Assessment of the quality of health care in emergency departments of governing hospitals in the Gaza Strip: A nurse’s perspective

Study design, setting, and participants

This observational, descriptive, and analytical study in Palestine that adhered to the Strengthening the Reporting of Observational Studies in Epidemiology checklist. Aimed to assess the quality of healthcare in EDs of government hospitals in the GS from the perspective of nurses. The research was carried out at major governmental hospitals in the GS, including primary and governmental hospitals. The researcher purposively selected key hospitals such as Al-Shifa Medical Complex, Nasser Medical Complex, European Gaza Hospital, Beit Hanoun Hospital, Indonesian Hospital, Al-Aqsa Hospital, and Al-Najar Hospital. Data collection was carried out from October 2022 to January 2023. The total duration of the study was ~1 year, from proposal approval to data analysis completion in April 2023. The study targeted nurses who work in adult EDs for at least 6 months (Supplemental Material).

Inclusion and exclusion criteria

The study included all nurses working in adult EDs in government hospitals in Gaza who had fixed-term contracts and consented to participate. Nurses who were absent during data collection, had <6 months of work experience or were on long-term leave were excluded from the study.

Governmental hospital services

The Ministry of Health (MOH) operates 13 hospitals in Gaza, providing secondary and some tertiary care. The average occupancy rate of these hospitals is about 90.2%. The hospitals serve the population of the GS, with the Beit Hanoun Hospital in the north, the Indonesian Hospital, the Al-Shifa Medical Complex in Gaza City, the Al-Aqsa Hospital in the midzone, and others in the southern GS.

Sample size and sampling

The study included all nurses who worked in adult EDs of selected government hospitals. The total sample size was 205 nurses. A census sample was used to avoid sampling errors, with questionnaires distributed to all participants in the selected hospitals. Of the 205 nurses, 193 responded (94.1%), which yielded satisfactory response rates.

The study was not equally distributed across all hospitals due to differences in hospital size, staffing levels, and patient volumes, with larger institutions such as Al-Shifa and Nasser Medical Complex naturally having more nurses working in EDs compared to smaller facilities. The study employed a census sampling method, aiming to include all eligible nurses in the selected hospitals rather than enforcing equal representation, which allowed for a more accurate reflection of the actual workforce distribution. Additionally, logistical factors such as nurse availability during different shifts, administrative cooperation, and accessibility challenges in certain areas of the GS may have influenced participation rates across hospitals.

Additionally, the hospitals included in this study were selected as major governmental healthcare providers in the GS, delivering essential emergency services to large portions of the population. These facilities such as Al-Shifa Medical Complex, Nasser Medical Complex, and European Gaza Hospital, were purposively chosen for their high patient volumes, strategic geographic distribution across the five Gaza governorates, and their pivotal role within the MOH’s emergency care network. Their inclusion ensured a broad and representative assessment of emergency healthcare quality across the primary public health facilities throughout the entire Gaza region.

Data collection

Data were collected using a self-administered questionnaire distributed during the morning, evening, and night shifts. The average time to complete the questionnaire was 20 min. The researcher visited different shifts to maximize response rates and clarified any ambiguities in the tool.

Study instruments

The study used a structured self-developed questionnaire in English, consisting of personal information (sociodemographic data) and six domains evaluating the quality of health services: (1) physician effectiveness; (2) nursing effectiveness; (3) medical equipment efficiency; (4) communication method; (5) safe environments; and (6) timeliness. ⁸ A five-point Likert scale was used to assess responses, ranging from “Very Low Degree” (1) to “Very High Degree” (5). ⁹ The mean, standard deviation, and relative weights (RW, %) for each response category were calculated.

Reliability and validity of study instruments

The reliability of the questionnaire was assessed using Cronbach’s alpha, with values ranging from 0.736 to 0.837 for the individual dimensions and 0.877 for the overall questionnaire, indicating good reliability. In our study, Cronbach’s alpha was applied to examine the internal consistency of the questionnaire items across the six domains, ensuring that each domain reliably measured a single underlying construct (e.g. nursing effectiveness, communication). Additionally, Cronbach’s alpha was applied to provide transparency about the questionnaire’s performance. Furthermore, the questionnaire was reviewed by experts and revised on the basis of their feedback.

Pilot study

A pilot study involving 20 nurses was carried out to verify clarity and improve the validity of the questionnaire.

Statistical analysis

The data was analyzed using the Statistical Package for the Social Sciences version 25. Various statistical methods were carried out including frequency tables, central tendency measures (mean), dispersion (standard deviation), and RW.

Ethical considerations

Ethical approvals were obtained from the University of Al-Butana, the MOH, and the Helsinki Committee (code no.: PHRC/HC/1211/22). Written informed consent was obtained from all participants prior to their inclusion in the study. The consent form explained the study’s purpose, procedures, the voluntary nature of participation, and assurances of confidentiality and anonymity. Participants were informed that they could withdraw from the study at any time without any consequences.

Demographic characteristics of EDs nurses

Table 1 summarizes the demographic details of the 193 EDs nurses who participated in the study. The majority of the nurses were male (69.0%) and just over half (51.0%) were younger than 30 years old. Most participants held a bachelor’s degree (75.0%) and were married (64.3%).

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Table 1.

Sociodemographic characteristics of the study participants.

Variables	Frequency (N = 193)	Percentage (100%)
Gender
Male	133	69.0
Female	60	31.0
Age (years)
<30	98	51.0
30–<40	81	42.0
More than 40	14	7.0
Education level
Diploma	36	18.5
Bachelor	145	75.0
Postgraduate	13	6.5
Marital status
Not married	69	35.7
Married	124	64.3
Total years of experience
<5	76	39.4
5–<10	64	33.3
10–<15	29	15.2
More than 15	23	12.1
Place of residence
North Gaza	52	26.7
Gaza City	40	20.7
Middle area	34	17.6
Khan Younis	37	19.3
Rafah	30	15.7
Work place
Al Shifa Medical Complex	54	28.1
European Gaza Hospital	32	16.6
Nasser Medical Complex	30	15.5
Al Aqsa Martyrs Hospital	29	15.2
Indonesian Hospital	28	14.4
Beit Hanon Hospital	11	5.6
Al Najar Hospital	9.0	4.6

Data are expressed for continuous variables and as percentages for different categorical variables.

In terms of professional experience, 39.4% of the nurses had <5 years of work experience. Regarding their place of residence, the largest proportion lived in the North Gaza Governorate (26.7%), while the fewest were from the Rafah Governorate (15.7%).

Nurses’ responses to dimensions 1 and 2 of the quality of health care “physician’s effectiveness” and “nursing effectiveness”

Table 2 presents nurses’ perceptions of healthcare quality in GS EDs, focusing on two key aspects: Physician’s Effectiveness and Nursing Effectiveness. For Physician’s Effectiveness, nurses rated the item “Physicians strive to provide medical care to their patients to the fullest” highest, with a mean score of 3.55 and a RW of 88.8%, reflecting strong agreement that physicians are dedicated to delivering comprehensive care. However, the lowest-rated item was “The ED has a sufficient number of physicians with various specialties,” scoring a mean of 2.11 and an RW of 52.8%, indicating concerns about the adequacy of specialized physicians. Overall, Physician’s Effectiveness was rated high, with an average RW of 77.1%. Regarding Nursing Effectiveness, the highest-rated item was “Nurses are keen to handle medical records with honesty and confidence,” with a mean score of 3.65 and an RW of 91.3%, showing strong agreement on the importance of professionalism in medical record handling. In contrast, the lowest-rated item was “The number of nursing staff corresponds to the number of patients,” which received a mean score of 1.95 and an RW of 48.8%, suggesting dissatisfaction with nurse staffing levels. Overall, Nursing Effectiveness was rated high, with an average RW of 68.5%.

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Table 2.

Nurses responses to dimensions 1 and 2 of the quality of health care “physician’s effectiveness” and “nursing effectiveness.”

No.	Items of dimension 1 “physician’s effectiveness”	Mean	SD	RW	Ranked
1.	The number of physicians in the emergency department is commensurate with the number of patients	3.01	0.85	75.3	6
2.	The emergency department has a sufficient number of physicians with various specialties	2.11	0.71	52.8	7
3.	The emergency department is staffed by physicians with outstanding scientific reputation and good experience	3.25	0.65	81.3	3
4.	The physician’s staff at the emergency department has high medical skills	3.42	0.96	85.5	2
5.	There are enough doctors during official working hours	3.11	0.64	77.8	5
6.	Physicians are present at their workplaces, making it easy to reach them when needed	3.15	0.79	78.8	4
7.	Physicians strive to provide medical care to their patients to the fullest	3.55	0.55	88.8	1
All items		3.09	0.67	77.1	-
No.	Items of dimension 2 “nursing effectiveness”	Mean	SD	RW	Ranked
1.	The number of nursing staff corresponds to the number of patients	1.95	0.85	48.8	9
2.	The number of nursing staff is appropriate for the administrative staff	2.12	0.74	53.0	7
3.	The head nurse participates with the nurses in planning activities that contribute to raising and improving the quality of work in the department	2.92	0.68	73.0	5
4.	Nurses provide nursing services on time and within protocols	3.11	0.88	77.8	4
5.	The emergency department has the necessary nursing staff to provide the best service	2.01	0.91	50.3	8
6.	Nurses are careful to wear uniforms and clean	3.42	0.63	85.5	2
7.	There are nurses who specialize in emergency nursing	3.33	0.55	83.3	3
8.	Nurses are keen to handle medical records with honesty and confidence	3.65	0.63	91.3	1
9.	Training and qualification courses are conducted periodically for nursing staff	2.16	0.78	54.0	6
All items		2.74	0.74	68.5	-

Data are expressed as average scores for continuous variables and as percentages for different categorical variables.

RW: relative weight; SD: standard deviation.

Nurses’ responses to dimensions 3 and 4 of the quality of health care: Quality of medical devices and instruments “efficiency” and “quality of the communication ‎method”

Table 3 presents nurses’ perceptions of two additional dimensions of healthcare quality: Quality of Medical Devices and Instruments (Efficiency) and Quality of the Communication Method. For Quality of Medical Devices, the mean scores ranged from 1.32 to 3.22. Nurses rated the item “In the ED, there are appropriate medical devices that contribute to the provision of the service, such as electrocardiograms, blood sugar tests, and others” highest, with a mean of 3.22 and an RW of 80.5%, indicating agreement that appropriate medical devices are available. However, the lowest-rated item, “When any of the devices are lacking, they are provided as soon as possible,” scored 1.32 with an RW of 56.5%, suggesting that timely delivery of missing devices is a concern. Overall, nurses rated the quality of medical devices and instruments as moderate with an average RW of 56.5%. For Quality of the Communication Method, the mean scores ranged from 3.22 to 3.72. The highest-rated item was “There is effective communication between the nurses in the department and the health team,” with a mean of 3.72 and an RW of 93.0%, indicating strong agreement on the effectiveness of communication within the health team. The lowest-rated item, “Commitment to effective communication and connection with the patient and his family,” still received a high mean score of 3.22 and an RW of 80.5%, showing that nurses agreed on the importance of communication with patients and families. Overall, the quality of communication methods was rated very high, with an average RW of 87.0%.

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Table 3.

Nurses’ responses to dimensions 3 and 4 of the quality of health care: quality of medical devices and instruments “efficiency” and “quality of the communication method.”

No.	Items of dimension 3 quality of medical devices and instruments “efficiency”	Mean	SD	RW	Ranked
1.	The emergency department has appropriate medical supplies that facilitate the provision of service	1.90	0.32	47.5	6
2.	The hospital has a laboratory that performs all the necessary tests to provide the best service	2.10	0.74	52.5	5
3.	The readiness of the emergency trolley and the verification and documentation of this in the form according to the text of the policy	1.85	0.85	46.3	7
4.	Medical devices work in a proper and effective manner around the hours	1.74	0.64	43.5	8
5.	The emergency department has the necessary medical consumables to carry out medical and nursing procedures on time	1.63	0.55	40.8	9
6.	Provide the necessary medical, nursing, and administrative forms to facilitate the services provided	2.85	0.48	71.3	2
7.	In the emergency department, there are appropriate medical devices that contribute to the provision of the service, such as ECG, blood sugar test and others	3.22	0.96	80.5	1
8.	In the emergency department, there are suitable monitoring devices that facilitate the provision of service	2.74	0.35	68.5	3
9.	Periodic maintenance of medical devices and equipment is carried out in the department	2.32	0.88	58.0	4
10.	When any of the devices are lacking, they are provided as soon as possible	1.32	0.63	56.5	10
All items		2.17	0.64	56.5	-
No.	Items of dimension 4 “quality of the communication method”	Mean	SD	RW	Ranked
1.	Patients and visitors in the department are treated well	3.61	0.85	90.3	2
2.	Commitment to effective communication and connection with the patient and his family and commitment to good dealing with patients and their families	3.22	0.68	80.5	7
3.	Emergency nurses are punctual and credibility	3.52	0.75	88.0	4
4.	Nurses understand the patients’ special circumstances	3.42	0.70	85.5	5
5.	There is effective communication between the nurses in the department and the health team	3.72	0.63	93.0	1
6.	Nurses understand the patients’ specific needs	3.55	0.92	88.8	3
7.	The nursing staff has sufficient skills in dealing with patients and visitors	3.32	0.73	83.0	6
All items		3.48	0.75	87.0	-

Data are expressed as average scores for continuous variables and as percentages for different categorical variables.

ECG: electrocardiograms; RW: relative weight; SD: standard deviation.

Nurses’ responses to dimensions 5 and 6 of the quality of health care “safe environment” and “timely”

Table 4 presents nurses’ responses regarding the “Safe Environment” and “Timely” dimensions of healthcare quality in EDs. Overall, nurses rated the safe environment positively with a score of 82.0%. The highest-rated item was “The ED is clean and tidy” (mean = 3.62, RW = 90.5%), showing strong agreement, while the lowest-rated was “Keep the patient’s unit tidy, clean, and equipped with the tools the patient needs” (mean = 2.85, RW = 71.3%), still reflecting general agreement. Similarly, the timeliness of care received a favorable overall score of 79.1%. Nurses strongly agreed that they “follow-up on patients continuously” (mean = 3.61, RW = 90.3%), whereas they expressed disagreement with the item stating that “The procedures and policies followed in the department facilitate the provision of nursing service to patients” (mean = 2.33, RW = 58.3%), which was the lowest-rated in this dimension.

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Table 4.

Nurses responses to dimensions 5 and 6 of the quality of health care “safe environment” and “timely.”

No.	Items of dimensions 5 “safe environment”	Mean	SD	RW	Ranked
1.	The emergency department has suitable waiting lounges	3.10	0.63	77.5	9
2.	The emergency department has the necessary ventilation, cooling, and heating	2.90	0.58	72.5	10
3.	Keep the patient’s unit tidy, clean, and equipped with the tools the patient needs	2.85	0.71	71.3	11
4.	Take care of providing adequate and clean sheets	3.15	0.88	78.8	8
5.	The department has sufficient and appropriate lighting	3.42	0.92	85.5	5
6.	The section uses appropriate signboards in the corridors	3.53	0.86	88.3	2
7.	The emergency department is clean and tidy	3.62	0.82	90.5	1
8.	Cleaning services in the department commensurate with the volume of work	3.46	0.67	86.5	3
9.	The department has suitable toilets for patients	3.34	0.72	83.5	6
10.	Taking care of arranging and cleaning the nursing station and files to serve the interest of work	3.25	0.66	81.3	7
11.	The department has convenient showers for patients	3.44	0.84	86.0	4
All items		3.28	0.76	82.0	-
No.	Items of dimensions 6 “timely”	Mean	SD	RW	Ranked
1.	Nurses have the right to respond promptly to patients’ complaints, no matter how busy they are	3.11	0.55	77.8	4
2.	Nurses follow up on patients continuously	3.61	0.74	90.3	1
3.	Nurses maintain a guarantee of speed and ease in the provision of nursing and health services	3.42	0.61	85.5	2
4.	Nurses accomplish their tasks in a specific time and with high efficiency	3.34	0.83	83.5	3
5.	The procedures and policies followed in the department facilitate the provision of nursing service to patients	2.33	0.77	58.3	5
All items		3.16	0.73	79.1	-

Data are expressed as average scores for continuous variables and as percentages for different categorical variables.

RW: relative weight; SD: standard deviation.

Overall level of the quality of health care in EDs of public hospitals in the GS

Table 5 summarizes nurses’ perceptions of the overall quality of healthcare in the EDs of government hospitals in the GS. The results indicate a generally high level of quality, with an overall score of 75.0%. Among the evaluated items, “Quality of the communication method” received the highest rating, with a mean score of 3.48 and a RW of 87.0%, reflecting strong agreement among nurses about the effectiveness of communication. In contrast, the lowest-rated item was “Quality of medical devices and instruments,” which had a mean score of 2.17 and an RW of 56.5%, indicating disagreement and highlighting concerns about the adequacy of medical equipment. These findings suggest that while communication in EDs is viewed positively, there are notable deficiencies in the availability or quality of medical devices.

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Table 5.

Overall level of the quality of health care in emergency departments of public hospitals in the Gaza Strip.

No.	Dimensions of the quality of health care in emergency departments	Mean	SD	RW	Ranked
1.	Physician’s effectiveness	3.09	0.67	77.1	4
2.	Nursing effectiveness	2.74	0.74	68.5	5
3.	Quality of medical devices and instruments “efficiency”	2.17	0.64	56.5	6
4.	Quality of the communication method	3.48	0.75	87.0	1
5.	Safe environment	3.28	0.76	82.0	2
6.	Timely	3.16	0.73	79.1	3
Overall quality healthcare		3.00	0.69	75.0	-

Data are expressed as average scores for continuous variables and as percentages for different categorical variables.

RW: relative weight; SD: standard deviation.

Physician effectiveness

The effectiveness of physicians in Gaza’s EDs was rated highly (77.1%). This is consistent with other study ¹⁰ that emphasize the importance of physician performance in improving emergency care quality. However, structural limitations imposed by the occupation restrict standard methods for strengthening physician capacity such as participation in international training, access to updated medical guidelines, and the importation of essential pharmaceuticals and technologies. ¹¹ While individual efforts remain commendable, the ability of physicians to meet rising and complex medical demands is severely constrained by restrictions on mobility and equipment, as well as recurrent military escalations that overload the healthcare system.

Nursing effectiveness

Nursing effectiveness was rated moderately (68.5%). Although nurses in Gaza’s EDs are dedicated to improving their skills, they face challenges like heavy workloads and understaffing. While nursing protocols, professional development, and training have helped address these issues to some extent, a lack of staff still negatively impacts care quality.^6–11 This is consistent with other studies that suggest nursing staff shortages can hinder overall care.^5,12 The Israeli-imposed restrictions on the entry of medical personnel, educational opportunities, and equipment severely hinder efforts to train, recruit, and retain qualified nursing staff.

Quality of medical devices and instruments

The quality of medical devices and instruments in Gaza’s EDs was rated 56.5%, showing a moderate level of satisfaction. This indicates that more investment is needed to upgrade and maintain medical equipment. These shortages are not incidental but are the direct result of a long-standing blockade that restricts the importation of medical devices, spare parts, and maintenance resources.^7,13 This situation undermines emergency preparedness and delays timely intervention, increasing morbidity and mortality in emergency cases. Even donations from international partners are often delayed or denied at border crossings, illustrating the geopolitical obstacles to healthcare provision. Despite challenges with limited resources and high patient volumes, nurses stressed the importance of maintaining the equipment they have to improve patient care. This finding contrasts with another study that rated medical devices as less adequate. ¹²

Quality of communication method

The communication method in EDs was rated very highly (87%). Nurses in Gaza place a strong emphasis on clear, compassionate, and respectful communication with patients. Effective communication is critical to building trust and ensuring patient satisfaction, particularly in high-stress environments like emergency care. This result aligns with previous studies,^14,15 which highlight the importance of communication in overall service quality. It reflects nurses’ commitment to providing patient-centered care, a key aspect of high-quality healthcare. However, this strength should not obscure the fact that external communication, including with referred facilities, medical consultants, or international agencies is often obstructed by restricted internet access, electricity shortages, and border closures.

Safe environment

The safety of the environment in Gaza’s EDs was rated highly (82%). Factors like cleanliness, space suitability, and available infrastructure contribute to a safe environment. This result supports previous studies^16–18 showing that a safe and well-equipped healthcare environment is crucial for providing quality care. However, there are still concerns about ED capacity and cleanliness, especially in areas with a high influx of patients. ¹² While staff work diligently to maintain hygiene and order, damage to infrastructure from airstrikes, electricity cuts, and inadequate construction materials due to import restrictions limit broader improvements.^16–18 Additionally, overcrowding due to repeated mass-casualty events places extreme strain on environmental controls and patient privacy.

Timeliness of care

Timeliness was also rated highly (79.1%). The ability to provide care quickly is essential in emergency settings, as delays can affect patient outcomes.^1,19,20 Nurses in Gaza are committed to minimizing delays, even though they face challenges such as limited resources and a high volume of patients. Timely care is linked to patient satisfaction and recovery, as shown in other study. ²¹ Again, these challenges are deeply intertwined with occupation-related barriers, including inconsistent electricity supplies, internet blackouts, and shortages of staff due to movement restrictions or sudden military escalations.^1,19,20

Strength and limitations of the study

This study provides a detailed and systematic assessment of healthcare quality in EDs across key governmental hospitals in the GS, capturing perspectives directly from frontline nurses. By including multiple major hospitals distributed across different governorates, the findings offer a broad and reasonably representative snapshot of the public emergency healthcare system in Gaza. However, while the selected hospitals serve large patient populations and cover diverse geographic areas, the results may not be fully generalizable to smaller or private healthcare facilities, or to hospitals in different contexts outside Gaza. Additionally, the cross-sectional design provides only a single time-point view, limiting insights into changes over time, or causal relationships. Future studies employing longitudinal or mixed-methods approaches could enhance understanding and support more generalizable conclusions across wider healthcare settings in the region. Additionally, the absence of a formal sample size calculation, which may affect the statistical power of subgroup comparisons or generalizability beyond the surveyed hospitals. However, the use of a census sampling approach across major governmental hospitals helped mitigate this limitation by capturing a wide range of nurse perspectives across diverse settings.