{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,28]],"date-time":"2026-10-28T05:32:28Z","timestamp":1793165548391,"version":"4.5.0"},"reference-count":42,"publisher":"SAGE Publications","issue":"7","license":[{"start":{"date-parts":[[2026,7,22]],"date-time":"2026-07-22T00:00:00Z","timestamp":1784678400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Nurs Ethics"],"published-print":{"date-parts":[[2026,11]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Nurses providing end-of-life care in conflict-affected settings navigate cultural traditions, professional duties, and structural violence. Existing frameworks address cultural and institutional dimensions separately but do not account for their simultaneous interaction under protracted conflict.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Aim<\/jats:title>\n                    <jats:p>This study explored how nurses\u2019 beliefs, intersecting with structural conditions, shape end-of-life care in a conflict-affected setting.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Research design<\/jats:title>\n                    <jats:p>A Gadamerian hermeneutic inquiry employed semi-structured interviews with dialogical openness. Data were analyzed using hermeneutic principles through iterative movement between transcripts and data.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants and research context<\/jats:title>\n                    <jats:p>Thirteen nurses were recruited from three hospitals in the occupied West Bank via purposive and snowball sampling. Interviews were conducted in Arabic.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Ethical considerations<\/jats:title>\n                    <jats:p>Ethical approval was obtained from the Palestinian Ministry of Health Ethics Committee and the university IRB. All participants provided written informed consent.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Findings<\/jats:title>\n                    <jats:p>Four themes emerged: sacred framing of death and suffering; family as moral authority; layered moral distress under structural constraint; and resilient adaptation under structural constraint.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>Layered moral distress is proposed as an analytical concept for nursing ethics in conflict settings, distinguished from cumulative moral distress, moral residue, and moral injury by its simultaneous, multiplicative interaction of cultural, professional, and structural layers without institutional resolution. Findings suggest a contextual refinement to Leininger\u2019s Theory: under structural-political violence, the political dimension can reorganize culturally congruent care.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Informal adaptive practices warrant formal recognition. Layered moral distress offers a transferable framework for other conflict-affected settings. Future research should extend this inquiry to comparable contexts with attention to contextual specificity.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/09697330261470060","type":"journal-article","created":{"date-parts":[[2026,7,23]],"date-time":"2026-07-23T05:18:51Z","timestamp":1784783931000},"page":"2044-2061","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":1,"title":["Layered moral distress in end-of-life nursing under occupation: A hermeneutic inquiry"],"prefix":"10.1177","volume":"33","author":[{"given":"Hamdallah H.","family":"Khaled","sequence":"first","affiliation":[{"name":"Nablus University for Vocational and Technical Education"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ehab","family":"Tumeh","sequence":"additional","affiliation":[{"name":"Nablus University for Vocational and Technical Education"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6339-9176","authenticated-orcid":false,"given":"Ibrahim","family":"Aqtam","sequence":"additional","affiliation":[{"name":"Nablus University for Vocational and Technical Education"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-0560-9327","authenticated-orcid":false,"given":"Mustafa","family":"Shouli","sequence":"additional","affiliation":[{"name":"Nablus University for Vocational and Technical Education"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Khulood","family":"Mansor","sequence":"additional","affiliation":[{"name":"Nablus University for Vocational and Technical Education"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2026,7,22]]},"reference":[{"key":"e_1_3_5_2_2","volume-title":"Health conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan","author":"World Health Organization","year":"2023","unstructured":"World Health Organization. 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