Psychological Stress and Psychological Well-Being Among Governmental Nurses in the Southern West Bank During the Gaza–Israel War: The Mediating Role of Coping Strategies

Abstract

Introduction

Nurses working in conflict-affected healthcare systems are exposed to persistent occupational and psychological stressors that may adversely influence their psychological well-being. Evidence examining the interplay between stress, coping strategies, and well-being among nurses in the Palestinian context during wartime remains limited.

Aim

This study aimed to examine the relationship between psychological stress and psychological well-being among governmental nurses in the southern West Bank during the Gaza–Israel war and to assess the mediating role of coping strategies.

Methods

A cross-sectional quantitative study was conducted among 337 governmental nurses recruited from five hospitals in the southern West Bank between August and November 2024. Data were collected using validated Arabic versions of the Perceived Stress Scale (PSS-10), the Ways of Coping Questionnaire, and the Psychological Well-Being Scale. Descriptive statistics, inferential tests, and regression analyses were performed using SPSS version 27. Mediation analysis was conducted using the PROCESS macro with 5,000 bootstrap samples. Statistical significance was set at p < .05.

Results

Participants reported moderate levels of psychological stress (M = 3.22, SD = 0.53) and moderate to high levels of psychological well-being (M = 3.53, SD = 0.60). Coping strategies were moderately utilized (M = 2.62, SD = 0.48). Psychological stress was significantly associated with lower psychological well-being (β = −0.454, p < .001), explaining 17.0% of the variance. Coping strategies demonstrated a modest association with well-being (R² = .041, p = .008), with thoughtful problem-solving showing a negative relationship. Mediation analysis indicated that coping strategies did not significantly mediate the stress–well-being relationship.

Conclusion

Psychological stress was significantly associated with reduced psychological well-being among nurses working in conflict conditions, while coping strategies demonstrated limited mediating effects. Strengthening institutional psychological support and context-appropriate coping interventions is essential to sustain nurses’ mental health in conflict-affected healthcare systems.

Keywords

coping strategies psychological stress psychological well-being nurses Gaza–Israel war occupational stress resilience West Bank

Introduction

Armed conflict constitutes one of the most profound and sustained stressors affecting healthcare systems and the professionals who sustain them. Nurses, who represent the largest segment of the healthcare workforce, are particularly vulnerable to psychological strain due to their continuous frontline exposure, ethical responsibility for patient survival, and limited control over violent and unstable working environments. Prolonged exposure to insecurity, mass casualties, and resource scarcity has been consistently associated with adverse psychological outcomes among nurses, including heightened stress, emotional exhaustion, moral distress, and deterioration in psychological well-being (Delgado et al., 2021; Elhadi et al., 2020). These consequences extend beyond individual suffering to compromise care quality, patient safety, and workforce retention, particularly in fragile health systems.

Within the occupied Palestinian territory, governmental nurses operate under uniquely protracted and cumulative stress conditions shaped by chronic political violence, recurrent military escalations, and systemic healthcare constraints. The Gaza–Israel war of 2023–2024 intensified these stressors, exposing nurses in the West Bank to increased patient influx, fear of spillover violence, moral injury from witnessing civilian trauma, and institutional limitations in psychological support. Empirical evidence from Palestine demonstrates that nurses frequently report moderate to severe psychological distress, burnout, alarm fatigue, and post-traumatic stress symptoms during periods of escalation (Ahmead et al., 2024; Alqaissi et al., 2025; Salameh et al., 2024). Despite this growing body of literature, most studies have examined stress or distress outcomes in isolation, with limited attention to protective mechanisms such as coping strategies and their role in sustaining psychological well-being during wartime.

The present investigation is grounded in the transactional model of stress and coping developed by Lazarus and Folkman (1984), which conceptualizes stress as a dynamic process arising from an individual’s appraisal of environmental demands relative to available coping resources. According to this model, psychological outcomes are not determined solely by exposure to stressors, but by how individuals cognitively and behaviorally respond to them. Coping strategies commonly classified as problem-focused or emotion-focused—mediate the relationship between stress and psychological adaptation by either modifying the stressor or regulating emotional responses (Folkman et al., 1986). This framework is particularly salient in conflict settings, where many stressors are uncontrollable, unpredictable, and externally imposed, potentially altering the effectiveness of traditionally adaptive coping strategies.

Psychological well-being, as conceptualized by Ryff (1995), extends beyond the absence of distress to encompass positive functioning across domains such as autonomy, environmental mastery, purpose in life, personal growth, self-acceptance, and positive relationships. Among nurses, higher psychological well-being has been associated with greater professional commitment, resilience, and safer patient care, whereas chronic stress and maladaptive coping predict absenteeism, disengagement, and reduced care quality (Aksu, 2020; Wang et al., 2020). In conflict-affected health systems, maintaining nurses’ psychological well-being is therefore not only a mental health priority but a strategic requirement for system sustainability.

International studies conducted in conflict and crisis settings including Libya, Sudan, Ukraine, and refugee-hosting contexts demonstrate that coping strategies can partially buffer the negative effects of occupational stress on mental health outcomes (Elhadi et al., 2020; Jin et al., 2025; Kowalczuk et al., 2024). However, evidence also suggests that the effectiveness of coping strategies is context-dependent. In environments characterized by continuous threat and limited agency, problem-focused coping may lose its protective value or even exacerbate psychological strain when stressors cannot be resolved (Qtait, 2025; Zasiekina et al., 2025). Despite these insights, empirical research examining stress, coping, and psychological well-being simultaneously among nurses in active conflict zones—particularly within Palestine—remains scarce.

This gap is especially notable in the southern West Bank, where governmental hospitals serve as the primary providers of acute and emergency care during wartime. Understanding how nurses psychologically adapt under these extreme conditions is essential for informing evidence-based mental health interventions, workforce policies, and leadership strategies tailored to conflict-affected healthcare systems. By empirically testing the relationships between psychological stress, coping strategies, and psychological well-being, and examining the mediating role of coping within a theoretically grounded framework, the present study addresses a critical gap in both regional and international nursing literature.

Accordingly, this study aimed to investigate the impact of psychological stress on psychological well-being among governmental nurses in the southern West Bank during the Gaza–Israel war and to evaluate whether coping strategies mediate this relationship. Generating context-specific evidence in this domain is vital for guiding institutional support mechanisms, strengthening nurse resilience, and safeguarding the continuity and quality of care in protracted conflict settings.

Review of Literature

The relationship between psychological stress, coping mechanisms, and psychological well-being among nurses has been extensively explored in global and regional literature. Stress among nurses is widely recognized as a multidimensional construct encompassing physiological, emotional, and occupational factors that emerge when environmental demands surpass available resources (Folkman et al., 1986). In hospital environments, particularly during emergencies or war, nurses face intensified workloads, uncertainty, and ethical tension, all of which amplify stress responses (Sadhaan et al., 2022).

Empirical studies highlight that nurses experience stress from long shifts, high patient acuity, and exposure to human suffering (Iwanowicz-Palus et al., 2022). In Palestine, nurses are additionally burdened by resource scarcity, security threats, and systemic constraints (Marie et al., 2017). During the 2023–2024 Gaza–Israel conflict, nurses reported moderate to severe psychological distress manifested as anxiety, irritability, and sleep disturbance (Alqaissi et al., 2025). Similar findings were reported among Libyan nurses working amid the civil war, where psychological strain was associated with workload and fear of injury (Elhadi et al., 2020). Stress, if unmitigated, can culminate in burnout, emotional exhaustion, and reduced professional efficacy (Ahmead et al., 2024).

Coping represents the adaptive mechanisms individuals employ to manage stress and restore psychological balance. According to Lazarus and Folkman’s transactional model, coping operates through cognitive appraisal and behavioral adjustment processes. Problem-focused coping (e.g., problem-solving, time management) targets stressors directly, while emotion-focused coping (e.g., seeking emotional support, positive reappraisal) manages emotional responses (Folkman et al., 1986). In nursing populations, effective coping correlates with enhanced resilience and job satisfaction (da Silva Oliveira et al., 2022). Conversely, avoidance-based coping predicts higher burnout and poorer psychological outcomes (Nuetzel, 2023). Research in Poland during the Ukrainian refugee crisis demonstrated that nurses who adopted positive reframing and planning exhibited lower stress levels (Kowalczuk et al., 2024). Similarly, Segev et al. (2024) emphasized that peer-based mental health programs among Israeli nurses during wartime improved coping efficacy and reduced emotional exhaustion.

Psychological well-being, as defined by Ryff (1995), captures an individual’s sense of purpose, autonomy, and self-acceptance. Delgado et al. (2021) found that well-being among mental health nurses was significantly associated with workplace resilience and lower emotional distress. In the Palestinian context, Sawalma et al. (2024) observed that resilience mediated the relationship between stress and work engagement among critical care nurses, emphasizing that adaptive coping enhances psychological stability. Studies from EMRO countries further indicate that well-being interventions—such as mindfulness training and emotional regulation workshops—can mitigate stress in healthcare workers (Al-Yaqoubi & Arulappan, 2023).

The interconnection between stress, coping, and well-being forms the conceptual foundation of this study. High psychological stress diminishes well-being, yet adaptive coping can attenuate its adverse effects. Empirical models show that coping partially mediates this relationship, influencing how stress translates into psychological outcomes (Burt and Katz, 1988). However, this mediating effect varies across contexts and coping types. In war-affected regions, the scarcity of professional psychological services often compels nurses to rely on personal resilience and informal social support (Witter et al., 2017). The Palestinian experience remains underexplored despite the severe and recurrent exposure of nurses to occupational trauma. Therefore, examining the mechanisms through which coping strategies influence well-being under extreme stress conditions provides essential evidence for designing culturally appropriate psychological support systems in conflict settings.

Aim of the Study

This study aims to examine the impact of psychological stress on the psychological well-being of governmental nurses in the southern West Bank during the Gaza–Israel war and to assess the mediating role of coping strategies in this relationship. Guided by Lazarus and Folkman’s (1984) transactional model of stress and coping, the study seeks to identify the levels of stress, coping mechanisms, and well-being among nurses, providing evidence to inform policies that strengthen psychological resilience and mental health support in conflict settings.

Hypotheses

H1: Psychological stress was significantly associated with psychological well-being among governmental nurses working in the southern West Bank during the Gaza–Israel war.

H2: Coping strategies are significantly associated with psychological well-being among governmental nurses.

H3: Coping strategies mediated the relationship between psychological stress and psychological well-being among governmental nurses.

Methods

Study Design

A cross-sectional, quantitative correlational design was employed to examine the relationships between psychological stress (exposure), coping strategies (mediator), and psychological well-being (outcome) among governmental nurses working during the Gaza–Israel war. This design was considered appropriate for capturing psychological responses within an active conflict context where longitudinal follow-up was not feasible due to security constraints and workforce instability. The study followed STROBE recommendations for observational studies.

Study Setting

The study was conducted in five governmental hospitals located in the southern West Bank (Hebron and Bethlehem districts). These hospitals provide secondary and tertiary care services and include medical, surgical, intensive care, emergency, obstetrics, pediatric, and psychiatric departments. To protect institutional confidentiality in a politically sensitive context, hospital names and specific unit identifiers were anonymized, as permitted by the ethics committee and journal guidelines.

Participants and Sampling Procedure

A stratified convenience sampling approach was used to ensure representation across hospitals and major clinical departments. Stratification was performed at two levels: Hospital level (five governmental hospitals), and, department level (medical, surgical, ICU, emergency, obstetrics, pediatrics, and psychiatric units). Within each stratum, eligible nurses were approached in person during shift changes and rest periods. Recruitment was conducted by the principal investigator with the support of designated nurse coordinators who were not in supervisory roles to minimize coercion.

Inclusion Criteria: Participants included registered nurses employed full-time in governmental hospitals, aged 20–60 years, holding a diploma, bachelor’s, or master’s degree, and providing direct patient care during the study period. Exclusion Criteria: Nurses on extended leave (e.g., maternity or sick leave) and administrative nurses without clinical responsibilities were excluded. A total of 362 nurses were approached; 347 agreed to participate (response rate = 95.9%). After excluding incomplete questionnaires (n = 10), the final analytic sample consisted of 337 nurses.

Sample Size Calculation

Sample size was calculated using G*Power version 3.1 for multiple linear regression with mediation analysis. Assuming a medium effect size (f² = 0.15), alpha = .05, power = 0.80, and up to five predictors in the model, the minimum required sample was 300 participants. The final sample of 337 nurses exceeded this threshold, enhancing statistical power and model stability.

Data Collection Procedure

Data were collected between August and November 2024 using paper-based, self-administered questionnaires. Paper-based collection was selected due to limited internet access in some hospital units, frequent power interruptions, and concerns regarding electronic data security during wartime. Questionnaires were completed anonymously and placed in sealed envelopes to reduce social desirability bias.

The principal investigator distributed and collected questionnaires without remaining present during completion. Participants received a standardized verbal explanation of the study objectives, voluntary nature of participation, and confidentiality safeguards. Written informed consent was obtained from all participants prior to data collection. Completed questionnaires were stored in locked cabinets accessible only to the research team. Data were subsequently entered into password-protected electronic files, with double-entry verification to minimize transcription errors.

Study Variables

• Exposure variable: Psychological stress

• Mediator: Coping strategies

• Outcome variable: Psychological well-being

• Covariates: Age, gender, marital status, education level, years of experience, department, and income

Study Instruments

Data were collected using three standardized and psychometrically validated instruments administered in Arabic to measure psychological stress, coping strategies, and psychological well-being among governmental nurses. Prior to implementation, all instruments underwent linguistic verification to ensure clarity and cultural appropriateness for the Palestinian healthcare context.

Perceived Stress Scale (PSS-10)

Psychological stress was measured using the Perceived Stress Scale–10 (PSS-10) developed by Cohen et al. (1983). The PSS-10 is widely used to assess the degree to which individuals perceive situations in their lives as stressful during the previous month. The scale consists of 10 items rated on a 5-point Likert scale ranging from 0 (never) to 4 (very often). Total scores range from 0 to 40, with higher scores indicating greater perceived stress.

For interpretation, scores are typically categorized as low stress (0–13), moderate stress (14–26), and high stress (27–40). The Arabic version of the PSS-10 has demonstrated acceptable psychometric properties in previous studies conducted in Arab populations, including healthcare workers (Ali et al., 2021). In the present study, the internal consistency reliability was acceptable, with a Cronbach’s alpha of .78, indicating adequate reliability for measuring perceived stress among nurses.

Ways of Coping Questionnaire (WCQ)

Coping strategies were assessed using the Ways of Coping Questionnaire (WCQ) developed by Folkman and Lazarus (1985). This instrument evaluates the cognitive and behavioral strategies individuals use to manage stressful situations. The scale includes multiple items representing several coping domains, including distancing, self-control, seeking social support, and planful problem-solving. Items are rated on a 4-point Likert scale ranging from 1 (not used) to 4 (used a great deal). Higher scores indicate greater use of the respective coping strategy. Domain scores are calculated by averaging the items within each coping dimension. The WCQ has been widely used in healthcare research and has demonstrated satisfactory validity and reliability across different cultural settings. In the current study, the overall internal consistency of the coping scale was Cronbach’s α = .84, indicating good reliability.

Psychological Well-Being Scale (PWB-18)

Psychological well-being was measured using the 18-item Psychological Well-Being Scale (PWB-18) developed by Ryff (1995). This scale evaluates six core dimensions of positive psychological functioning: autonomy, environmental mastery, personal growth, positive relations with others, purpose in life, and self-acceptance. Each dimension is represented by three items.

Responses are rated on a 7-point Likert scale, ranging from 1 (strongly disagree) to 7 (strongly agree). Higher scores indicate higher levels of psychological well-being. The PWB-18 has been widely applied in psychological and nursing research and has demonstrated acceptable reliability across diverse populations. In the present study, the scale showed acceptable internal consistency with a Cronbach’s alpha of .73.

Validity and Reliability

Content validity of the instruments was established through expert review by three academic specialists in psychiatric and community health nursing, who evaluated the clarity, relevance, and cultural appropriateness of each item. The content validity index (CVI) for all instruments exceeded 0.85, indicating satisfactory content validity. Internal consistency reliability for each scale was assessed using Cronbach’s alpha coefficients, which demonstrated acceptable reliability across all instruments used in the study.

Bias and Mitigation Strategies

Potential sources of bias included self-reporting bias, non-random sampling, and survivorship bias. To mitigate these risks, anonymity was ensured to reduce social desirability bias, non-supervisory recruiters were used, participation was voluntary with no incentives, and data collection occurred across multiple shifts and departments.

Statistical Analysis

Data were analyzed using IBM SPSS Statistics version 27. Descriptive statistics, including means, standard deviations, frequencies, and percentages, were computed to summarize participants’ characteristics and study variables. Prior to inferential analyses, key statistical assumptions were assessed. Normality was evaluated using skewness and kurtosis values, multicollinearity was examined using variance inflation factors (VIF < 3), and homoscedasticity was verified to ensure the suitability of regression analyses. Bivariate relationships between study variables were examined using Pearson’s correlation coefficients. Multiple linear regression analysis was then conducted to assess the predictive relationships between independent variables and psychological well-being. Standardized beta (β) coefficients, 95% confidence intervals, and effect sizes (Cohen’s f²) were reported to evaluate the strength and significance of associations. To examine the mediating role of coping strategies, mediation analysis was performed using the PROCESS macro (Model 4) developed by Andrew F. Hayes (2017), with 5,000 bootstrap samples and bias-corrected 95% confidence intervals. Missing data (<3%) were handled using listwise deletion, as the proportion of missingness was minimal and assumed to be random. Statistical significance was set at p < .05.

Ethical Considerations

Ethical approval was obtained from the Institutional Review Board of University (Approval No. 411-50-2024) and from participating hospitals. Written informed consent was obtained from all participants. Data confidentiality, anonymity, and the right to withdraw at any time were strictly upheld in accordance with the Declaration of Helsinki and international research ethics standards.

Results

Participant Characteristics

A total of 337 governmental nurses from five hospitals in the southern West Bank completed the questionnaires and were included in the final analysis. Table 1 summarizes participants’ sociodemographic and professional characteristics. The majority were female (58.2%), married (87.2%), and aged 30–39 years (46.3%). Most participants held a bachelor’s degree (68.5%) and reported 10–15 years of nursing experience (30.0%).

Table 1.

Sociodemographic and Professional Characteristics of Participants (N = 337)

Variable	Category	n	%
Gender	Male	141	41.8
	Female	196	58.2
Age (years)	20–29	116	34.4
	30–39	156	46.3
	40–49	52	15.4
	50–60	13	3.9
Marital status	Single	39	11.6
	Married	294	87.2
	Divorced	4	1.2
Education level	Diploma	74	22.0
	Bachelor’s	231	68.5
	Master’s	32	9.5
Years of experience	1–5	66	19.6
	5–10	85	25.2
	10–15	101	30.0
	15–20	51	15.1
	>20	34	10.1

Psychological Stress Levels

Psychological stress measured by the PSS-10 showed an overall mean score of 3.22 (SD = 0.53), indicating a moderate level of perceived stress. A one-sample t-test demonstrated that this mean was significantly higher than the neutral midpoint of 3.0 (t = 7.63, p < .001, 95% CI [3.16, 3.28], Cohen’s d = 0.45). Item-level statistics are presented in Table 2. The highest-rated stress items reflected emotional reactivity and lack of control, while items related to perceived coping control were rated lower.

Table 2.

Descriptive Statistics for the Perceived Stress Scale (PSS-10)

Item	M	SD	t	p	95% CI	Interpretation
Upset by unexpected events	3.49	0.89	10.10	< .001	[3.36, 3.62]	High
Unable to control important things	3.23	0.93	4.54	< .001	[3.12, 3.34]	Moderate
Felt nervous or stressed	3.58	0.85	12.63	< .001	[3.47, 3.69]	High
Confident in handling problems	2.92	1.11	−1.33	.185	[2.74, 3.10]	Low
Felt things were going your way	3.26	1.04	4.50	< .001	[3.14, 3.38]	Moderate
Could not cope with tasks	3.20	0.98	3.66	< .001	[3.08, 3.32]	Moderate
Controlled irritations	2.98	0.95	−0.40	.687	[2.81, 3.15]	Low
Felt on top of things	3.04	1.03	0.69	.493	[2.87, 3.21]	Moderate
Angered by uncontrollable events	3.50	1.02	9.02	< .001	[3.38, 3.62]	High
Felt difficulties piling up	3.01	1.01	0.16	.871	[2.83, 3.19]	Moderate
Overall stress score	3.22	0.53	7.63	< .001	[3.16, 3.28]	Moderate

Coping Strategies

The overall coping score indicated moderate utilization (M = 2.62, SD = 0.48). Table 3 presents mean scores for each coping domain. Self-control emerged as the most frequently used strategy, while distancing was the least used.

Table 3.

Coping Strategy Domains and Mean Scores

Coping domain	M	SD	Interpretation
Distancing	3.42	0.69	Moderate
Self-control	4.10	0.76	High
Seeking social support	3.50	0.72	Moderate
Thoughtful problem-solving	3.54	0.67	Moderate
Overall coping score	2.62	0.48	Moderate

Psychological Stress as a Predictor of Psychological Well-Being

Linear regression analysis demonstrated that psychological stress significantly predicted psychological well-being (Table 4). Stress explained 17.0% of the variance in well-being (R² = .170, F(1,335) = 68.60, p < .001). Higher stress was associated with lower psychological well-being (β = −0.454).

Table 4.

Linear Regression Analysis Predicting Psychological Well-Being From Psychological Stress

Predictor	B	SE	β	t	95% CI	p
Constant	2.07	0.18	—	11.61	[1.72, 2.42]	< .001
Psychological stress	−0.454	0.055	−.41	−8.29	[−0.56, −0.35]	< .001

Model statistics: R² = .170, Cohen’s f² = 0.20.

Coping Strategies as Predictors of Psychological Well-Being

Multiple regression analysis examined coping domains as predictors of psychological well-being (Table 5). The model was statistically significant (R² = .041, F(4,332) = 3.54, p = .008). Thoughtful problem-solving was the only significant predictor, showing a negative association with well-being.

Table 5.

Multiple Regression Analysis of Coping Strategies Predicting Psychological Well-Being

Predictor	B	SE	β	t	95% CI	p
Constant	4.03	0.21	—	19.39	[3.63, 4.43]	< .001
Distancing	−0.043	0.084	−.04	−0.51	[−0.21, 0.13]	.612
Self-control	−0.112	0.080	−.09	−1.40	[−0.27, 0.05]	.163
Seeking social support	0.118	0.068	.10	1.75	[−0.02, 0.26]	.082
Thoughtful problem-solving	−0.150	0.065	−.14	−2.33	[−0.27, −0.02]	.021

Discussion

This study examined the relationships between psychological stress, coping strategies, and psychological well-being among governmental nurses working in the southern West Bank during the Gaza–Israel war. The findings provide important insight into how nurses psychologically adapt to sustained occupational stress in conflict-affected healthcare environments. Consistent with Lazarus and Folkman’s transactional model of stress and coping, the results showed that psychological stress was significantly associated with lower levels of psychological well-being, while coping strategies demonstrated a limited and context-dependent role in influencing this relationship (Folkman et al., 1986; Lazarus & Folkman, 1984).

The present findings revealed that nurses experienced moderate levels of psychological stress during the study period. This observation is consistent with evidence from conflict-affected healthcare settings where frontline healthcare professionals frequently report elevated psychological strain due to increased patient demand, exposure to traumatic events, and ethical challenges associated with emergency care (Bartosiewicz et al., 2025; Elhadi et al., 2020). Similar patterns have also been reported during major health crises such as the COVID-19 pandemic; where nurses experienced substantial psychological burden resulting from high workloads, uncertainty, and prolonged exposure to critically ill patients (Delgado et al., 2021; Sadhaan et al., 2022). In the Palestinian healthcare system, the coexistence of chronic political instability, limited healthcare resources, and repeated military escalation has been shown to intensify occupational stress among nurses and other healthcare workers (Ahmead et al., 2024; Marie et al., 2017). Recent studies conducted in the West Bank during the Gaza war further confirmed that nurses experienced high levels of psychological distress, moral stress, and post-traumatic symptoms associated with conflict exposure (Alqaissi et al., 2025b; Qtait et al., 2025a).

The results of this study also demonstrated that psychological stress was significantly associated with reduced psychological well-being among nurses. This finding aligns with previous research indicating that persistent occupational stress can negatively affect psychological functioning, emotional stability, and professional satisfaction among healthcare workers (Aksu, 2020; Wang et al., 2020). Similarly, studies conducted in multiple healthcare contexts have reported that elevated levels of stress among nurses are strongly associated with burnout, reduced engagement, and diminished psychological well-being (Al-Yaqoubi & Arulappan, 2023; Alqaissi et al., 2025b; Iwanowicz-Palus et al., 2022; Qtait et al., 2025b). These findings support the conceptual premise that sustained exposure to environmental stressors can overwhelm coping resources and impair psychological adaptation.

Despite the presence of moderate levels of stress, participants in this study reported moderate to relatively high levels of psychological well-being. This pattern may reflect the presence of resilience-promoting factors that support psychological adaptation among nurses working in difficult environments. Previous research conducted in the Palestinian context suggests that social cohesion, cultural values, and religious coping mechanisms can help healthcare workers maintain psychological stability during periods of crisis (Marie et al., 2017; Sawalma et al., 2024). Studies conducted in other conflict settings have similarly shown that healthcare professionals often demonstrate substantial psychological resilience despite persistent exposure to stress and trauma (Bartosiewicz et al., 2025).

Coping strategies were moderately utilized among nurses, with self-control emerging as the most frequently reported strategy. This finding is consistent with research showing that healthcare workers often rely on internal coping mechanisms when institutional mental health services are limited or inaccessible (da Silva Oliveira et al., 2022). In conflict-affected settings, nurses frequently depend on personal resilience, emotional regulation, and peer support networks to manage occupational stress (Qtait et al., 2025c; Segev et al., 2024; Witter et al., 2017). Previous studies also indicate that adaptive coping strategies such as seeking social support and positive reframing may help reduce emotional exhaustion and enhance psychological resilience among nurses working in crisis environments (Kowalczuk et al., 2024).

An important finding of the present study is that coping strategies demonstrated only a modest association with psychological well-being. Moreover, the thoughtful problem-solving coping domain showed a negative association with well-being. Although problem-focused coping is generally considered beneficial in managing controllable stressors, its effectiveness may be limited in situations characterized by persistent uncertainty and lack of control, such as armed conflict. In these contexts, attempts to directly resolve stressors that cannot be controlled may increase emotional strain and frustration (Zasiekina et al., 2025). Similar findings have been reported in studies examining healthcare workers in conflict zones, where traditional coping strategies were not always sufficient to mitigate the psychological consequences of war-related stress (Ahmed et al., 2025).

The mediation analysis also indicated that coping strategies did not fully mediate the relationship between psychological stress and psychological well-being. This suggests that although coping mechanisms contribute to psychological adaptation, they are insufficient to fully buffer the negative effects of chronic occupational stress. Comparable findings have been reported in recent studies examining the psychological experiences of nurses in high-intensity healthcare environments, where coping strategies only partially mediated the relationship between stress and mental health outcomes (Jin et al., 2025). These findings highlight that addressing psychological stress among nurses requires not only strengthening individual coping mechanisms but also addressing broader organizational and systemic stressors within healthcare systems.

Overall, the findings of this study reinforce the importance of implementing comprehensive mental health support systems for nurses working in conflict-affected healthcare environments. Previous research has demonstrated that organizational interventions such as psychological counseling services, peer-support programs, and resilience training can significantly improve coping capacity and psychological well-being among healthcare workers (Al-Yaqoubi & Arulappan, 2023; Segev et al., 2024). In fragile healthcare systems such as those operating in conflict zones, strengthening institutional support mechanisms is therefore essential to protect nurses’ psychological health and maintain the continuity and quality of healthcare delivery.

Implications for Nursing Practice and Policy

The findings of this study have several implications for nursing practice and healthcare policy. First, the significant association between psychological stress and reduced well-being underscores the need for institutional mental health support for nurses working in conflict settings. Hospitals and health authorities should consider implementing structured psychological support programs, including peer support groups, trauma-informed leadership training, and stress management interventions.

Second, educational and professional development programs should incorporate training on adaptive coping strategies that are appropriate for high-stress environments. While problem-solving strategies may be beneficial in controllable situations, emotion-focused coping approaches such as emotional regulation, social support, and meaning-making may be more effective in contexts characterized by persistent uncertainty.

Third, healthcare policymakers should address organizational stressors that contribute to psychological strain among nurses. Improving staffing levels, ensuring safe working conditions, and strengthening leadership support may help reduce occupational stress and enhance nurses’ psychological well-being.

Strengths and Limitations

This study provides timely evidence regarding the psychological experiences of nurses working in a conflict-affected healthcare environment. The relatively large sample size and inclusion of multiple governmental hospitals enhance the representativeness of the findings. Additionally, the use of validated Arabic instruments strengthens the reliability of the measurements.

However, several limitations should be acknowledged. First, the cross-sectional design limits the ability to establish causal relationships between stress, coping strategies, and psychological well-being. Second, the use of self-reported questionnaires may introduce measurement bias and common method bias. Third, the use of convenience sampling may limit the generalizability of the findings to other healthcare settings. Future research using longitudinal or mixed-method designs may provide a more comprehensive understanding of how psychological stress and coping mechanisms evolve over time in conflict environments.

Conclusion

In summary, the findings of this study indicate that psychological stress is significantly associated with reduced psychological well-being among governmental nurses working during wartime conditions in the southern West Bank. Coping strategies appear to have a limited and context-dependent role in mitigating this relationship. These findings highlight the importance of strengthening institutional psychological support systems and addressing organizational stressors to protect nurses’ mental health and sustain healthcare service delivery in conflict-affected settings.

Supplemental Material

Supplemental material - Psychological Stress and Psychological Well-Being Among Governmental Nurses in the Southern West Bank During the Gaza–Israel War: The Mediating Role of Coping Strategies

Supplemental material for Psychological Stress and Psychological Well-Being Among Governmental Nurses in the Southern West Bank During the Gaza–Israel War: The Mediating Role of Coping Strategies by Mohannad Khalil Mosa Hamedit, Amal Alhosainy Ramadan, Hussein Jabareen, and Mohammad Qtait in Sage Open Nursing.

Footnotes

Acknowledgments

The authors would like to thank who participated in this study for their time and valuable insights.

ORCID iD

Mohammad Qtait

Ethical Considerations

Ethical approval for this study was obtained from the Palestinian Ministry of Health, Research Ethics Committee (Approval No. 411-50-2024) and from the participating governmental hospitals in the southern West Bank. Permission to conduct data collection was secured from hospital directors and nursing administrations prior to recruitment. Confidentiality and anonymity were ensured by assigning unique identification codes to questionnaires, with no personal identifiers recorded. All data were stored securely and used solely for academic purposes. The study adhered to the principles of the Declaration of Helsinki (2013 revision) and complied with the ethical requirements for research involving human participants as outlined by the SAGE Open Nursing editorial policies on human subjects’ protection.

Consent to Participate

Participation was entirely voluntary, and informed consent was obtained from all participants after a detailed explanation of the study purpose, procedures, potential risks, and benefits.

Funding

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

Declaration of Conflicting Interests

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

Supplemental Material

Supplemental material for this article is available online.

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