Armed conflict has been a major cause of morbidity and mortality for most of human history.Reference Bendavid, Boerma and Akseer 1 Due to occupational violence, individuals face direct and indirect physical and psychological health risks. The adverse effects of war and prolonged military occupations on health are not limited to injuries, disability, and deaths caused by violence. War has an indirect impact on health through attacks on health care and interruptions to health systems, resulting in diminished availability to curative and preventative services.
The challenging situation increases the suffering of the population and makes accessing necessary medical care a daunting task, putting many lives at risk and creating a dire need for proper health care support. Emergency health care, especially in conflict zones, is crucial for reducing the numbers of deaths and injuries of those affected by conflicts. Nurses, particularly those in emergency care, play a pivotal role in providing this essential service. They are often the primary frontline responders in armed conflict zones, managing disastrous incidents, and attending to the health needs of affected populations and injured soldiers.Reference Veenema, Lavin and Bender 2
In areas close to armed conflict, emergency departments (EDs) often face overwhelming numbers of cases, leading to extreme and fluctuating workloads with unpredictable injuries.Reference Mani, Kuhn and Plummer 3 Despite these challenges, the role of emergency nurses remains vital. Emergency departments (EDs) in Palestine play a crucial role in delivering urgent medical care to the population. Despite their significance, these departments face substantial challenges that affect the quality and accessibility of emergency services.
The management of the patient’s condition and the way it is dealt with by the emergency nursing staff is very important, as they help in the patient’s improvement, especially psychologically. However, there are psychological and physical challenges faced by emergency nursing staff during these events. These challenges exist on psychological and physical levels.Reference Ferreira and Cividini 4 There are several problems, such as the lack of medical resources needed to deal with the patient’s condition, the medical staff’s lives being endangered, the medical staff’s poor psychological state due to some of the injuries that patients may suffer, a lack of experience and competence in some members of the emergency nursing staff, and the occurrence of poor management. The medical staff, whether making decisions, distributing other staff members, etc., suffer from fatigue and physical weakness due to their workload.Reference Sadhaan, Brown and McLaughlin 5
The health sector in Palestine suffers from a lack of knowledge to confront the challenges it faces in conflict areas that occur between Palestinians and the occupying army, which has led to a complex humanitarian situation characterized by violence and restricted access to health care services. Mark D. Fleming mentioned in his article, Medical Neutrality and Structural Competency in Conflict Zones, “Health care workers must be trained in the necessary structural competency.”Reference Horton 6
The importance of this study lies in its potential contribution to enhancing our understanding of the challenges faced by emergency nursing teams in Palestine working in active conflict zones, and its impact on improving emergency health care in the region. The main objective of our research is to gain a better understanding of the challenges facing emergency nursing teams in Palestine working in active conflict zones.
Methodology
Research Design
In this study, the researcher used a quantitative, descriptive study design that was applied using the objective of this study, which was to know the challenges of emergency nurse teams in Palestine that are working in active conflict zones.
Study setting
The setting for this study was the emergency department at 7 hospitals in the West Bank; Table 1 these hospitals are located in North, middle, and south West Bank. Alia, Bet-Jalla, Rafidia, Al Watani, Sulfit, Tulkarim, and Jenin Hospitals are in the north of WB and, lastly, Palestine Medical Complex and Al Makassed Hospitals are in the middle of WB. The total number of nurses at the time of data collection was 171.
Numbers of nurses and beds in each emergency in the targeted hospitals
Inclusion and exclusion criteria
For inclusion criteria, all nurses working in emergency department hospitals were included. Nurses who were new to working in emergencies (less than 6 months) were excluded. Nurses who were unable to fill the questionnaires were also excluded.
Study tools
Three tools were used to achieve the research objectives and to answer the research questions and contain tow section.
Sociodemographic questionnaire. The first section contained socio-demographic information and included gender, age, qualification, years of experience, and marital status.
Challenge of nursing. The study questionnaire was designed by the study investigator after scanning related studies and literature, and the questionnaire’s content validity was ensured through an intensive review of Hammad et al.Reference Hammad, Arbon and Gebbie 7 and discussion with many specialists in this field.
The questionnaire’s items were arranged into a 5-point Lickert Scale format from strongly agree-strongly disagree. The responses were rated as strongly agree, 5 points; agree, 4 points; neutral, 3 points; disagree, 2 points; and strongly disagree, 1 point.
Ethical approval
After getting ethical approval from Al-Quds University, approval letters were requested from the hospitals (Alia, Almaqased, Beit Jala, Thabit Thabit, Jenin, Rafidia, and Ramallah) to get their permission to conduct this study. The hard copy of the questionnaire was distributed among the employees.
Validity
The content validity of the questionnaire was also assessed by the original authors in a population of 20 ICU nurses in many countries to check the clarity and readability of the questionnaire (Esposito, Guillari and Angelillo, 2017). For this research, The validity of the questionnaire was assessed by a researcher and experts in the field, who served as content specialists. Their feedback and recommendations helped refine the questionnaire, ensuring its clarity, relevance, and appropriateness for the study.
The questionnaires were administered to nurses using the original English language versions. Health care workers in Palestine study in English (Aboul-Enein;Reference Aboul-Enein 8 TumultyReference Tumulty 9), and English is the formal method of documentation between all health team members in Palestine hospitals. Furthermore, English is the language of instruction for medicine, nursing, and health sciences in Palestinian universities (Suliman & TadrosReference Suliman and Tadros 10). The Ministry of Health organizes examinations in English for candidates to ensure their level of proficiency and capabilities of providing safe, state of the art nursing services (Ministry of Health Report 11).
The pilot test in this research was performed involving a group of emergencies before starting the main data collection process to confirm that the instrument is suitable for the emergency setting in West Bank. In addition, we considered any need for adjustment based on participants’ suggestions and feedback. The pilot test was conducted including 20 emergency nurses. Data were analyzed using SPSS software version 28.
Reliability
For the present study, the pilot phase was analyzed for the questionnaire of study. The instrument was tested using the Cronbach alpha coefficient test to test the internal consistency of each subscale of the instrument, and the alpha score was used discover the reliability degree of the questionnaire; the reliability coefficient (Cronbach alpha) is calculated as an indicator of the homogeneity to the level of the instrument. An accepted level would be >70% (Fraenkel & WallenReference Fraenkel, Wallen and Hyun 12). Cronbach’s alpha value of the exploratory sample was 0.92, which represents the consistency of assessment; all items in the instrument measure the same construct if we distribute the instrument again among the sample.
Data Collection
We took an official letter from Al Quds University and sent it to the Ministry of Health. We obtained written approval to distribute the questionnaire within government hospitals and collect data from nurses. We took an official letter from Al Quds University to private hospital directors in private hospitals, and we obtained written approval to distribute the questionnaire within these hospitals and collect data from nurses. Data will be collected in this study through a questionnaire that determines the level of knowledge and behavior level of nurses working in the ED. The questionnaires were distributed to the nurses and their consent to participate was obtained when then they were completed and returned.
Results
What are the Challenges of Nurses Working in Emergency Departments in Palestine?
The table 2 demographic variables. We will use the following scale to assess the levels of the challenges of emergency nurses in Palestine. This scale depends on interval length=range/number of intervals, interval length= (5-1)/3=1.33. The following scale represents the result: 1-less than 2.33 is low; 2.33-less than 3.66 is medium, and 3.66-5 is high. To answer this question, means and standard deviations are calculated to find the levels of the challenges of nurses working in the emergency departments in Palestine.
Socio-demographic characteristics among employees of emergency nurse teams in Palestine (n=108)
According to Table 3, it is clear that the total average of the challenges of nurses working in the emergency departments in Palestine represents the medium level, with 3.44; the statement’s mean was located between 3.05, related to the statement “you feel safe when commuting to work,” with a medium level, and 3.80, related to the statement “necessary medications are immediately available for use during emergencies,” with a high level.
Descriptive statistics of the challenges of nurses working in the emergency departments in Palestine
As shown in Table 4, there is no statistically significant relationship at the level of α<=0.05 regarding challenges posed by marital status for nurses working in emergencies. There is no statistically significant relationship at the level of α<=0.05 by educational level. There is a statistically significant relationship at the level of α<=0.05 by training in advanced cardiac life support (ACLS), to the favor of employees taking advanced cardiac life support (ACLS).
Independent t test shows the significance of high challenge for nurses working during emergencies by sex
One Way ANOVA was used to find out the significant mean differences regarding available trauma resuscitation (Table 5).
Significant differences means for independent samples among the participants according to available trauma resuscitation
** Significant at the level of α<=0.01.
Discussion
The overall purpose of this research was to measure the level of the challenges of emergency nurses in Palestine; and to examine the significant mean differences among employees of the emergency nurses’ teams, according to our hypothesis.
This study reveals that the age of 70% of the sample size was between 25-29 years old, 51% were males, 60% were married, the majority of respondents had gained a bachelor’s degree (95%), 72% of respondents had received training in advanced cardiac life support (ACLS) or similar training, 68% of respondents had received advanced trauma life support (ATLS) training or similar training, and 76% of respondents were informed about critical cases before these patients arrived at the hospital.
The results of this study indicated that the total average of the challenges of nurses working in the emergency departments in Palestine represents the medium level, with 3.44; the statement’s mean was located between 3.05, related to the statement “you feel safe when commuting to work,” with a medium level, and 3.80, related to the statement “necessary medications are immediately available for use during emergencies,” with a high level.
This means that there are many challenges facing nursing staff working in emergency departments in Palestine. The respondents rated the extent of the difficulties they face in managing patients in active conflict areas as medium; the main challenge was the availability of medications for use during emergencies, followed by the recurrence of conflict around the hospitals, causing stress at a high rate. Furthermore, the numbers of physicians and nurses in emergency departments coping with the challenges of active conflict zones are not adequate.
This result agreed with Atakro et al.,Reference Atakro, Atakro and Akuoko 13 who identified the general challenges facing nurses employed in the ED and categorized them into 5 groups, including the lack of preparation of ED nurses (i.e., absence of adequate training), verbal abuse, lack of resources, the stressful nature of the ED, and overcrowding in the ED.
We found that nurses between the ages of 25 and 29 years, and 30 and 34 years, felt that security was insufficient for protection against possible attacks (such as threats or attacks from patients or members of patients’ families toward members of the nursing staff). Moreover, they work more than 1 shift to apply the commitment of life and working environment in emergency not stable.
This result agreed with Suleiman et al.’sReference Suleiman, Hijazi and Al Kalaldeh 14 finding that nurses employed in this department care for patients suffering from life-threatening conditions, and various challenges influence their ability to provide high-quality care. The results also show that there is no statistically significant relationship at the level of α<=0.05 due to the high challenge for nurses working during emergencies by sex; both male and female nurses are living and working under the same conditions, and they agreed that the poor psychological state of medical staff represents a challenging factor in working near active conflict areas.
This result is consistent with Wong et al.,Reference Wong, Gupta and Deckelbaum 15 who found that the burden of emergency care is particularly high in low-resource countries, where deficiencies in organizational planning, shortages of trained health care personnel, and inadequate resources are common.
The result of hypothesis 3 revealed that there is no statistically significant relationship at the level of α<=0.05 due to the high challenge for nurses working during emergencies by marital status. This indicated that married and single nurses feel that nurses in emergency departments are not adequately trained to handle the challenges of active conflict zones due to a lack of necessary medications available for use during emergencies.
This result agreed with Atakro et al.,Reference Atakro, Atakro and Akuoko 13 who identified key challenges for emergency department (ED) nurses, including lack of preparation, verbal abuse, resource shortages, and overcrowding. The result of hypothesis 4 revealed that there is no statistically significant relationship at the level of α<=0.05 due to the high challenge for nurses working during emergencies by educational level. This indicated that the necessary equipment is not immediately available for use during emergencies.
This result agreed with Zakaria et al.,Reference Zakaria, Manshor and Pin 16 which found that the main challenges emergency nurses faced included poor orientation, access blocks, and communication barriers; the most striking findings in these settings were the diversity of armed conflict injuries, clinical profiles, triage of mass causality, trauma care, surge capacity, orientation, communication, and strategies for preparing nurses.
The result of hypothesis 5 revealed that there is a statistically significant relationship at the level of α<=0.05 due to the high challenge for nurses working during emergencies by receiving advanced cardiac life support (ACLS) training. This indicated that the poor psychological state of medical staff represents a challenging factor in working near active conflict areas.
This result agreed with Smith & Jones,Reference Smith and Jones 17 which found that nurses, often the first point of contact for patients, use their clinical expertise to assess patients’ vital signs, symptoms, and medical history to determine the urgency of their condition.
The result of hypothesis 6 revealed that there is a statistically significant relationship at the level of α<=0.05 due to the high challenge for nurses working during emergencies by taking advanced trauma life support (ATLS) or similar training. This indicated the extent of the psychological impact that conflict zones have on nursing staff and their work.
The result of hypothesis 7 revealed that there is no statistically significant relationship at the level of α<=0.05 due to ambulances informing about critical cases before their arrival to the hospital, which means the nurses are available and ready to work in all conditions.
This finding evidenced that the high challenge for nurses working during emergencies has a statistically positive relationship with available trauma resuscitation to the favor of a “yes” response, where nurses felt that trauma resuscitation courses adequately trained them to handle the challenges of active conflict zones.
This result agreed with the registered nurses’ association of George, et al.,Reference George, Bowman and Aaronson 18 who found that a lack of training and qualification for medical teams in conflict areas affected their ability to deal with emergency cases and critically injured people.Reference Aciksoz 19, Reference Qtait and Sayej 20
Conclusion
The scope of emergency nurses’ challenges in managing several hospitals in areas of armed conflict was examined in this study. The resulting overview of their duties, difficulties, and experiences serves as a useful tool and presents crucial details for future emergency nursing workforce readiness. To perform effectively in armed conflict situations, emergency nurses complete a variety of preparatory courses; however, the necessary education and training should be carefully designed in accordance with their actual roles and responsibilities in these circumstances.
Open access
