Prevalence of violence and quality of life among nursing students during the 7th of October War in Palestine

Abstract

Background

Nursing students in Palestine face unique stressors during armed conflict, including exposure to violence and disruptions in clinical education. The 7th of October War in Gaza heightened these challenges, impacting their psychological well-being and overall quality of life (QoL).

Objective

To assess the prevalence of violence and quality of life among nursing students at Palestine Polytechnic University during the 7th of October War.

Methods

A descriptive cross-sectional study was conducted in April 2025 among 335 undergraduate nursing students using a self-administered questionnaire. It included sociodemographic data, war-related exposures, and the Arabic version of the WHOQOL-BREF. Data were analyzed using SPSS version 26.

Results

More than half (63.3%) reported regularly passing through Israeli military checkpoints, and among them, 83% experienced violence, mostly verbal (50%), followed by psychological (39%) and physical (11%). Additionally, 92% witnessed violence against others at these checkpoints. QoL scores were lowest in the environmental (48.2) and psychological (56.2) domains. Overall, 74.6% reported poor QoL in the environmental domain. Students exposed to checkpoints or violence had significantly lower QoL scores (p < .001). City residents reported higher QoL compared to rural and campus-based students (p = .006).

Conclusion

Nursing students in Palestine endure high rates of violence and poor quality of life during conflict, especially in environmental and psychological aspects. These findings call for urgent interventions, including psychosocial support and institutional policies that prioritize student safety and well-being in conflict zones.

Introduction

Armed conflicts continue to have devastating impacts on individuals and societies, particularly those regions that were exposed to chronic political and military instability [1]. The October 7th, 2023, war in the Gaza Strip deteriorated humanitarian and psychological crises across the entirety of Palestine, disproportionately affecting university students, and more so those majoring in health sciences, by exposing them to increased levels of direct and indirect violence and disruption to education [1, 2].

Nursing students are at high risk for exposure to those risks, as student and trainee healthcare providers, usually forced to go through danger areas to reach university and clinical practice. Subsequently, impairing their quality of life (QoL) and future professional preparedness [3, 4].

Violence in this regard includes verbal, psychological, and physical violence, to which one is constantly subjected at Israeli military checkpoints or during daily trips to schools. As per local news, almost half (49.2%) of nursing students have encountered such violence during their passage through checkpoints [2]. QoL refers to individuals’ overall perception of their position in life in relation to their goals, expectations, and concerns within the context of the cultural and value systems in which they live. It encompasses multiple domains such as physical, psychological, social, functional, and environmental [5].

Globally, armed conflicts have been found to affect education and the well-being of adolescents in several nations, such as Ukraine, Ethiopia, and Sudan [6–9]. For example, in Sudan’s 2023 civil war, medical schools were deliberately targeted, forcing closures and displacing students [9]. Similarly, 78% of Ukrainian medical students reported that the ongoing conflict caused them significant psychological distress [7].

At the local level, Palestine faces the highest burden of mental health conditions in the Eastern Mediterranean region, with over 1 million individuals estimated to require mental health services [10, 11]. In the West Bank, mental health services are critically limited. There are few specialized facilities, a shortage of trained professionals, and serious barriers to access due to movement restrictions and underfunding [12].

College and school students in Palestine face complex set of issues. Ongoing violence, unstable economies, and mobility and transportation restriction greatly hinder their access to higher education and mental health support services in the West Bank and the Gaza Strip [1]. Additionally, the lasting impacts of war and occupation have caused a dramatic deterioration in the youths’ standard of living, especially in the educational system, where over 92% of the schools in Gaza are destroyed or damaged [13]. In spite of these significant challenges, a strong commitment to education persists among Palestinian youth, reflecting both resilience and an urgent need for targeted institutional support [14, 15].

For nursing students in the West Bank, these disruptions have created serious constraints on learning conditions, clinical practice experiences, mobility, and emotional well-being [2]. Building on an earlier local investigation conducted by Amro [2] and Bdier et al. [16] whose result highlights the negative effects of long-term exposure to violence, especially at checkpoints, on students’ academic progress, this study addresses a critical gap by examining the specific impact of the 7th of October war on QoL of nursing students in Palestine. It aims to assess the prevalence of violence and QoL among nursing students during the 7th of October War in Palestine during an acute phase of conflict.

This study offers novel contributions to the literature on nursing education in conflict zones. It is the first research conducted in real-time during the acute phase of the 7th of October 2023 war in Palestine. By capturing students’ immediate experiences of violence and its impact on QoL and with the focus on nursing students, who are considered a high-risk group that must continue attending hospital clinical rotations even during military activity, this study offers essential insights to inform educational planning, psychosocial support strategies, and conflict-sensitive interventions that enhance the safety, well-being, and resilience of future healthcare professionals in Palestine.

Methods

Research design

This study employs a quantitative, descriptive cross-sectional design to assess the prevalence of violence and QoL among nursing students during the 7th of October War in Palestine.

Population and sampling

The target population consisted of undergraduate nursing students enrolled at Palestine Polytechnic University (PPU). The required sample size was calculated using the Raosoft Sample Size Calculator at a 95% confidence level, 5% margin of error, 50% response distribution, and a population of 820 students. Using the parameters above, the minimum suggested sample size was 262 participants. A convenience sampling method was used, and a total of 335 nursing students from first to fourth year were recruited during April 2025.

Inclusion and exclusion criteria

In this research, the participants were undergraduate nursing students at the PPU who were 18 years and older. The criteria for selection helped to ensure that all the participants were legally competent to give informed consent and were currently involved in academic and clinical training in the university environment. Students with a known past history of psychiatric illness were excluded since such illnesses would interfere with the assessment of violence exposure and QoL by introducing pre-existing mental health variables. Students who failed to respond to the whole questionnaire were also excluded in order to achieve reliability and completeness of the data.

Setting

This study was conducted at PPU, located in Hebron, southern West Bank, Palestine. The faculty of nursing offers an undergraduate program combining classroom learning and clinical training. Although based in Hebron, PPU’s nursing students come from the city, nearby villages, surrounding campuses, and various regions across Palestine. This diverse student groups allows the study to capture experiences from both urban and rural backgrounds.

Instrumentation

Data were collected using self-administered questionnaire. The questionnaire consists of two sections. The first section dealt with sociodemographic and war variables and included questions about age, gender, academic year, marital status, residence, and income. This section also evaluated participants’ experiences with Israeli security checkpoints by questioning whether they pass through any security checkpoints to reach university and/or clinical training areas, whether they have been subjected to any type of violence while passing through Israeli security checkpoints, the nature of the violence if any, and whether they witnessed any citizen experience any type of violence at these security checkpoints.

The second part included the Arabic version of WHOQOL-BREF, a standardized instrument designed to assess QoL comprising 26 items. A single item addressing sex life was omitted in the current study due to cultural sensitivity and appropriateness for nursing students, making it a 25-item tool. The WHOQOL-BREF measures four domains: physical health, psychological well-being, social relationships, and environment. The respondents rated items on a 5-point Likert scale.

According to the WHO guidelines, raw domain scores [4–20] were standardized on a 0-100 scale. Standardization allows comparison and interpretation across domains [17]. To classify QoL, a 60% cutoff was used for all domain scores in the (0-100) scale. A converted score of ≥ 60% represented good quality of life, and scores < 60% represented poor quality of life [18].

Reliability and validity

The questionnaire’s validity was evaluated through the content validity assessment. Three academic experts in public health, mental health, and nursing research reviewed the instrument to assess the relevance, clarity, and cultural appropriateness of the items. From their feedback, some questions in section one of the instrument were revised. The revised version was reassessed and found to be valid for application in the study context. A pilot study was then carried out among 25 nursing students who were excluded from the final sample. The pilot was designed to test the instrument for simplicity, understandability, and feasibility. Internal consistency reliability of the Arabic version of the WHOQOL-BREF, culturally adapted to 25 items, was assessed by Cronbach’s alpha coefficient. Total internal consistency was high, with Cronbach’s alpha = 0.90.

Data collection process

Data were collected in April 2025 after the ethical approval from the Institutional Review Board (IRB) at PPU was obtained. The students were fully explained the study purpose and their voluntary right to withdraw from participation at any time. The ones who accepted signed informed consent and responded to the self-administered questionnaire in Arabic. To ensure no responses were lost, questionnaires were collected daily when finished by the research team. 400 questionnaires were distributed and 335 completed questionnaires were returned, result in a response rate of 83.7%.

Data analysis

Analysis of data was done by IBM SPSS Statistics version 29. Descriptive statistics such as means, standard deviations, frequencies, and percentages were employed to explain sociodemographic information, exposure to violence, and QoL domain scores. Raw scores of WHOQOL-BREF domains were converted to a 0–100 scale following WHO guidelines. In order to classify QoL, the cutoff of 60% was used for all domains, and scores of ≥ 60% defined good QoL and scores of < 60% defined poor QoL [18].

Inferential statistics included independent sample t-tests and one-way ANOVA. T-tests compared differences in mean QoL scores based on binary variables such as gender, income, exposure to checkpoints, and experiences of violence. One-way ANOVA compared differences in QoL across multiple categories such as academic year, and place of residence. Post-hoc Scheffé tests were run in the event of significant differences indicated by ANOVA. Statistical significance was set at p < .05.

Ethical consideration

Ethical approval for the conduction of the study was obtained from the Ethical Committee of College of Nursing/ Palestine Polytechnic University Approval no. (EA/2025/50). Written informed consent was provided to all the participants prior to their enrollment in the research. Rapport was built with the participants, and participants were informed that they were voluntarily participating. Confidentiality while gathering data was ensured. Additionally, participants were assured that all personal information would be protected, secured, and kept confidential. The research adhered to the ethical standards outlined in the Declaration of Helsinki regarding the rights, protection, and well-being of research participants.

Results

The study sample included 335 undergraduate nursing students. Most of the participants were females (71.3%) with a mean age of 20.36 years (SD ± 1.83). The majority of them were singles (89.3%) and resided in villages (68%). Students were fairly distributed across academic years, and 51.3% had a monthly income of less than 2000 NIS (555 $). In relation to exposure to checkpoints, most students 63.3% indicated moving through Israeli security checkpoints on their way to the university or clinical training areas. Among them, 83% (n = 176) indicated exposure to violence. Verbal violence was most common (50%), followed by psychological (39%) and physical violence (11%). Also92% witnessed citizens exposed to violence at these checkpoints. These findings underscore the high prevalence of violence among nursing students in conflict zones. Table 1.

Table 1.

Sociodemographic and war related variables (n = 335)

Item	Category	n	%
Gender	Female	239	71.3
	Male	96	28.7
Academic Year	First Year	66	19.7
	Second Year	66	19.7
	Third Year	103	30.7
	Fourth Year	100	29.9
Marital status	Single	299	89.3
	Married	35	10.4
	Divorced	1	0.3
Place of residence	Village	228	68.0
	Campus	15	4.5
	City	72	21.5
	Out the City	20	6.0
Income	< 2000 Nis	172	51.3
	> 2000 Nis	163	48.7
Do you pass any Israel security checkpoints when coming to university and/or clinical training places?	No	123	36.7
	Yes	212	63.3
Have you been exposed to any form of violence (verbal, physical, psychological) when crossing Israeli security checkpoints?	No	36	17.0
	Yes	176	83.0
Type of violence	Psychological	69	39.0
	Physical	19	11.0
	Verbal	88	50
Have you seen any citizen exposed to any form of violence at these security checkpoints?	No	17	8.0
	Yes	195	92.0

Note. N/n: Number; %: Percentage

The quality of life among nursing students in four domains was measured using the WHOQOL-BREF scale during the 7th October Gaza war. In the physical health domain, the mean raw score on a scale of [1–5] was 3.21 with a corresponding transformed score of 55.2 on a scale of (0–100). The psychological health domain recorded a better mean raw score of 3.25 with a corresponding transformed score of 56.2 on a scale of (0–100). The highest raw scores were in the social relationship’s domain, yielding a mean raw score of 3.54, which is equal to 63.5 on a (0–100) scale, reflecting relatively stronger social support during the conflict. The lowest mean scores were in the environmental health domain, with a raw score of 2.93. This was equal to the [4–20] scale score of 11.72 and 48.2 when converted to the (0–100) scale, showing considerable struggle in the living situation of the participants during wartime.

For WHOQOL-BREF general questions, the general quality of life mean score was 3.40 and health satisfaction mean score was 3.70. Both scores were slightly above the scale’s midpoint, as seen in Table 2.

Table 2.

WHOQOL-BREF domain scores (Mean on 1–5, 20-Point, and 100-Point Scales) among nursing students

Domain/ Item	1–5 Scale M (SD)	4–20 Scale* M	0–100 Scale** M
WHOQOL-BREF Domains (23 Items)
Physical Domain (7 items)	3.21 (0.69)	12.84	55.2
Psychological Domain (6 items)	3.25 (0.59)	13.00	56.2
Social Domain (2 items)	3.54 (0.87)	14.16	63.5
Environmental Domain (8 items)	2.93 (0.67)	11.72	48.2
WHOQOL-BREF /General QoL (2 items)
General Quality of Life	3.44 (0.90)
Satisfaction with health	3.75 + (0.93)
Overall QoL (25 items)	3.19 (0.56)

Notes

M = Mean. SD = Standard Deviation

* Transformed score [4–20] = domain mean [1–5] *4 /(WHOQOL-BREF guidelines)

** Transformed score (0-100) = Transformed score [4–20] − 4 * (100/16)/ (WHOQOL-BREF guidelines)

To provide a more meaningful interpretation, the results were categorized based on a cutoff point developed specifically for the WHOQOL-BREF instrument, where a transformed score of ≥ 60% indicates good quality of life, and scores below 60% indicate poor quality of life [18]. 74.6% (n = 250) of the students were identified as having poor Qol in the environmental health domain, indicating a significant decline in living and safety conditions. Likewise, 56.4% (n = 189) and 55.5% (n = 186) of the students scored below the cutoff in the psychological and physical health domains, respectively, suggesting widespread psychological and physical strain. In contrast, 68.4% of students had good quality of life in the social relationship’s domain. Table 3.

Table 3.

Levels of WHOQOL-BREF domain scores among nursing students categorized by 60-Point cutoff (N = 335)

Domains	Poor QoL n (%)	Good QoL n (%)
Physical	186 (55.5)	149 (44.5)
Psychological	189 (56.4)	146 (43.6)
Social	106 (31.6)	229 (68.4)
Environmental	250 (74.6)	85 (25.4)

Note. N/n: Number; %: Percentage

One-way ANOVA and independent samples t-tests were used to assess differences in mean QoL for all 25 items by war-related event exposure and socio-demographic factors. The t-test comparison revealed statistically significant variations in QoL means according to checkpoint experiences. Students who had gone through Israeli checkpoints scored significantly lower on QoL (M = 3.11) compared to students who had not (M = 3.33), p < .001. Similarly, participants exposed to violence at checkpoints reported significantly poorer QoL (M = 2.96) compared to those less exposed (M = 3.81), p < .001. Regarding place of residence, the one-way ANOVA revealed a significant difference in QoL among nursing students across their places of residence, F = 4.22, p = .006. Post-hoc Scheffé tests indicated that city residents nursing students exhibited significantly higher QoL (M = 3.36) compared to both campus (M = 2.95) and village residents (M = 3.14). Conversely, none of the other demographic variables resulted in statistically significant differences in QoL mean scores. Table 4.

Table 4.

Comparison of QoL by selected demographic and war experience variables

Variable	Category	Mean	n	SD	t/f test	P value
Gender	Male	3.23	96	0.68	− 0.805-	0.42
	Female	3.17	239	0.50
Income	< 2000	3.13	172	0.57	-1.774-	0.077
	> 2000	3.24	163	0.53
Academic year	First Year	3.18	66	0.55	0.963	0.411
	Second Year	3.10	66	0.65
	Third Year	3.19	103	0.48
	Fourth Year	3.25	100	0.57
Marital Status	Single	3.19	299	0.56	0.078	0.925
	Married	3.16	35	0.54
	Divorced	3.36	1	.
Place or residence	Village	3.14	228	0.54	4.22	0.006
	Campus	2.95	15	0.70
	City	3.36	72	0.57
	Out the City	3.31	20	0.46
Do you pass any Israel security checkpoints when coming to university and/or clinical training places?	No	3.33	123	0.47	3.72	0.000
	Yes	3.11	212	0.59
Have you been exposed to any form of violence (verbal, physical, psychological) when crossing Israeli security checkpoints?	No	3.81	36	0.35	11.77	0.000
	Yes	2.96	176	0.52

Note. M = Mean; SD = Standard Deviation

Discussion

This research discussed the prevalence of violence and QoL among nursing students of PPU during the 7th of October War with focus on the great psychological and physical strains brought about by the war. Most students were female (71.3%), unmarried (89.3%), and from rural areas (68%). This matches national trends in nursing, where women from villages often make up the majority [19, 20]. The majority of the students (83%) reported that they faced violence at Israeli checkpoints. Most of it was verbal or psychological. This corroborates earlier research by Amro [2] and Hamdan & Hallaq ([1], which reported widespread exposure among Palestinian students to these incidents during times of armed conflict. In addition, 92% of the students witnessed others being subjected to violence, which contribute indirectly to psychological suffering, as supported by Abu-El-Noor et al. [4]. Increased exposure to checkpoints and violence is also in conformity with Bdier et al. [16] who identified chronic conflict-related stressors as core contributors to deteriorating student mental and physical health.

Low scores of QoL were in all aspects, particularly in the environment (0-100 score = 48.2) and physical health (0-100 score = 55.2) aspects. The findings mirror the extreme living standards and poor health consequences due to continuous conflict, as shown by Giacaman [14]. More than 74% of the participants were in poor QoL category in the environment domain, showing concerns regarding safety, transport, and infrastructure, as also highlighted by Ives et al. [21] and Giacaman [14]. The Psychological well-being domain was also impacted negatively (0-100 score = 56.2), were the majority of participant nurses, n = 189 (56.4%), fall under poor QoL category in this domain. This result was consistent with Mousa Thabet & Abu Sultan [22] study findings, whose reported that PTSD symptoms was high among war exposed nursing students. Even though this study could not identify a probable difference in QoL between female and male students, earlier research by Abudayya et al. [23] indicates that female students are prone to have psychological distress.

Notably, the highest QoL scores came in social relationships (0-100 score = 63.5), and the majority of participant student nurses (68.4%) fall under good QoL category in this domain. This testifies to the significant role of family and social support as a buffer mechanism in areas of conflict, as explained by [24]. The outcomes suggest the possibility that close peer and family relationships may serve to buffer against the psychological effects of conflict.

Students who regularly had to pass through Israeli military check-points also had significantly lower QoL (M = 3.11) compared to students who were not passing through checkpoints (M = 3.33), *p* < 0.001. This identifies the drastic emotional and physical effect of crossing repeatedly through military territories. Amro [2] and Bdier et al. [16] linked these issues to high anxiety, tiredness, and poor focus. This harms students’ well-being. A large number of students (63.3%) were affected. The link between stress and low quality of life supports earlier studies [1, 4], which found that checkpoints are a main cause of trauma and low well-being among Palestinian adolescents. These findings show the need to address wider political and structural problems to protect students’ well-being. Schools and colleges must see that daily travel through military zones is more than a transport issue. It adds constant stress that affects mental health, safety, and learning.

In addition, city-residing students experienced higher QoL than those residing in villages or on campus (p = .006). This has also been supported by Li & Zhong [25], who mentioned that residence contributes to differences in the QoL of students. Contrary to our expectations, gender and income level were not from the predictive variables of QoL in this research. This is unlike Abudayya et al. [23], in which poor QoL was predicted by low income and female gender. This could be due to the massive extent of the conflict reaching all students irrespective of gender and income levels at times of peak violence levels.

Regionally, Giacaman [14], Shibib [15], and Hamdan & Hallaq [1] document Palestinian students’ resilience to adversity through learning. This is supported by relatively high levels of social support from this study, showing how the strength of these two dimensions of support, family and cultural support, is one of the determinants of students’ resilience to stress.

Although the situation in Palestine is shaped by a long history of occupation and severe restrictions on movement, the war that began on October 7, 2023, in Gaza represented a major escalation with effects across the entire country. In the West Bank, there was an increase in military raids, the closure of many checkpoints, and a rise in psychological stress among civilians, including university students. What makes the Palestinian case different, especially during this war, is that people are experiencing both occupation and active conflict at the same time. This combination makes it very difficult to access support systems such as relocation, humanitarian aid, or online learning. While other countries in conflict like Ukraine and Sudan also show how students suffer from violence, school disruptions, and trauma [7–9], Palestinian students face continuous challenges even when there is no open war. Therefore, although our findings are useful for understanding conflict in general, they also show the special burden faced by Palestinian nursing students, whose education is constantly affected by political and military conditions.

Strength and limitations

This study targeted nursing students at a period of ongoing war. It is grounded on robust research methodology. The study included large sample size across all the academic years and utilized validated tools (WHOQOL-BREF) scale to assess QoL. The real-time information that was produced during the war provides an insight into the direct effect of violence on medical students in war-torn areas, making significant contributions to the existing literature on the subject.

However, as with any research, it is not without limitation. Since it’s cross-sectional and the absence of baseline (pre-conflict) QoL data limits causal inferences regarding the war’s direct impact on student well-being and QoL. While convenience sampling was chosen due to field constraints and security concerns, it may have led to an overrepresentation of students more affected by the conflict, introducing possible bias. The reliance on self-reported data introduces potential response bias related to perception, emotional state, or social desirability, especially in a conflict setting. Additionally, as the study was limited to a single institution in Hebron, the findings may not be representative of nursing students in other regions of the West Bank or Gaza, who may experience different conditions.

Implications and recommendations

The findings have far-reaching implications for nursing education, mental health service in such conflict-affected zones as Palestine. The high prevalence of exposure to violence and corresponding deterioration of QoL for nursing students highlights the need for learning institutions to adopt trauma-informed approaches. Nursing institutions should integrate psychosocial support services into curricular programs to offer students access to counseling, stress management techniques, and mental health education relevant to the situation of ongoing conflict.

In addition, there is a pressing need for responsive educational policy maker to mitigate against the interference of delays at check points, security threats, and psychological trauma. This would be done by extending deadlines on certain assignments, remote or hybrid learning formats, and flexible rotation clinic training times during periods of prolonged violence. Preceptors and faculty of nursing education must intervene to alleviate students’ symptoms of emotional burnout and trauma.

Nursing education programs must also integrate teaching coping behaviors, resilience, and self-care practices in order to enable students to adapt psychologically under situations of adversity. As future healthcare providers, these students will require not only academic skills but also emotional resilience to function well under stressful situations. In general, there is a need to implement multi-level context-sensitive interventions to foster nursing students’ well-being, learning, and long-term professional success within politically unstable contexts.

Future mixed-method and multi center studies, as well as considering longitudinal or retrospective designs to better assess changes in student well-being before, during, and after periods of conflict are needed. Such studies could help differentiate between conflict-specific effects and broader resilience or adaptation patterns, particularly in nursing populations.

Conclusion

This research aimed to investigate the effects of violence related to war on nursed students QoL during 7th of October war in Palestine. Pervasive checkpoint violence was reported; more than half of the students had been verbally, psychologically, or physically abused. Higher level of exposure to these stressors was associated with lower QoL scores in physical, psychological and environmental domains. Despite widespread adversity, students reported relatively higher scores in the social relationship’s domain, reflecting the protective role of family and peer support during conflict. Yet ongoing threats to safety and freedom of movement continued to impact students’ ability to learn and participate fully in academic life. Students exposed to checkpoints or violence had significantly lower QoL. City residents reported higher QoL compared to rural and campus-based students. likely due to improved access to basic services and safer environments.

While the 7th October War created distinct challenges for Gaza’s nursing students, the prevalence of violence and poor QoL echoes findings from other conflict-affected regions like Sudan and Ukraine. This underscores the urgent need for international frameworks to protect education in war zones, tailored to local geopolitical realities. The results of the study highlight the necessity for immediate institutional/national interventions for nursing students in war-related areas. Tackling these challenges is essential in order to protect the mental health of students, their academic progression and future contributions to healthcare in crisis-affected regions.

Abbreviations

QoL

Quality of Life

WHO

World Health Organization

WHOQOL-BREF

World Health Organization Quality of Life - BREF Instrument

PPU

Palestine Polytechnic University

SPSS

Statistical Package for the Social Sciences

IRB

Institutional Review Board

ANOVA

Analysis of Variance

PTSD

Post-Traumatic Stress Disorder

M

Mean

SD

Standard Deviation

NIS

New Israeli Shekel

Author contributions

FF: Conceptualization, methodology design, supervision, writing– original draft, and final manuscript review. NA: Data collection coordination, fieldwork supervision, and ethical approval follow-up. MQ: Statistical analysis, data interpretation, and contribution to results and discussion sections. ZM: Instrument adaptation and validation, literature review, and critical revisions of the manuscript. KA: Participant recruitment, data entry oversight, and proofreading of final manuscript.

Funding

The authors have not received any funding.

Data availability

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

Declarations

Ethics approval and consent to participate

Ethical approval for the conduction of the study was obtained from the Ethical Committee of College of Nursing/ Palestine Polytechnic University Approval no. (EA/2025/50). Written informed consent was provided to all the participants prior to their enrollment in the research. Rapport was built with the participants, and participants were informed that they were voluntarily participating. Confidentiality while gathering data was ensured. Additionally, participants were assured that all personal information would be protected, secured, and kept confidential. The research adhered to the ethical standards outlined in the Declaration of Helsinki regarding the rights, protection, and well-being of research participants.

Consent for publication

Not applicable. This manuscript does not contain any individual person’s data in any form (including individual details as name, images, or videos).

Competing interests

The authors declare no competing interests.