions

This study employed a qualitative descriptive approach to explore the experiences of nursing educators and students across three West Bank universities, focusing on both the profound challenges and the innovative adaptations enabling educational continuity. Research questions addressed: (1) How do movement restrictions impact nursing education delivery? (2) What pedagogical adaptations have educators and students developed? and (3) What institutional and systemic factors support or hinder sustainability?

Methodology

Research Design and Study Period

A qualitative descriptive design was employed for its suitability in obtaining rich, straight descriptions of a phenomenon from participants’ perspectives (Kim et al., 2017; Sandelowski, 2000). This approach prioritizes participant-led description using their own language and framing, offers practical utility by generating findings directly applicable to practice and policy, and provides contextual sensitivity for an in-depth exploration of how the specific political and educational environment of the West Bank shapes experiences and adaptations. Unlike phenomenological approaches seeking the essence of lived experience or grounded theory aiming to generate new theory, qualitative description presents a clear, organized account of the facts of the case in participants’ language, essential for capturing the practical realities and adaptive strategies of nursing education under constraint (Kim et al., 2017). The entire research process spanned ten months (May 2024–February 2025), with active data collection occurring in July–August 2024.

Setting, Participants, and Sampling

The study was conducted at three major West Bank public universities offering accredited BSN programs, selected to represent the geographic and political diversity of the region: University A (Northern West Bank) regularly contends with checkpoint delays and restricted clinical access; University B (Central West Bank) benefits from proximity to governmental ministries but serves students with significant commute challenges; and University C (Southern West Bank) operates in one of the most politically tense urban environments, with complex checkpoint networks creating daily challenges for access and clinical training.

A purposive sampling strategy with maximum variation (Palinkas et al., 2015) recruited 33 participants: 15 nursing faculty (five per university) and 18 final-year BSN students (six per university). Faculty inclusion required ≥2 years of full-time teaching experience, active undergraduate BSN roles, and willingness to discuss educational challenges. Student inclusion required final-year enrollment and ≥3 completed clinical rotations. Data saturation—the point at which no substantial new themes emerged, was achieved after the 13th faculty interview and 15th student participant; remaining sessions confirmed saturation (Malterud et al., 2016).

Data Collection

Semi-structured interview guides (faculty) and focus group discussion (FGD) guides (students) were developed through comprehensive literature review, expert consultation, and piloting with two faculty members not included in the sample. Core questions addressed: typical weekly schedules and access challenges; specific checkpoint impacts; adaptive strategies; technology’s role; institutional support; and how the context shaped professional identity. Faculty interviews (n=15) lasted 75–120 minutes (mean: 90 min), conducted face-to-face in Arabic by the lead researcher. Three FGDs (six students each, deliberately mixed across universities to reduce institutional power dynamics) lasted 90–120 minutes each. All sessions were audio-recorded with consent; field notes documented contextual observations and preliminary analytical thoughts. MAXQDA software supported data management.

Data Analysis

Analysis followed Braun and Clarke’s (2006) six-phase thematic analysis framework: (1) familiarization through repeated reading and listening to Arabic transcripts; (2) systematic line-by-line coding by two independent researchers reconciling discrepancies after initial transcripts; (3) searching for patterns across codes into candidate themes; (4) two-level review of coded extracts and the full dataset; (5) defining and naming themes capturing their core conceptual contribution; and (6) producing the final narrative with representative data extracts. Analysis engaged both semantic and latent interpretive levels, moving beyond descriptive restatement to distinguish empirical findings from conceptual innovations.

Reflexivity, Rigor, and Ethics

All three researchers are Palestinian academics with extensive West Bank nursing education experience. This insider positionality facilitated rapport and contextual understanding, while risks of over-identification were managed through: reflective journals documenting assumptions and emotional reactions; peer debriefing with an external qualitative methodologist who challenged interpretations; member checking with six participants; and deliberate seeking of disconfirming evidence. The researchers were particularly vigilant about avoiding the tendency to frame all challenges through the lens of political constraint, acknowledging that institutional management decisions, pedagogical choices, and resource limitations common to middle-income country higher education also shape the educational landscape.

Trustworthiness was established per Lincoln and Guba’s (1985) criteria: credibility (prolonged engagement, member checking, triangulation of faculty interviews, student FGDs, and field notes); transferability (thick description, maximum variation sampling); dependability (comprehensive audit trail of all research decisions); and confirmability (reflexivity documentation with clear data-to-finding linkages). Ethical approval was obtained from the Institutional Review Board of Ibn Sina College for Health Professions, Nablus University for Vocational and Technical Education (Reference #: Nrs. May 2024/9). All participants provided written informed consent, with confidentiality ensured through numerical identifiers (e.g., Faculty 1, Student FGD1-1), encrypted data storage, and destruction of audio recordings following verbatim transcription.

Results

Participant Demographics

A total of 33 participants took part: 15 nursing faculty and 18 final-year BSN students. Table 1 summarizes faculty demographics (mean age 42.3 ± 8.6 years; 73.3% female; 73.3% Master’s-educated; mean teaching experience 14.8 ± 7.3 years). Table 2 summarizes student demographics (mean age 22.1 ± 0.8 years; 77.8% female; mean clinical rotations 6.4 ± 1.2). Participants were evenly distributed across the three university sites.

Table 1.

Faculty Participant Characteristics (N=15)

Characteristic	n (%) or Mean ± SD
Age (years)	42.3 ± 8.6
25–39 years	7 (46.7)
40–49 years	5 (33.3)
50+ years	3 (20.0)
Gender
Female	11 (73.3)
Male	4 (26.7)
Years of Teaching Experience	14.8 ± 7.3
2–5 years	3 (20.0)
6–15 years	7 (46.7)
>15 years	5 (33.3)
Highest Degree
Master’s	11 (73.3)
PhD	4 (26.7)
University Location
Northern West Bank	5 (33.3)
Central West Bank	5 (33.3)
Southern West Bank	5 (33.3)

Table 2.

Student Participant Characteristics (N=18)

Characteristic	n (%) or Mean ± SD
Age (years)	22.1 ± 0.8
Gender
Female	14 (77.8)
Male	4 (22.2)
University of Enrollment
Northern West Bank	6 (33.3)
Central West Bank	6 (33.3)
Southern West Bank	6 (33.3)
Clinical Rotations Completed	6.4 ± 1.2

Thematic Analysis Results

Three superordinate themes were identified through iterative analysis moving from semantic description to latent interpretation. These themes were consistent across all three university sites and among both faculty and students, though with variations in emphasis and specific manifestations based on geographic location and role. Each theme encompasses multiple sub-themes providing deeper insight into the complexity of pedagogical adaptation under systemic constraint. Importantly, these themes represent a synthesis of empirical description (what participants reported) and conceptual innovation (how their experiences extend existing theoretical frameworks) (Table 3).

Table 3.

Superordinate Themes and Subthemes

Superordinate theme	Subthemes
1. THE CHECKPOINT AS A PEDAGOGICAL DISRUPTOR Movement restrictions as a fundamental, daily disrupter to planned education	1.1 The Fragmentation of Time and Learning 1.2 The Fractured Clinical Experience 1.3 The Psychological Tax of Chronic Unpredictability
2. PEDAGOGICAL SUMUD: IMPROVISATION AND RESOURCEFULNESS AS INSTITUTIONAL PRACTICE Strategic adaptation and innovation to ensure educational continuity	2.1 ′Making Do’ and the Ethic of Resourcefulness 2.2 Simulation as a Necessity, Not a Luxury 2.3 Digital Bridges and New Divides
3. THE SYSTEMIC BIND: NAVIGATING SCARCITY AND CULTIVATING POLITICAL COMPETENCE The tension between institutional support and overwhelming political/resource constraints	3.1 Chronic Scarcity and the Moral Burden of ‘Rationing’ Education 3.2 Weaving Political Competence into the Curriculum 3.3 The Structural Void in Educator and Student Support

Theme 1: “The Checkpoint as a Pedagogical Disruptor”

This theme describes how participants made sense of movement restrictions as a fundamental daily disruptor to the planned, progressive, and predictable structure that traditionally characterizes nursing education. All participants described experiences fitting within this theme, emphasizing that the checkpoint was not merely a logistical hurdle but a core pedagogical factor that required constant recalibration of teaching and learning. This conceptualization reframes a geopolitical structure as an active, non-human agent that directly shapes educational processes and outcomes. While Sub-theme 1.1 addresses the fragmentation of time and learning, Sub-themes 1.2 and 1.3 explore the resulting fractured clinical experiences and the psychological toll of navigating this unpredictable environment.

Sub-Theme 1.1: The Fragmentation of Time and Learning

Participants across all three universities described the systematic erosion of educational time, where checkpoint delays and closures transformed schedules from reliable plans into aspirational frameworks, normalizing chronic lateness and compressed learning. Faculty described the profound pedagogical burden of accommodating this temporal fragmentation—not as an occasional disruption, but as the structuring condition of their daily educational practice.

“I schedule a clinical placement to begin at 7:00 AM... By 9:00, most are there, but sometimes a student arrives at 10:00... We've lost two or three hours of an eight-hour clinical day. What do you do? You can't penalize students for checkpoints. The educational value of that day is fundamentally compromised.”

(Faculty 3, Medical-Surgical Nursing Instructor, Northern WB)

Students described the psychological exhaustion of commuting uncertainty, which began long before any clinical activity:

“You leave home two hours before you need to be at the hospital, but you never know if that will be enough. The constant calculation, the anxiety of watching the clock while you're stuck in a line of cars, it's mentally exhausting before your clinical day even begins. You arrive already drained.”(Student FGD2-4, Female, Central WB)

“I've had to completely restructure how I teach. I record all my lectures and post them online, I build redundancy into every schedule, I have 'Plan B′ and 'Plan C′ for every class session. This isn't innovative teaching; it's crisis management.”(Faculty 11, Psychiatric-Mental Health Instructor, Central WB)

Sub-Theme 1.2: The Fractured Clinical Experience

Participants articulated how the inability to reliably access clinical sites, particularly specialized hospitals in other governorates, resulted in a clinical education that was patchwork and inconsistent. Students’ learning opportunities became dictated by political geography and permit availability rather than pedagogical sequencing. Faculty described being forced into ethically difficult decisions about clinical placement equity.

“Ideally, nursing students should have exposure to a range of clinical settings... But when a specialized hospital is in a different governorate... and some of your students can't reliably get there, you have to make difficult choices. Do you send only some students? Do you skip it entirely? This creates inequality and gaps in training.”(Faculty 1, Medical-Surgical Nursing Instructor, Northern WB)

“Some students in our cohort have Jerusalem IDs, so they can access hospitals in Jerusalem that the rest of us can't. They get experiences in advanced trauma centers, specialized cardiac units... It creates inequality among students in the same program based purely on your ID and permit status.”(Student FGD1-6, Southern WB)

“When I studied nursing education, we learned about creating equal learning opportunities. Here, that's impossible. The playing field is not level, not because of intelligence or effort, but because of a political system that determines who can go where.”(Faculty 5, Community Health Nursing Instructor, Central WB)

Sub-Theme 1.3: The Psychological Tax of Chronic Unpredictability

Beyond the logistical impact, participants described the significant psychological burden of operating in a state of constant uncertainty. This “psychological tax” affected concentration, morale, and the overall learning environment. This finding extends existing literature on stress in nursing education (Pulido-Martos et al., 2012) by situating it within a context of politically-induced, chronic instability rather than acute, performance-related stressors. Crucially, this burden affected not only students but faculty, who were expected to model professionalism while subject to the same unpredictable barriers.

“The stress isn't just the checkpoint itself, it's the uncertainty. You're constantly on edge, waiting for the next closure, the next incident that will disrupt everything. It creates a background level of anxiety that permeates the entire educational experience.”(Student FGD3-2, Northern WB)

“As educators, we're supposed to model professionalism and punctuality, but we're subject to the same unpredictable barriers as our students. We arrive late, flustered, and stressed. It undermines the professional environment we're trying to create.”(Faculty 14, Maternal-Child Health Instructor, Southern WB)

Theme 2: “Pedagogical Sumud: Improvisation and Resourcefulness as Institutional Practice”

In response to the disruptions described in Theme 1, participants described a culture of persistent innovation and adaptation. This theme captures how educators and students have developed a form of “Pedagogical Sumud”, where Sumud is an Arabic term deeply rooted in Palestinian cultural and political identity, denoting steadfastness, perseverance, and resilient existence in the face of adversity. The researchers employ this concept as an analytical lens to describe not passive endurance, but active, collective, and innovative persistence in maintaining educational continuity. This concept extends conventional understandings of resilience in education, which often emphasize individual psychological traits or passive coping—by describing resilience as collective, active, innovative, and deeply embedded within institutional practice. Sub-themes 2.2 and 2.3 explore specific innovations in simulation and technology.

Sub-Theme 2.1: ‘Making Do’ and the Ethic of Resourcefulness

A pervasive sub-theme was the shared value placed on “making do”, a collective ethos of solving problems with whatever resources are at hand. This was framed not as a deficit but as a core competency developed within this context, representing a shift from deficit-based framing to an asset-based understanding of educational practice under constraint. This ethos was evident across all three universities and among both faculty and students.

“We don't have the high-fidelity simulators they have in American universities. So we create our own. We use moulage kits to create realistic wounds, we use old equipment and repair it ourselves, we write our own case studies based on the patients we actually see here. We are experts at ‘making do.’”(Faculty 8, Emergency Nursing Instructor, Southern WB)

Students noted how this ethos translated into meaningful professional learning, reframing resource scarcity as a pedagogical advantage:

“My instructors are incredibly creative. When we couldn't practice IV insertion on enough manikins, they set up stations using oranges and fake veins. You learn that nursing isn’t about having the best equipment; it’s about understanding the principle and adapting.”(Student FGD2-2, Central WB)

Sub-Theme 2.2: Simulation as a Necessity, Not a Luxury

Simulation has been elevated from a supplementary educational tool to a cornerstone of the curriculum, directly compensating for inaccessible clinical placements. Participants described developing sophisticated, context-specific scenarios that prepare students for the realities of Palestinian healthcare. This represents a form of “pedagogical transfer” (Tikly, 2004), where an international best practice is not merely adopted but radically adapted to meet local realities, and in doing so, transformed into a form of curricular decolonization that centers local knowledge and experience.

“We’ve invested significantly in our simulation lab out of necessity. We deliberately incorporate context-specific scenarios, we simulate a patient arriving at the emergency department having been delayed at a checkpoint, they've been injured for several hours, they’re medically unstable, the family is traumatized and angry.”(Faculty 8, Emergency Nursing Instructor, Southern WB)

“The trauma scenarios we practice in simulation are realistic for our context. We simulate a young person with a gunshot wound, an elderly person who fell during tear gas exposure... These are real situations nurses face here. Practicing them in simulation prepares us better than generic scenarios from international textbooks.”(Student FGD1-5, Northern WB)

Sub-Theme 2.3: Digital Bridges and New Divides

Technology was universally described as a critical, yet imperfect, lifeline. While digital platforms enabled continuity across geographic divides, they also created new layers of inequality and highlighted the irreplaceable nature of hands-on learning. This finding highlights a critical tension in digital education for resource-limited settings: technology can partially mitigate geographic fragmentation but may simultaneously exacerbate existing socioeconomic inequalities (Selwyn, 2011).

“The ability to access lectures online has been so important. When I couldn't get to campus for a week because the checkpoint near my village was closed... I didn’t fall completely behind. Without technology, I would have just lost that entire week.” (Student FGD2-3, Northern WB)

“Not all students have reliable internet access at home. Some live in villages with poor connectivity, some can’t afford data plans... So while online resources theoretically provide equity of access, in practice they can reinforce existing inequalities.” (Faculty 2, Medical-Surgical Nursing Instructor, Central WB)

Participants were also acutely aware of technology’s fundamental limitations for a practice-based profession:

“You cannot learn to insert a catheter, start an IV, do wound care, or assess breath sounds through a screen. Nursing is a hands-on profession... This became painfully obvious during COVID when everything moved online.” (Faculty 12, Psychiatric-Mental Health Instructor, Northern WB)

Theme 3: “The Systemic Bind: Navigating Scarcity and Cultivating Political Competence”

This superordinate theme describes the broader context in which adaptations described in Theme 2 occur: a tense negotiation between institutional support and overwhelming systemic constraints. Participants made sense of their work as existing within a “bind,” where their remarkable ingenuity was simultaneously necessitated and limited by political and economic structures. This theme captures the limits of resilience: while local innovation is impressive, it operates within structural constraints that individual effort alone cannot overcome. While Sub-theme 3.1 addresses the moral burden of chronic scarcity, Sub-theme 3.2 explores the deliberate integration of political awareness into the curriculum, and Sub-theme 3.3 reveals the critical gap in structural support for educators and students.

Sub-Theme 3.1: Chronic Scarcity and the Moral Burden of ‘Rationing’ Education

Participants described working within a system of chronic financial and resource constraints that forced them into a perpetual state of rationing, not just medical supplies, but educational opportunities themselves. This rationing produced a distinctive moral burden: educators were acutely aware of the gap between what they were providing and what was ideally required for professional preparation.

“Our simulation lab equipment is outdated and frequently breaks down. We have manikins that don’t respond properly, monitors that malfunction. You do your best with what you have, but you know that in a properly resourced program, students would be better prepared. That knowledge sits with you as a moral burden.” (Faculty 13, ICU Nurse Instructor, Central WB)

Faculty also described the structural dimensions of this scarcity, pointing beyond equipment to systemic underfunding:

“The Ministry tries, but the budget is limited... Salaries are sometimes delayed, supplies are minimal. You feel like you’re constantly working with one hand tied behind your back... we’re working against structural impossibilities.” (Faculty 8, Emergency Nursing Instructor, Southern WB)

Sub-Theme 3.2: Weaving Political Competence Into the Curriculum

In this context, the political situation is not an external factor but a central component of professional practice. Educators deliberately integrated content on social determinants of health, the health impacts of occupation, and advocacy, not as political indoctrination but as professional necessity. This finding challenges notions of apolitical nursing education and aligns with calls for “structural competence” in health professions education (Metzl & Hansen, 2014), demonstrating how such competence emerges from immediate necessity in politically constrained contexts.

“I’m not teaching politics for its own sake; I’m teaching what nurses need to understand to address the actual health challenges their patients face. You can’t separate health from context here.” (Faculty 5, Community Health Nursing Instructor, Central WB)

Students similarly articulated the professional necessity of this integration:

“Some people might say we should just learn ‘pure’ nursing without politics. But that's impossible here, and honestly it would be inadequate preparation... Understanding those realities makes me a better, more effective nurse, not a politicized one. It's about understanding causation and context.” (Student FGD1-1, Central WB)

Sub-Theme 3.3: The Structural Void in Educator and Student Support

Despite the profound challenges described across all themes, participants identified a critical gap in formal, institutional-level support for their psychological well-being and professional development. The reliance on informal peer support was valued but recognized as insufficient and a significant risk factor for burnout and compassion fatigue.

“We support each other, but we’re all carrying the same burdens. Sometimes I worry that we’re just pooling our trauma rather than actually processing it... we need something more structured, something that helps us truly heal rather than just survive.” (Faculty 13, ICU Nurse Instructor, Southern WB)

“There is no debriefing after a difficult day, no counseling service for students who are stressed about checkpoints and exams and the political situation. The institution expects us to be resilient, but does little to build that resilience systematically.” (Student FGD3-6, Northern WB)

Discussion

This qualitative study uncovered not only the challenges facing nursing education in the West Bank, but the core conceptual categories through which educators and students navigate their politically constrained reality. The findings reveal a landscape where profound systemic constraint has catalyzed a distinctive, resilient, context-aware pedagogy. In the discussion below, we focus on theoretical advancement and broader implications for international nursing education policy, making two primary conceptual contributions that extend beyond empirical description.

Conceptual Contributions: The Checkpoint as a Pedagogical Actor and Pedagogical Sumud

The concept of “the checkpoint as a pedagogical disruptor” extends structural violence frameworks (Farmer, 2004; Quesada et al., 2011) by specifying a mechanism: the checkpoint operates as an active non-human agent directly shaping pedagogical processes and outcomes—determining who can learn what, when, and where. Unlike conventional understandings of educational barriers as contextual background factors, our analysis positions the checkpoint as a co-constructor of the educational experience, fundamentally altering curriculum delivery, clinical exposure, and professional identity formation. This lens offers analytical utility for education in other securitized, militarized, or politically fragmented contexts globally, from refugee education in camp settings to Indigenous education under settler-colonial regimes and regions affected by climate-induced displacement where mobility is increasingly constrained (Cowen, 2009).

“Pedagogical Sumud”extends conventional resilience frameworks (Rushton et al., 2016) in three key ways: (1) it emphasizes collective agency rather than individual adaptation; (2) it foregrounds cultural and political identity as a resource for persistence; and (3) it positions innovation as a form of resistance rather than mere problem-solving. Crucially, we distinguish Pedagogical Sumud from romanticized resilience by also documenting its limits, the moral burden, psychological tax, and structural constraints that individual and collective ingenuity cannot overcome without systemic support. This provides a new model for understanding and supporting health professions education in fragile and conflict-affected settings that honors local agency while acknowledging structural conditions necessitating such adaptation.

Pedagogical Sumud: From Coping to Innovation

The findings around Theme 2 demonstrate a shift from mere coping to active, sophisticated innovation. The strategic pivot to community-based learning, while born of necessity, demonstrates how constraints can force a beneficial reconnection with community health needs, producing graduates with strong skills in resourcefulness, primary care, and social determinants of health, competencies increasingly relevant worldwide (Frenk et al., 2010; Lea & Cruickshank, 2015). The advanced use of context-specific simulation represents a form of “pedagogical transfer” (Tikly, 2004) where an international best practice is not merely adopted but radically adapted to local realities, contrasting with the often-criticized trend of importing educational models from the Global North without sufficient adaptation (Shields & Watson, 2007). The development of simulation scenarios reflecting local trauma patterns and healthcare access barriers represents curricular decolonization, centering local knowledge and experience.

The dual role of technology as both a “bridge” and a source of “new divides” highlights a critical tension in digital education for resource-limited settings. While technology provides a partial solution to geographic fragmentation, it can exacerbate existing socioeconomic inequalities (Selwyn, 2011). This calls for a more nuanced approach to technology integration, one that includes infrastructure support and digital literacy training to ensure equitable access. For international partners and donors, technology investments must be accompanied by attention to connectivity infrastructure and device access to avoid reinforcing existing disparities.

The Systemic Bind: The Limits of Resilience

The “Systemic Bind” (Theme 3) is a critical analytical contribution: it prevents romanticization of resilience by documenting how local ingenuity operates within structural limits that individual or collective effort alone cannot transcend. The chronic underfunding of the Palestinian higher education sector and the political immobility of the occupation create a structural ceiling for what institutional adaptation can achieve. This finding is essential because it ensures that the study’s documentation of impressive local innovation does not inadvertently provide justification for the continued absence of adequate external support.

The “structural void” in formal psychological support is particularly concerning. Qualitative research in other politically constrained health systems has similarly documented how practitioners must develop contextual literacy, a sophisticated understanding of how macro-level political forces shape micro-level clinical realities (Jaffré & Olivier de Sardan, 2003). However, developing such literacy under conditions of chronic adversity without formal institutional support creates unsustainable cognitive and emotional burdens. The risk of burnout, attrition, and compassion fatigue (Rushton et al., 2016) ultimately threatens the very educational continuity these educators work so hard to maintain. The explicit integration of political awareness into the curriculum, while pedagogically necessary and professionally sound—challenges the notion of apolitical nursing education and reflects a pragmatic understanding that effective care in Palestine requires understanding the political structures shaping patients’ health, aligning with calls for structural competence (Metzl & Hansen, 2014) arising from immediate necessity rather than theoretical commitment.

Strengths and Limitations

Strengths include the multi-site qualitative design capturing geographic and political diversity, maximum variation sampling, triangulation of faculty interviews and student FGDs, Arabic-language data collection ensuring authentic participant expression, and a sustained reflexivity framework. Limitations include sampling confined to public universities (excluding private institutions and community-based programs), the specific ten-month study period within a volatile and dynamic context, potential social desirability bias, and the insider positionality that—while providing contextual depth—may produce analytical blind spots. The researchers also acknowledge that institutional management decisions, pedagogical choices, and resource limitations common to nursing education in middle-income countries intersect with political constraints to shape the educational reality. Transferability to other conflict-affected contexts must be considered cautiously given the West Bank’s geopolitical specificities, though the conceptual frameworks, particularly “the checkpoint as a pedagogical disruptor” and “Pedagogical Sumud”; offer analytical tools applicable to other settings characterized by protracted crisis, mobility restrictions, or structural violence.

Implications for Practice, Policy, and Future Research

Implications for Nursing Education Practice

The effectiveness of context-specific simulation-based learning suggests that nursing programs in conflict-affected contexts should invest in simulation that authentically reflects local healthcare realities. The strategic use of community-based clinical training, while necessitated by the context, holds promise as a pedagogical approach equipping graduates with primary care competencies, resourcefulness, and social determinants of health knowledge relevant in any healthcare context globally. The peer support networks identified by participants, while informal and inadequately supported, point to the value of formalizing communities of practice among nursing educators and students who share the experience of operating under adversity.

Implications for Policy and Institutional Support

At the level of institutions and policy, the study emphasizes the pressing need for formal acknowledgment and support of crisis-responsive pedagogies. University administrations and ministry officials must: (1) formulate institutional policies to formally accommodate the unpredictability of movement restrictions, for instance, by designing flexible attendance policies, creating contingency planning frameworks, and recognizing simulation-based learning as equivalent to clinical hours when hospital access is limited; (2) secure dedicated budgets for simulation equipment as essential educational infrastructure rather than supplementary equipment; (3) establish psychological support services, counseling, ethical debriefing, and trauma-informed pedagogical training, for faculty navigating the compounding stressors of occupation, institutional resource scarcity, and the moral burden of providing constrained education; and (4) develop mechanisms to document and disseminate effective adaptive pedagogies, converting individual innovation into collective institutional knowledge that can be evaluated, refined, and scaled.

For international accrediting bodies and nursing education regulatory agencies, the findings argue for developing accreditation standards relevant to crisis contexts. The researchers recommend that accrediting agencies: develop guidelines for assessing educational quality in protracted crisis; formally recognize adaptive strategies (simulation emphasis, community-based clinical education, curriculum sequencing adaptations) as indicators of educational quality rather than deviations; and include structural competence, understanding how political and social structures shape health outcomes, as a core nursing curriculum competency globally. Current accreditation frameworks, largely developed in stable, resource-rich contexts, may inadvertently penalize institutions operating with exceptional skill within systems beyond their control.

Implications for Future Research

Several avenues for further research emerge: (1) longitudinal studies investigating the progression of adaptive mechanisms over time and their long-term effects on graduate competence; (2) comparative research across settings, refugee environments, active conflict zones, and climate displacement contexts, to test the generalizability of the conceptual frameworks; (3) interventionist research investigating the efficacy of formal psychological support interventions for nursing educators and students in protracted crisis settings; (4) quantitative research examining relationships between educational disruption and graduate competence outcomes; and (5) participatory action research not only investigating research questions but building adaptive capacity within these settings.

Conclusion

This study demonstrates that nursing education in the West Bank is characterized by a profound duality: it is a system under severe constraint, yet also a site of remarkable innovation and resilience. Educators and students navigate a landscape shaped by checkpoints and scarcity, yet they have developed a sophisticated, context-aware pedagogy that ensures the continued production of a nursing workforce capable of serving their communities under extraordinary circumstances. By distinguishing empirical description from conceptual innovation, we have shown how the concepts of “the checkpoint as a pedagogical disruptor” and “Pedagogical Sumud” extend existing theoretical frameworks while remaining grounded in participants’ lived experiences.

The “crisis-responsive pedagogy” that has emerged, centered on simulation, community-based learning, and digital adaptation, represents a valuable blueprint for nursing education in other constrained environments globally. As the world faces increasing crises, from climate change to political instability to pandemics, the capacity for crisis-responsive pedagogy will become increasingly relevant across diverse contexts. However, this resilience must not be romanticized or used to justify inadequate support. The reliance on individual and peer-level ingenuity is unsustainable without corresponding institutional and systemic investment. We have deliberately highlighted the limits of resilience, the moral burden, psychological tax, and structural constraints, to ensure that the study’s findings do not inadvertently excuse the absence of formal support systems.

Three concrete, actionable recommendations emerge for nursing education leaders and accrediting bodies: (1) Develop and integrate crisis-responsive pedagogy standards into international nursing accreditation frameworks, explicitly recognizing adaptive strategies such as context-specific simulation and community-based clinical training as quality educational practices; (2) Allocate dedicated funding streams for simulation infrastructure, faculty development, and educational innovation in conflict-affected and resource-limited settings, recognizing these as essential investments in global health workforce capacity; and (3) Establish formal psychological support mechanisms (including counseling services, ethical debriefing spaces, and peer support programs) for nursing educators and students operating under protracted adversity, acknowledging that psychological sustainability is foundational to educational continuity.

The path forward requires a concerted effort from Palestinian educational authorities (supported by the international community) to formally recognize, resource, and strengthen these adaptive strategies. By doing so, they can ensure that the steadfast commitment (the sumud) of Palestinian nursing educators and students is met with the institutional support necessary to sustain it, thereby safeguarding the future of nursing and healthcare in Palestine.

Supplemental Material

Supplemental Material - Educating Behind Barriers: A Qualitative Study of Nursing Education Adaptations to Geographic and Systemic Constraints in the West Bank

Supplemental Material for Educating Behind Barriers: A Qualitative Study of Nursing Education Adaptations to Geographic and Systemic Constraints in the West Bank by Ibrahim Aqtam, Mustafa Shouli in Sage Open Nursing.

Supplemental Material

Supplemental Material - Educating Behind Barriers: A Qualitative Study of Nursing Education Adaptations to Geographic and Systemic Constraints in the West Bank

Supplemental Material

Supplemental Material - Educating Behind Barriers: A Qualitative Study of Nursing Education Adaptations to Geographic and Systemic Constraints in the West Bank

Footnotes

Acknowledgments

The authors extend their sincere gratitude to the nursing faculty and students who generously shared their experiences for this study. We also thank the deans and administrative staff at the participating universities for facilitating this research. We are grateful to Nablus University for Vocational and Technical Education for its funding support and to the Institutional Review Board of Ibn Sina College for Health Professions for its ethical oversight. Finally, we acknowledge the external qualitative consultant for their valuable feedback. This work is dedicated to the pedagogical sumud (steadfastness) of all Palestinian educators and students

ORCID iDs

Ibrahim Aqtam

Mustafa Shouli

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 2024/9) 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.

Author Contributions

I.A.: Conceptualization, Methodology, Investigation, Formal Analysis, Writing – Original Draft, Project Administration. M.S.: Conceptualization, Methodology, Investigation, Formal Analysis, Writing – Review & Editing. All authors reviewed and approved the final manuscript.

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

Supplemental Material

Supplemental Material for this article is available online.

Appendix

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Supplementary Material

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