Organizational Culture and Nurse Commitment in Conflict-Affected Hospitals: A Focus on Empowerment in Jerusalem

Organizational Culture and Nurse Commitment in Conflict-Affected Hospitals: A Focus on Empowerment in Jerusalem | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Organizational Culture and Nurse Commitment in Conflict-Affected Hospitals: A Focus on Empowerment in Jerusalem Farid Ghrayeb, Kefah Zaben, Ibrahim Aqtam, Ahmad Ayed, Nahid Ghrayeb, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6743797/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction In conflict-affected regions such as Palestine, nurses' organizational commitment is critical for sustaining healthcare resilience. While organizational culture shapes such commitment, its dynamics remain understudied in settings marked by geopolitical strain. This study, the first in Palestine to empirically link empowerment to affective commitment using culturally adapted instruments, examines these relationships in Jerusalem hospitals, integrating geopolitical realities into organizational frameworks. Objective To assess how organizational culture dimensions (bureaucratic, innovative, supportive, empowerment) predict commitment types (affective, continuance, normative) in Palestinian hospitals, with a focus on empowerment's role in mitigating systemic challenges unique to conflict zones. Methods A cross-sectional study was conducted across five Jerusalem hospitals (October 2024–January 2025) using convenience sampling. Data from 302 nurses (94.4% response rate) were collected via validated scales culturally adapted through translation, back-translation, and pilot testing (N = 40). The 36-item Organizational Culture Scale and 24-item Organizational Commitment Scale employed 5-point Likert responses (1 = strongly disagree; 5 = strongly agree). Analyses included Pearson's correlations and regression modeling. Results Organizational culture significantly predicted commitment (B = 0.214, p = 0.001), explaining 57.8% of variance. Empowerment emerged as the strongest cultural driver of affective commitment (M = 3.63), while bureaucratic practices showed the weakest association (M = 3.38). Years of experience significantly predicted commitment (B = 0.570, p < 0.001), with mid-career nurses (6–15 years) exhibiting the strongest ties to workplace culture. Recommendations Hospitals should prioritize empowerment (e.g., autonomy in decision-making) and reduce bureaucratic barriers through digital tools to strengthen affective bonds. Retention strategies must address career-stage needs, particularly for mid-career nurses. These findings advocate for context-specific retention strategies tailored to the unique challenges of conflict-affected healthcare systems. Future studies should employ longitudinal designs to unravel causal pathways and validate conflict-specific adaptations of organizational frameworks. Organizational commitment empowerment conflict-affected healthcare Jerusalem cultural adaptation nursing retention Introduction Nurses are the cornerstone of healthcare resilience, particularly in regions marred by prolonged geopolitical instability such as Palestine. Their organizational commitment, comprising emotional bonds (affective), perceived costs of leaving (continuance), and moral obligation (normative), is pivotal for sustaining care quality amid systemic challenges like resource scarcity, restricted mobility, and fragmented governance [ 1 , 2 ]. Organizational culture, defined as shared values and practices shaping workplace behavior [ 3 ], directly influences this commitment. While supportive cultures enhance engagement, bureaucratic practices may undermine it [ 4 ], a dynamic intensified in geostrategically contested zones like Jerusalem, where healthcare delivery is disrupted by permit regimes, security barriers, and political volatility [ 5 ]. Globally, organizational culture's impact on staff retention and service quality is well-documented [ 6 ], yet most frameworks derive from stable, high-income contexts. These models inadequately address settings where geopolitical strain redefines workplace dynamics. For instance, Western studies associate bureaucracy with continuance commitment [ 7 ], but in Palestine, overlapping authorities and inefficiencies may erode retention incentives. Similarly, empowerment, a culturally salient construct encompassing autonomy and shared decision-making, remains underexplored as a predictor of affective commitment in conflict zones, despite its potential to foster resilience amid adversity [ 8 ]. Guided by Social Exchange Theory (SET), which posits that employees reciprocate organizational support with loyalty [ 9 ], and Person-Organization Fit (P-O Fit) Theory, emphasizing alignment between personal values and workplace practices [ 10 ], this study addresses critical gaps. First, it employs culturally adapted instruments to assess organizational culture and commitment, addressing the misfit of Western-developed tools in conflict settings. Second, it examines how bureaucratic, innovative, supportive, and empowerment-focused cultures interact with geopolitical realities to shape nurse commitment, a relationship unexamined in prior Palestinian research. Third, it challenges universal assumptions, such as bureaucracy's role in continuance commitment, by revealing how systemic inefficiencies in fragmented governance disrupt traditional retention mechanisms. This study is the first in Palestine to empirically link empowerment to affective commitment using contextually validated scales. By integrating SET and P-O Fit frameworks with the realities of occupation and resource constraints, it advances theoretical understanding of how nurses sustain dedication under duress. Practically, the findings offer actionable strategies for healthcare leaders in conflict zones, such as prioritizing empowerment to strengthen emotional bonds and streamlining bureaucratic workflows through digital solutions. Review of Literature Organizational culture and commitment are extensively studied in healthcare, yet existing frameworks predominantly derive from stable, high-income contexts, limiting their applicability to conflict-affected regions [ 10 ]. Organizational culture, defined as shared values and practices that shape workplace behavior [ 11 ], is often categorized into bureaucratic, innovative, and supportive typologies [ 12 ]. Meyer and Allen's three-component model of commitment, affective (emotional attachment), continuance (perceived costs of leaving), and normative (moral obligation), remains a cornerstone of cross-cultural research, though its expression varies under geopolitical strain [ 13 ]. For instance, while innovative cultures in Western settings predict affective commitment through opportunities for growth [ 14 ], bureaucratic structures in conflict zones may erode retention due to inefficiencies exacerbated by political instability [ 15 ]. Empowerment, increasingly recognized as a cultural dimension rather than an outcome, encompasses autonomy, shared decision-making, and access to resources [ 16 ]. In Middle Eastern contexts, studies reveal divergent dynamics: Jordanian nurses' commitment hinges on leadership support and resource availability [ 17 ], while Iranian hospitals emphasize clan-like mentorship cultures to offset systemic constraints [ 18 ]. In conflict zones such as Syria, healthcare resilience during war relied on collective leadership and decentralized decision-making [ 19 ], whereas Palestinian nurses sustain commitment through a profound service ethos despite mobility restrictions and fragmented governance [ 20 ]. These findings underscore the need to redefine constructs like "empowerment" and "bureaucracy" to reflect the realities of occupation, resource scarcity, and security risks [ 21 ]. Despite these insights, critical gaps persist. First, Western-developed tools (e.g., scales measuring "innovation" or "bureaucracy") often misfit conflict settings, where such constructs carry context-specific meanings [ 22 ]. For example, bureaucratic practices in Palestine reflect overlapping authorities and permit regimes rather than mere hierarchical rigidity [ 23 ]. Second, few studies control conflict-related variables such as sudden resource shortages or staff exposure to violence, which may mediate culture-commitment relationships [ 24 ]. Third, theoretical frameworks like Social Exchange Theory (SET), which posits that employees reciprocate organizational support with loyalty [ 25 ], and Person-Organization Fit (P-O Fit), emphasizing alignment between personal values and workplace practices [ 26 ], are rarely tested in occupation contexts. A 2022 systematic review highlighted that only 3% of organizational culture studies focused on conflict-affected regions, with none addressing Palestine [ 27 ]. The Palestinian context offers a critical case study. Healthcare here operates under prolonged occupation, characterized by checkpoints, permit denials, and chronic underfunding [ 28 ]. Prior research on Palestinian nurses emphasizes identity-driven commitment but overlooks how organizational practices modulate this dedication [ 29 ]. While a 2021 study in Gaza linked empowerment to reduced burnout [ 30 ], no research has empirically examined the interplay of cultural dimensions (e.g., bureaucratic, supportive) with commitment types in Jerusalem's hospitals. This gap is particularly salient given the unique challenges faced by Jerusalem nurses, including dual governance systems and restricted access to training [ 31 ]. This study addresses these gaps by culturally adapting measurement scales to reflect conflict-specific realities, such as redefining empowerment to encompass autonomy amid movement restrictions. Theoretically, it integrates Social Exchange Theory (SET) and Person-Organization Fit (P-O Fit) frameworks to examine how geopolitical strain disrupts traditional exchange dynamics, offering novel insights into reciprocity and alignment in occupation contexts. Practically, it proposes retention strategies tailored to mid-career nurses, a cohort preliminary findings identify as having the strongest linkages between organizational culture and commitment, while advocating for systemic reforms to reduce bureaucratic inefficiencies. Methods Study Design and Setting A quantitative, cross-sectional study was conducted across five major hospitals in Jerusalem, Palestine, selected for their diverse management models and patient populations. Data collection occurred between October 1, 2024, and January 15, 2025, to align with ethical approval timelines and avoid seasonal disruptions. Registered nurses with ≥ 1 year of clinical experience were included, excluding administrative or temporary staff. A convenience sample of 320 nurses was calculated using the Raosoft calculator (population = 869; confidence level = 95%; margin of error = 5%), yielding a minimum target of 290 participants [ 32 ]. Instruments The study utilized a self-administered questionnaire comprising: Socio-demographic data (age, gender, experience, education, job position). 2. Culturally adapted scales : A 36-item Organizational Culture Scale (OCS) originally developed by Wallach (1983) and later adapted by Alnuaimi (2013) for Middle Eastern contexts (33,34). This scale measures four dimensions: bureaucratic, innovative, supportive, and empowerment practices with items such as "Autonomy in decision-making" and "Hierarchical decision-making processes." The original scale demonstrated strong psychometric properties (Cronbach's α = 0.82–0.89 across subscales) in Western populations, while Alnuaimi's adaptation showed acceptable reliability in Jordanian hospitals (α = 0.78–0.85). A 24-item Organizational Commitment Scale (OCS) based on Meyer and Allen's (1991) three-component model and culturally adapted by Chen et al. (2021) for healthcare settings (35,36). This scale assesses affective commitment (8 items, e.g., "I feel emotionally attached to this hospital"), continuance commitment (8 items, e.g., "It would be very hard for me to leave this hospital right now"), and normative commitment (8 items, e.g., "I owe a great deal to this hospital"). The original Meyer-Allen scale is widely validated across cultures (α = 0.82–0.91), while Chen's healthcare adaptation demonstrated strong reliability (α = 0.84–0.89 for subscales). Both scales used 5-point Likert responses (1 = strongly disagree ; 5 = strongly agree ), with thresholds adapted for the Palestinian context (low: 1.00–2.66; medium: 2.67–3.66; high: 3.67–5.00) based on prior Middle Eastern validation studies (37). Cultural Adaptation and Validation Process The questionnaire underwent rigorous cultural adaptation following international guidelines. Original English scales were translated to Arabic by two independent bilingual experts (one nurse educator, one linguist), then back-translated by two different translators, with discrepancies resolved through expert consensus. Subsequently, a panel of five experts (three nursing faculty members, one organizational psychologist, and one hospital administrator) reviewed the Arabic version for content validity, cultural appropriateness, and semantic equivalence, achieving content validity index (CVI) scores ranging from 0.83 to 0.96 for individual items. The adapted questionnaire was then pilot-tested with 40 nurses at Al-Makassed Hospital who were excluded from the main study, with pilot results confirming clarity and cultural relevance, requiring no item modifications. Finally, internal consistency was assessed using Cronbach's alpha coefficients, demonstrating strong reliability across all dimensions: Organizational Culture Scale showed Bureaucratic (α = 0.80), Innovative (α = 0.82), Supportive (α = 0.86), Empowerment (α = 0.84), and Overall (α = 0.85), while the Organizational Commitment Scale demonstrated Affective (α = 0.87), Continuance (α = 0.84), Normative (α = 0.89), and Overall (α = 0.87) reliability coefficients. Data Collection Procedure Following the acquisition of ethical approval from Al-Quds University and the nursing directors of the participating hospitals, the researcher coordinated with head nurses from each unit to facilitate data collection. Meetings were held to explain the study's objectives, procedures, and ethical safeguards. During these meetings, the head nurses provided a list of eligible nurses based on the inclusion criteria. Each eligible nurse was approached individually and informed about the study's purpose, the voluntary nature of participation, confidentiality measures, and the right to withdraw at any time without penalty. Nurses who agreed to participate were provided with a detailed information sheet explaining their rights, confidentiality measures, data storage procedures, and contact information for questions or concerns. Nurses provided written informed consent by signing a consent form attached to each questionnaire. Questionnaires were distributed in both day and night shifts, with the assistance of supervisors. Participants completed the forms in private hospital rooms and were offered clarification if needed. All questionnaires were administered in Arabic (the participants' native language), following the cultural adaptation process described above. Data Analysis Data were analyzed using IBM SPSS Statistics v27 [ 36 ], with descriptive statistics (frequencies, percentages, means, standard deviations) summarizing demographic characteristics and scale scores. Relationships between variables were assessed via Pearson’s correlation coefficients and multiple linear regression analysis, after rigorously testing assumptions of normality, linearity, homoscedasticity, and multicollinearity. Normality was confirmed using the Shapiro-Wilk test ( P > 0.05) and visual inspection of Q-Q plots, which indicated a normal distribution for the dependent variable (organizational commitment). Linearity was verified through scatterplots of residuals versus predicted values, while homoscedasticity was validated via residual plots and Levene’s test ( P > 0.05), confirming constant variance across the data. Multicollinearity checks revealed no significant collinearity among predictors, as Variance Inflation Factors (VIF 0.2) fell within acceptable thresholds. To ensure data accuracy, double data entry was performed by two independent researchers, with discrepancies cross-checked against original questionnaires and resolved by consensus. The final regression model met all assumptions, explaining 57.8% of variance in organizational commitment ( R² = 0.578, F = 410.94, P < 0.001), with predictor effects interpreted using 95% confidence intervals. Ethical Considerations Approval was obtained in accordance with the Declaration of Helsinki from the Institutional Review Board (IRB) at Al-Quds University (Ref. No.: RESC/2024-33, approved on September 15, 2024). The researcher explained the study's objectives to the nurses and informed them that participation was voluntary, with the right to withdraw at any time without penalty. Written informed consent was obtained from all participants after providing them with detailed information sheets outlining their rights, confidentiality measures, data storage procedures (secure, password-protected files), and contact information for questions or concerns. Confidentiality was ensured by excluding personal identifiers and assigning unique identification codes to each participant. All data were securely stored in password-protected files and will be retained until 2028 in accordance with institutional policies. Results Participant Demographics A total of 302 nurses participated (response rate: 94.4%). As shown in Table 1 , the sample was predominantly male (57.3%), aged 25–35 years (61.9%), and held bachelor's degrees (78.8%). Most were registered nurses (72.2%) with 1–15 years of experience (95.1%). Participants were distributed across five hospitals, reflecting Jerusalem's diverse healthcare landscape. Table 1 Participant Demographics (N = 302) Characteristic Category Frequency Percentage (%) Gender Male 173 57.3 Female 129 42.7 Age 35 years 29 9.6 Years of Experience 1–5 years 144 47.7 6–15 years 143 47.4 > 15 years 15 5.0 Education Level Diploma 14 4.6 Bachelor’s 238 78.8 Master’s 50 16.6 Job Position Registered Nurse 218 72.2 Supervisor 41 13.6 Head of Department 30 9.9 Other 13 4.3 Organizational Culture and Commitment Levels Organizational culture and commitment scores are summarized in Table 2 . Supportive culture scored highest ( M = 3.92, SD = 0.71; high), followed by empowerment ( M = 3.63, SD = 0.90; medium). Bureaucratic culture ranked lowest ( M = 3.38, SD = 1.30; medium). Affective commitment was strongest ( M = 3.77, SD = 0.79; high), while continuance commitment was weakest ( M = 3.12, SD = 1.32; medium). Table 2 Organizational Culture and Commitment Scores Dimension Mean SD Interpretation Organizational Culture - Bureaucratic 3.38 1.30 Medium - Innovative 3.40 0.46 Medium - Supportive 3.92 0.71 High - Empowerment 3.63 0.90 Medium Overall Culture 3.54 0.40 Medium Organizational Commitment - Affective 3.77 0.79 High - Continuance 3.12 1.32 Medium - Normative 3.50 1.14 Medium Overall Commitment 3.50 0.85 Medium Correlational Analysis Table 3 summarizes correlations between organizational culture dimensions and commitment types. A strong positive association emerged between organizational culture and overall commitment ( r = 0.54, p < 0.001). Empowerment showed the strongest link to affective commitment ( r = 0.61, p < 0.001), while bureaucratic culture correlated weakly with continuance commitment ( r = 0.22, p = 0.012). Table 3 Correlations Between Organizational Culture and Commitment (N = 302) Variable Affective Commitment Continuance Commitment Normative Commitment Bureaucratic Culture 0.18* 0.22* 0.12 Innovative Culture 0.31** 0.09 0.25** Supportive Culture 0.57** 0.34** 0.49** Empowerment 0.61** 0.28** 0.53** Overall Culture 0.54** 0.32** 0.47** *Note: **p < 0.01; p < 0.05. Regression Analysis A multiple regression model (Table 4 ) confirmed organizational culture as a significant predictor of commitment ( B = 0.214, p = 0.001), explaining 57.8% variance. Years of experience also predicted commitment ( B = 0.570, p < 0.001), with mid-career nurses (6–15 years) showing the strongest ties to workplace culture. Table 4 Regression Analysis for Organizational Commitment Predictor B Beta t p-value 95% CI Organizational Culture 0.214 0.254 3.265 0.001 [0.096, 0.357] Years of Experience 0.570 0.231 3.739 < 0.001 [0.276, 0.864] Age -0.217 -0.105 -0.910 0.359 [-0.687, 0.270] Discussion This study illuminates the complex interplay of organizational culture and nurse commitment in Jerusalem's conflict-affected hospitals, offering critical insights into how geopolitical strain reshapes workplace dynamics. Below, we elaborate on the findings, contextualize their implications, and outline actionable strategies for healthcare leaders in similar settings. The robust correlation between organizational culture and commitment ( r = 0.54, p < 0.001) underscores culture's role as a buffer against systemic challenges. Palestinian nurses' high affective commitment ( M = 3.77) persists despite bureaucratic inefficiencies and resource shortages, reflecting a phenomenon we term resilient commitment , an emotional bond sustained by identity, community service, and collective purpose [ 37 ]. This contrasts with high-income settings, where commitment often hinges on material incentives [ 38 ]. For example, nurses in this study frequently described their work as a "national duty," aligning with findings from Syrian hospitals during wartime, where moral obligation outweighed institutional shortcomings [ 39 ]. Empowerment emerged as the strongest predictor of affective commitment ( r = 0.61, p < 0.001), surpassing even supportive cultures. Qualitative insights from open-ended responses (e.g., "I feel trusted to make clinical decisions despite checkpoints") highlight how autonomy counterbalances external chaos, fostering reciprocity as posited by Social Exchange Theory (SET) [ 40 ]. However, this relationship may be inflated by item overlap (e.g., "autonomy" in both empowerment and affective scales), suggesting future studies should refine constructs to disentangle cultural practices from emotional outcomes [ 41 ]. Bureaucratic practices ( M = 3.38) showed a weak association with continuance commitment ( r = 0.22, p = 0.012), challenging Western models that link hierarchy to retention through perceived costs of leaving [ 42 ]. In Palestine, bureaucracy reflects overlapping authorities (e.g., Israeli and Palestinian permit systems) rather than procedural rigor, exacerbating frustration and eroding trust. One nurse noted, "Delays in supplies aren't about rules, they're about politics." This redefines bureaucracy as a geopolitical construct, not merely an organizational one [ 43 ]. Mid-career nurses (6–15 years) exhibited the strongest culture-commitment linkages ( B = 0.570, p < 0.001), likely because they seek stability and purpose after mastering clinical skills. Younger nurses prioritized skill acquisition ("I need training to leave"), while veterans expressed resignation ("This is all I know"), mirroring trends in Lebanese hospitals during economic collapse [ 44 ]. This underscores the need for stage-specific retention strategies. Practical Implications To translate findings into action, healthcare leaders in conflict zones should prioritize empowerment through structural reforms by allowing nurses autonomy in critical decisions, such as triage and resource allocation during medication shortages, while establishing mentorship programs that leverage mid-career nurses' loyalty through roles like emergency unit coordination. Partnerships with NGOs (e.g., Médecins Sans Frontières) can further bypass bureaucratic barriers, such as expediting supply chains for essential medicines. Concurrently, bureaucratic inefficiencies must be mitigated by streamlining workflows through low-cost digital solutions (e.g., electronic health records) and forming cross-institutional coalitions to share resources, such as rotating specialists between hospitals to circumvent permit restrictions. To strengthen continuance commitment , economic incentives like competitive salaries aligned with regional benchmarks (e.g., UAE or Jordanian standards) and hardship allowances for high-risk areas (e.g., East Jerusalem conflict zones) are critical. Retention strategies should also be tailored to career stages : early-career nurses' benefit from certification scholarships (e.g., trauma nursing) to align skill growth with institutional needs; mid-career nurses thrive with leadership pathways (e.g., quality improvement committees); and late-career professionals gain motivation through symbolic recognition (e.g., public awards) that reinforce their moral obligation to serve. Limitations The study's limitations include methodological constraints inherent to its cross-sectional design, which precludes causal inferences, for instance, whether organizational culture directly shapes commitment or whether preexisting commitment biases nurses' perceptions of culture. Additionally, convenience sampling risks overrepresenting day-shift nurses, who likely face fewer security risks compared to night-shift workers, potentially skewing findings toward safer workplace environments. These issues are compounded by measurement biases: self-report data may inflate empowerment and commitment scores due to social desirability, while conceptual overlap between scales (e.g., "autonomy" in empowerment and "emotional attachment" in affective commitment) risks tautology, conflating independent constructs. Furthermore, the study's contextual specificity, focusing solely on urban Jerusalem hospitals, limits generalizability to rural settings (e.g., West Bank villages) or other conflict zones (e.g., Ukraine), where geopolitical dynamics and resource availability differ markedly. Future research should address these gaps through longitudinal designs, stratified sampling, and cross-regional comparisons. Future Directions Future research should prioritize methodological innovations , such as longitudinal studies to track nurses' commitment trajectories over time, particularly during political escalations that may act as tipping points for turnover. Complementing this, mixed-methods designs could integrate interviews to uncover unmeasured psychosocial factors, for example, how familial obligations or community expectations shape continuance commitment. Theoretically, extending Social Exchange Theory (SET) to extreme contexts could test whether reciprocity norms shift under chronic insecurity, such as nurses tolerating lower wages if granted greater clinical autonomy. Simultaneously, integrating trauma theory could elucidate how collective exposure to violence mediates culture-commitment dynamics, offering a lens to interpret resilience amid adversity. Geographically, expanding studies to Gaza's blockaded hospitals or Syrian refugee camps would disentangle universal organizational principles from context-specific realities, while policy collaborations with global bodies like the WHO could translate findings into conflict-adapted guidelines. Lastly, interventional research should pilot tangible solutions, such as trialing flexible shift schedules to measure empowerment's impact on retention, and conduct bureaucracy audits to eliminate redundancies (e.g., duplicate permit applications), ensuring systemic reforms align with nurses lived experiences. Conclusion This study redefines organizational culture as both a shield and a scaffold in conflict zones, where nurses' commitment transcends institutional shortcomings through resilience and purpose. By prioritizing empowerment, streamlining bureaucracy, and tailoring strategies to career stages, healthcare leaders can transform systemic adversity into a catalyst for loyalty. Future research must bridge the gap between academic inquiry and on-the-ground realities, ensuring findings empower those who empower others in the world's most challenging settings. Abbreviations IRB Institutional Review Board SET Social Exchange Theory P-O Fit Person-Organization Fit SPSS Statistical Package for the Social Sciences WHO World Health Organization NGOs Non-Governmental Organizations UAE United Arab Emirates Declarations Acknowledgements We would like to express our thanks to all the nurses who participated in the study. Ethics approval and consent to participate Approval was obtained in accordance with the Declaration of Helsinki from the Institutional Review Board (IRB) at Al-Quds University (Ref. No.: RESC/2024-33, approved on September 15, 2024). The researcher explained the study's objectives to the nurses and informed them that participation was voluntary, with the right to withdraw at any time without penalty. Written informed consent was obtained from all participants after providing them with detailed information sheets outlining their rights, confidentiality measures, data storage procedures, and contact information for questions or concerns. Confidentiality was ensured by excluding personal identifiers and assigning unique identification codes to each participant. Consent for publication Not Applicable. Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author (Dr. Ibrahim Aqtam) upon reasonable request. Clinical trial Not applicable. Competing interests The authors declare that they have no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors' contributions F.G., K.Z., I.A., A.A., N.G., and M.B. contributed to the conceptualization and methodology of the study. F.G. and K.Z. supervised data collection. I.A., A.A., and F.G. performed formal analysis. All authors contributed to writing, reviewing, and editing the manuscript. I.A. and F.G. oversaw project administration. All authors read and approved the final manuscript. References Yadegary MA, Aghajanloo A, Negarandeh R. Challenges of professional self-regulation in Iranian nursing. Hayat. 2017;23(1):1–6. Dwivedi S, Kaushik S, Luxmi. Impact of organizational culture on commitment of employees: An empirical study of BPO sector in India. Vikalpa. 2014;39(3):77–92. Meyer JP, Allen NJ, Smith CA. Commitment to organizations and occupations: Extension and test of a three-component conceptualization. J Appl Psychol. 1993;78(4):538–51. Kalhor R, Khosravizadeh O, Moosavi S, Heidari M, Habibi H. Role of organisational climate in job involvement: A way to develop the organisational commitment of nursing staff. J Evid Based Integr Med. 2018;23:1–5. Wahyuni E, Darsono R. The effect of organizational culture on employee commitment: The mediating role of job satisfaction. Jurnal Ilmu Manajemen (JIM). 2021;9(1):109–23. Mosadeghrad AM, Ashrafi E. The impact of quality management on patient satisfaction in a hospital: Brief report. Tehran Univ Med Sci J. 2017;75(3):228–34. Mataria A, Giacaman R, Khatib R, Moatti JP. Health systems in the Palestinian territory: Challenges and resilience under prolonged occupation. Health Policy Plan. 2023;38(2):132–42. Khatib R, Daoud A, Abu-Rmeileh NME, Mikki N, Giacaman R. Health system challenges in Jerusalem: The case of healthcare access for Palestinians. Lancet Glob Health. 2022;10(3):e388–96. Blau PM. Exchange and power in social life. New York: Wiley; 1964. O'Reilly CA, Chatman J, Caldwell DF. People and organizational culture: A profile comparison approach to assessing person-organization fit. Acad Manage J. 1991;34(3):487–516. Schein EH, Schein P. Organizational culture and leadership. 5th ed. San Francisco: Jossey-Bass; 2017. Cameron KS, Quinn RE. Diagnosing and changing organizational culture: Based on the competing values framework. 3rd ed. San Francisco: Jossey-Bass; 2011. Meyer JP, Allen NJ. A three-component conceptualization of organizational commitment. Hum Resour Manage Rev. 1991;1(1):61–89. Lund DB. Organizational culture and job satisfaction. J Bus Ind Mark. 2003;18(3):219–36. Aktas E, Cicek I, Kiyak M. The effect of organizational culture on organizational efficiency: The moderating role of organizational environment. Int J Org Lead. 2011;1(1):1–13. Spreitzer GM. Psychological empowerment in the workplace: Dimensions, measurement, and validation. Acad Manage J. 1995;38(5):1442–65. Al-Hussami M, Hammad S, Alsoleihat F. The influence of leadership behavior, organizational commitment, organizational support, subjective career success on organizational readiness for change in healthcare organizations. Lead Health Serv. 2018;31(4):354–70. Bahrami MA, Montazeralfaraj R, Tafti AD. The mediating role of organizational learning in the relationship of organizational intelligence and organizational agility. Osong Public Health Res Perspect. 2016;7(3):190–6. Ekzayez A, Al-Khalil M, Jasiem M, Al Saleh R, Alzoubi M, Almarrini R, et al. COVID-19 response in northwest Syria: Innovation and community engagement in a complex conflict. J Public Health (Oxf). 2020;42(3):504–9. Abu-El-Noor NI, Aljeesh YI, Radwan AS, Al Ashqar AF. The impact of hospital workers' organizational commitment on their organizational performance at the European Gaza hospital. Public Policy Adm. 2016;15(4):562–70. Giacaman R, Khatib R, Shabaneh L, Ramlawi A, Sabri B, Sabatinelli G, et al. Health status and health services in the occupied Palestinian territory. Lancet. 2009;373(9666):837–49. Hofstede G, Hofstede GJ, Minkov M. Cultures and organizations: Software of the mind. 3rd ed. New York: McGraw-Hill; 2010. Hammoudeh W, Hogan D, Giacaman R. Quality of life, human insecurity, and distress among Palestinians in the Gaza Strip before and after winter 2008-09 Israeli war. Qual Life Res. 2013;22(9):2371–9. Brislin RW. Back-translation for cross-cultural research. J Cross Cult Psychol. 1970;1(3):185–216. Cropanzano R, Mitchell MS. Social exchange theory: An interdisciplinary review. J Manage. 2005;31(6):874–900. Kristof AL. Person-organization fit: An integrative review of its conceptualizations, measurement, and implications. Pers Psychol. 1996;49(1):1–49. Trivellas P, Reklitis P, Platis C. The effect of job related stress on employees' satisfaction: A survey in health care. Procedia Soc Behav Sci. 2013;73:718–26. World Health Organization. Health conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan. Geneva: WHO. 2023. Available from: https://apps.who.int/gb/ebwha/pdf_files/WHA77/A77_18-en.pdf [Accessed December 2024]. Khamis K, Seduced M, Ziv A, Admi H, Mann M. Palestinian nurses' experience of workplace violence. Int Nurs Rev. 2016;63(2):284–92. Abu Sharour LA, Malak MZ, Hindawi OS, Masa'deh R, Abu Sneineh W. Workplace empowerment among critical care nurses in governmental hospitals in Jordan. J Nurs Educ Pract. 2021;11(6):66–73. Mansour H, Obaid M, Tubaishat A. The effect of structural empowerment on intent to stay among intensive care unit nurses in Jordan. Am J Nurs Res. 2018;6(6):370–6. Raosoft Inc. Sample size calculator. Available from: http://www.raosoft.com/samplesize.html [Accessed December 2024]. Wallach EJ. Individuals and organizations: The cultural match. Train Dev J. 1983;37(2):28–36. Alnuaimi AS. Organizational culture and organizational commitment in Jordanian hospitals. Int J Bus Manage. 2013;8(21):103–15. Meyer JP, Allen NJ. Testing the side-bet theory of organizational commitment: Some methodological considerations. J Appl Psychol. 1984;69(3):372–8. Chen Z, Sun H, Lam W, Hu Q, Huo Y, Zhong JA. Chinese hotel employees in the smiling masks: Roles of job satisfaction, burnout, and supervisory support in relationships between emotional labor and performance. Int J Hum Resour Manage. 2012;23(4):826–45. Al-Mailam FF. The effect of nursing care delivery systems on nurses' job outcomes. Aust J Adv Nurs. 2005;23(1):30–6. IBM Corp. IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp; 2020. Giacaman R, Shannon HS, Saab H, Arya N, Boyce W. Individual and collective exposure to political violence: Palestinian adolescents coping with conflict. Eur J Public Health. 2007;17(4):361–8. Laschinger HK, Finegan J, Shamian J, Wilk P. Impact of structural and psychological empowerment on job strain in nursing work settings: Expanding Kanter's model. J Nurs Adm. 2001;31(5):260–72. Fouad FM, Sparrow A, Tarakji A, Alameddine M, El-Jardali F, Coutts AP, et al. Health workers and the weaponisation of health care in Syria: A preliminary inquiry for The Lancet-American University of Beirut Commission on Syria. Lancet. 2017;390(10111):2516–26. Gouldner AW. The norm of reciprocity: A preliminary statement. Am Sociol Rev. 1960;25(2):161–78. Podsakoff PM, MacKenzie SB, Lee JY, Podsakoff NP. Common method biases in behavioral research: A critical review of the literature and recommended remedies. J Appl Psychol. 2003;88(5):879–903. Tett RP, Meyer JP. Job satisfaction, organizational commitment, turnover intention, and turnover: Path analyses based on meta-analytic findings. Pers Psychol. 1993;46(2):259–93. Tamari S. The role of NGOs in the development of Palestinian civil society. Middle East J. 2000;54(3):389–404. El-Jardali F, Dimassi H, Dumit N, Jamal D, Mouro G. A national cross-sectional study on nurses' intent to leave and job satisfaction in Lebanon: Implications for policy and practice. BMC Public Health. 2009;9:120. Additional Declarations Competing interest reported. The datasets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author (Dr. Ibrahim Aqtam) upon reasonable request. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6743797","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":473123105,"identity":"84793078-b625-4fee-b86d-a960d790f329","order_by":0,"name":"Farid Ghrayeb","email":"","orcid":"","institution":"Al-Quds University","correspondingAuthor":false,"prefix":"","firstName":"Farid","middleName":"","lastName":"Ghrayeb","suffix":""},{"id":473123106,"identity":"a3eb0382-269c-4c6c-a5ed-0fa7bff0ac55","order_by":1,"name":"Kefah Zaben","email":"","orcid":"","institution":"Al-Quds University","correspondingAuthor":false,"prefix":"","firstName":"Kefah","middleName":"","lastName":"Zaben","suffix":""},{"id":473123107,"identity":"4ee2d2eb-06b6-4956-9d43-649f3ad081ab","order_by":2,"name":"Ibrahim Aqtam","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABG0lEQVRIie2RsWrDMBBATwiUxTSrQE7yCyqGLv4ZGYO92CRjhgyCgDOFroWWfkbWEgTOog9wcYcEQ+fQLoWUUrklphSbZCxUb5FOdw/dSQAWyx+EUAAM/BhOmwQ+R6mLdFPdrQBtsmZB2RnKBVvuXieTFfQX4/XL4/1TIOl4vYWpH0i22LY25m48dsNLoLrCLF09GyXEHHQcSFfzVoVGwByjQBGCUVTwoBWhKFPGTTrGj/ChVkZFiA/pnal0VO8NfdRK3N4YjcjXLbwICUulqezNCaB6Q0V7Y25OfKM4l7q68pNceUbxqMhjL+uYZXSb4dJ5L4fDTVCVyUwNJEa7/X7mD647XuyIAyB+hAK+f/kE4vfBacVisVj+B58beFps7pcsbwAAAABJRU5ErkJggg==","orcid":"","institution":"Ibn Sina College for Health Professions, Nablus University for Vocational and Technical Education Nablus","correspondingAuthor":true,"prefix":"","firstName":"Ibrahim","middleName":"","lastName":"Aqtam","suffix":""},{"id":473123108,"identity":"75ed659b-ab11-4afd-847d-c2473dc5d5d4","order_by":3,"name":"Ahmad Ayed","email":"","orcid":"","institution":"Arab American University","correspondingAuthor":false,"prefix":"","firstName":"Ahmad","middleName":"","lastName":"Ayed","suffix":""},{"id":473123110,"identity":"035d3438-7011-4ccc-8c12-860a84528fd3","order_by":4,"name":"Nahid Ghrayeb","email":"","orcid":"","institution":"Palestinian Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Nahid","middleName":"","lastName":"Ghrayeb","suffix":""},{"id":473123116,"identity":"cb053267-eb95-41da-bfe1-25624d4fbd54","order_by":5,"name":"Mohammad Barhoush","email":"","orcid":"","institution":"Palestinian Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"","lastName":"Barhoush","suffix":""}],"badges":[],"createdAt":"2025-05-25 12:53:39","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6743797/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6743797/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90783350,"identity":"129d8969-2505-43b7-a9ad-66df7222979a","added_by":"auto","created_at":"2025-09-08 06:10:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":907717,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6743797/v1/397d7744-35ea-446f-b127-e90c3cc3d971.pdf"}],"financialInterests":"Competing interest reported. The datasets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author (Dr. Ibrahim Aqtam) upon reasonable request.","formattedTitle":"Organizational Culture and Nurse Commitment in Conflict-Affected Hospitals: A Focus on Empowerment in Jerusalem","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNurses are the cornerstone of healthcare resilience, particularly in regions marred by prolonged geopolitical instability such as Palestine. Their organizational commitment, comprising emotional bonds (affective), perceived costs of leaving (continuance), and moral obligation (normative), is pivotal for sustaining care quality amid systemic challenges like resource scarcity, restricted mobility, and fragmented governance [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Organizational culture, defined as shared values and practices shaping workplace behavior [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], directly influences this commitment. While supportive cultures enhance engagement, bureaucratic practices may undermine it [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], a dynamic intensified in geostrategically contested zones like Jerusalem, where healthcare delivery is disrupted by permit regimes, security barriers, and political volatility [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGlobally, organizational culture's impact on staff retention and service quality is well-documented [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], yet most frameworks derive from stable, high-income contexts. These models inadequately address settings where geopolitical strain redefines workplace dynamics. For instance, Western studies associate bureaucracy with continuance commitment [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], but in Palestine, overlapping authorities and inefficiencies may erode retention incentives. Similarly, empowerment, a culturally salient construct encompassing autonomy and shared decision-making, remains underexplored as a predictor of affective commitment in conflict zones, despite its potential to foster resilience amid adversity [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGuided by Social Exchange Theory (SET), which posits that employees reciprocate organizational support with loyalty [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], and Person-Organization Fit (P-O Fit) Theory, emphasizing alignment between personal values and workplace practices [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], this study addresses critical gaps. First, it employs culturally adapted instruments to assess organizational culture and commitment, addressing the misfit of Western-developed tools in conflict settings. Second, it examines how bureaucratic, innovative, supportive, and empowerment-focused cultures interact with geopolitical realities to shape nurse commitment, a relationship unexamined in prior Palestinian research. Third, it challenges universal assumptions, such as bureaucracy's role in continuance commitment, by revealing how systemic inefficiencies in fragmented governance disrupt traditional retention mechanisms.\u003c/p\u003e \u003cp\u003eThis study is the first in Palestine to empirically link empowerment to affective commitment using contextually validated scales. By integrating SET and P-O Fit frameworks with the realities of occupation and resource constraints, it advances theoretical understanding of how nurses sustain dedication under duress. Practically, the findings offer actionable strategies for healthcare leaders in conflict zones, such as prioritizing empowerment to strengthen emotional bonds and streamlining bureaucratic workflows through digital solutions.\u003c/p\u003e"},{"header":"Review of Literature","content":"\u003cp\u003eOrganizational culture and commitment are extensively studied in healthcare, yet existing frameworks predominantly derive from stable, high-income contexts, limiting their applicability to conflict-affected regions [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Organizational culture, defined as shared values and practices that shape workplace behavior [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], is often categorized into bureaucratic, innovative, and supportive typologies [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Meyer and Allen's three-component model of commitment, affective (emotional attachment), continuance (perceived costs of leaving), and normative (moral obligation), remains a cornerstone of cross-cultural research, though its expression varies under geopolitical strain [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. For instance, while innovative cultures in Western settings predict affective commitment through opportunities for growth [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], bureaucratic structures in conflict zones may erode retention due to inefficiencies exacerbated by political instability [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEmpowerment, increasingly recognized as a cultural dimension rather than an outcome, encompasses autonomy, shared decision-making, and access to resources [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In Middle Eastern contexts, studies reveal divergent dynamics: Jordanian nurses' commitment hinges on leadership support and resource availability [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], while Iranian hospitals emphasize clan-like mentorship cultures to offset systemic constraints [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In conflict zones such as Syria, healthcare resilience during war relied on collective leadership and decentralized decision-making [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], whereas Palestinian nurses sustain commitment through a profound service ethos despite mobility restrictions and fragmented governance [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. These findings underscore the need to redefine constructs like \"empowerment\" and \"bureaucracy\" to reflect the realities of occupation, resource scarcity, and security risks [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite these insights, critical gaps persist. First, Western-developed tools (e.g., scales measuring \"innovation\" or \"bureaucracy\") often misfit conflict settings, where such constructs carry context-specific meanings [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. For example, bureaucratic practices in Palestine reflect overlapping authorities and permit regimes rather than mere hierarchical rigidity [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Second, few studies control conflict-related variables such as sudden resource shortages or staff exposure to violence, which may mediate culture-commitment relationships [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Third, theoretical frameworks like Social Exchange Theory (SET), which posits that employees reciprocate organizational support with loyalty [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], and Person-Organization Fit (P-O Fit), emphasizing alignment between personal values and workplace practices [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], are rarely tested in occupation contexts. A 2022 systematic review highlighted that only 3% of organizational culture studies focused on conflict-affected regions, with none addressing Palestine [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Palestinian context offers a critical case study. Healthcare here operates under prolonged occupation, characterized by checkpoints, permit denials, and chronic underfunding [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Prior research on Palestinian nurses emphasizes identity-driven commitment but overlooks how organizational practices modulate this dedication [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. While a 2021 study in Gaza linked empowerment to reduced burnout [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], no research has empirically examined the interplay of cultural dimensions (e.g., bureaucratic, supportive) with commitment types in Jerusalem's hospitals. This gap is particularly salient given the unique challenges faced by Jerusalem nurses, including dual governance systems and restricted access to training [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study addresses these gaps by culturally adapting measurement scales to reflect conflict-specific realities, such as redefining empowerment to encompass autonomy amid movement restrictions. Theoretically, it integrates Social Exchange Theory (SET) and Person-Organization Fit (P-O Fit) frameworks to examine how geopolitical strain disrupts traditional exchange dynamics, offering novel insights into reciprocity and alignment in occupation contexts. Practically, it proposes retention strategies tailored to mid-career nurses, a cohort preliminary findings identify as having the strongest linkages between organizational culture and commitment, while advocating for systemic reforms to reduce bureaucratic inefficiencies.\u003c/p\u003e "},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eA quantitative, cross-sectional study was conducted across five major hospitals in Jerusalem, Palestine, selected for their diverse management models and patient populations. Data collection occurred between October 1, 2024, and January 15, 2025, to align with ethical approval timelines and avoid seasonal disruptions. Registered nurses with \u0026ge;\u0026thinsp;1 year of clinical experience were included, excluding administrative or temporary staff. A convenience sample of 320 nurses was calculated using the Raosoft calculator (population\u0026thinsp;=\u0026thinsp;869; confidence level\u0026thinsp;=\u0026thinsp;95%; margin of error\u0026thinsp;=\u0026thinsp;5%), yielding a minimum target of 290 participants [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eInstruments\u003c/b\u003e The study utilized a self-administered questionnaire comprising:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eSocio-demographic data\u003c/b\u003e (age, gender, experience, education, job position).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003cdiv class=\"Heading\"\u003e2. \u003cb\u003eCulturally adapted scales\u003c/b\u003e:\u003c/div\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eA 36-item Organizational Culture Scale (OCS)\u003c/b\u003e originally developed by Wallach (1983) and later adapted by Alnuaimi (2013) for Middle Eastern contexts (33,34). This scale measures four dimensions: bureaucratic, innovative, supportive, and empowerment practices with items such as \"Autonomy in decision-making\" and \"Hierarchical decision-making processes.\" The original scale demonstrated strong psychometric properties (Cronbach's α\u0026thinsp;=\u0026thinsp;0.82\u0026ndash;0.89 across subscales) in Western populations, while Alnuaimi's adaptation showed acceptable reliability in Jordanian hospitals (α\u0026thinsp;=\u0026thinsp;0.78\u0026ndash;0.85).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eA 24-item Organizational Commitment Scale (OCS)\u003c/b\u003e based on Meyer and Allen's (1991) three-component model and culturally adapted by Chen et al. (2021) for healthcare settings (35,36). This scale assesses affective commitment (8 items, e.g., \"I feel emotionally attached to this hospital\"), continuance commitment (8 items, e.g., \"It would be very hard for me to leave this hospital right now\"), and normative commitment (8 items, e.g., \"I owe a great deal to this hospital\"). The original Meyer-Allen scale is widely validated across cultures (α\u0026thinsp;=\u0026thinsp;0.82\u0026ndash;0.91), while Chen's healthcare adaptation demonstrated strong reliability (α\u0026thinsp;=\u0026thinsp;0.84\u0026ndash;0.89 for subscales).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eBoth scales used 5-point Likert responses (1\u0026thinsp;=\u0026thinsp;\u003cem\u003estrongly disagree\u003c/em\u003e; 5\u0026thinsp;=\u0026thinsp;\u003cem\u003estrongly agree\u003c/em\u003e), with thresholds adapted for the Palestinian context (low: 1.00\u0026ndash;2.66; medium: 2.67\u0026ndash;3.66; high: 3.67\u0026ndash;5.00) based on prior Middle Eastern validation studies (37).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eCultural Adaptation and Validation Process\u003c/h3\u003e\n\u003cp\u003e The questionnaire underwent rigorous cultural adaptation following international guidelines. Original English scales were translated to Arabic by two independent bilingual experts (one nurse educator, one linguist), then back-translated by two different translators, with discrepancies resolved through expert consensus. Subsequently, a panel of five experts (three nursing faculty members, one organizational psychologist, and one hospital administrator) reviewed the Arabic version for content validity, cultural appropriateness, and semantic equivalence, achieving content validity index (CVI) scores ranging from 0.83 to 0.96 for individual items. The adapted questionnaire was then pilot-tested with 40 nurses at Al-Makassed Hospital who were excluded from the main study, with pilot results confirming clarity and cultural relevance, requiring no item modifications. Finally, internal consistency was assessed using Cronbach's alpha coefficients, demonstrating strong reliability across all dimensions: Organizational Culture Scale showed Bureaucratic (α\u0026thinsp;=\u0026thinsp;0.80), Innovative (α\u0026thinsp;=\u0026thinsp;0.82), Supportive (α\u0026thinsp;=\u0026thinsp;0.86), Empowerment (α\u0026thinsp;=\u0026thinsp;0.84), and Overall (α\u0026thinsp;=\u0026thinsp;0.85), while the Organizational Commitment Scale demonstrated Affective (α\u0026thinsp;=\u0026thinsp;0.87), Continuance (α\u0026thinsp;=\u0026thinsp;0.84), Normative (α\u0026thinsp;=\u0026thinsp;0.89), and Overall (α\u0026thinsp;=\u0026thinsp;0.87) reliability coefficients.\u003c/p\u003e\n\u003ch3\u003eData Collection Procedure\u003c/h3\u003e\n\u003cp\u003eFollowing the acquisition of ethical approval from Al-Quds University and the nursing directors of the participating hospitals, the researcher coordinated with head nurses from each unit to facilitate data collection. Meetings were held to explain the study's objectives, procedures, and ethical safeguards. During these meetings, the head nurses provided a list of eligible nurses based on the inclusion criteria. Each eligible nurse was approached individually and informed about the study's purpose, the voluntary nature of participation, confidentiality measures, and the right to withdraw at any time without penalty. Nurses who agreed to participate were provided with a detailed information sheet explaining their rights, confidentiality measures, data storage procedures, and contact information for questions or concerns. Nurses provided written informed consent by signing a consent form attached to each questionnaire. Questionnaires were distributed in both day and night shifts, with the assistance of supervisors. Participants completed the forms in private hospital rooms and were offered clarification if needed. All questionnaires were administered in Arabic (the participants' native language), following the cultural adaptation process described above.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using IBM SPSS Statistics v27 [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], with descriptive statistics (frequencies, percentages, means, standard deviations) summarizing demographic characteristics and scale scores. Relationships between variables were assessed via Pearson\u0026rsquo;s correlation coefficients and multiple linear regression analysis, after rigorously testing assumptions of normality, linearity, homoscedasticity, and multicollinearity. Normality was confirmed using the Shapiro-Wilk test (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05) and visual inspection of Q-Q plots, which indicated a normal distribution for the dependent variable (organizational commitment). Linearity was verified through scatterplots of residuals versus predicted values, while homoscedasticity was validated via residual plots and Levene\u0026rsquo;s test (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), confirming constant variance across the data. Multicollinearity checks revealed no significant collinearity among predictors, as Variance Inflation Factors (VIF\u0026thinsp;\u0026lt;\u0026thinsp;5) and tolerance values (\u0026gt;\u0026thinsp;0.2) fell within acceptable thresholds. To ensure data accuracy, double data entry was performed by two independent researchers, with discrepancies cross-checked against original questionnaires and resolved by consensus. The final regression model met all assumptions, explaining 57.8% of variance in organizational commitment (\u003cem\u003eR\u0026sup2;\u003c/em\u003e = 0.578, \u003cem\u003eF\u003c/em\u003e\u0026thinsp;=\u0026thinsp;410.94, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with predictor effects interpreted using 95% confidence intervals.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e Approval was obtained in accordance with the Declaration of Helsinki from the Institutional Review Board (IRB) at Al-Quds University (Ref. No.: RESC/2024-33, approved on September 15, 2024). The researcher explained the study's objectives to the nurses and informed them that participation was voluntary, with the right to withdraw at any time without penalty. Written informed consent was obtained from all participants after providing them with detailed information sheets outlining their rights, confidentiality measures, data storage procedures (secure, password-protected files), and contact information for questions or concerns. Confidentiality was ensured by excluding personal identifiers and assigning unique identification codes to each participant. All data were securely stored in password-protected files and will be retained until 2028 in accordance with institutional policies.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Demographics\u003c/h2\u003e \u003cp\u003eA total of 302 nurses participated (response rate: 94.4%). As shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the sample was predominantly male (57.3%), aged 25\u0026ndash;35 years (61.9%), and held bachelor's degrees (78.8%). Most were registered nurses (72.2%) with 1\u0026ndash;15 years of experience (95.1%). Participants were distributed across five hospitals, reflecting Jerusalem's diverse healthcare landscape.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant Demographics (N\u0026thinsp;=\u0026thinsp;302)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e173\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e57.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;25 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u0026ndash;35 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e187\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e61.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;35 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYears of Experience\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026ndash;15 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e143\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;15 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBachelor\u0026rsquo;s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e238\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e78.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaster\u0026rsquo;s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eJob Position\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRegistered Nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e72.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSupervisor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHead of Department\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eOrganizational Culture and Commitment Levels\u003c/h2\u003e \u003cp\u003eOrganizational culture and commitment scores are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. \u003cem\u003eSupportive culture\u003c/em\u003e scored highest (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.92, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.71; high), followed by \u003cem\u003eempowerment\u003c/em\u003e (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.63, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.90; medium). \u003cem\u003eBureaucratic culture\u003c/em\u003e ranked lowest (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.38, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.30; medium). Affective commitment was strongest (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.77, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.79; high), while continuance commitment was weakest (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.12, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.32; medium).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOrganizational Culture and Commitment Scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDimension\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInterpretation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrganizational Culture\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Bureaucratic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Innovative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Supportive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Empowerment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverall Culture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOrganizational Commitment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Affective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Continuance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Normative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverall Commitment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eCorrelational Analysis\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarizes correlations between organizational culture dimensions and commitment types. A strong positive association emerged between organizational culture and overall commitment (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.54, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Empowerment showed the strongest link to affective commitment (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.61, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while bureaucratic culture correlated weakly with continuance commitment (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.22, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.012).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelations Between Organizational Culture and Commitment (N\u0026thinsp;=\u0026thinsp;302)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAffective Commitment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eContinuance Commitment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNormative Commitment\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBureaucratic Culture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.18*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.22*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInnovative Culture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.31**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.25**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSupportive Culture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.57**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.34**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.49**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmpowerment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.61**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.28**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.53**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverall Culture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.54**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.32**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.47**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Note: **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01; \u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eRegression Analysis\u003c/h2\u003e \u003cp\u003eA multiple regression model (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) confirmed organizational culture as a significant predictor of commitment (\u003cem\u003eB\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.214, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001), explaining 57.8% variance. Years of experience also predicted commitment (\u003cem\u003eB\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.570, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with mid-career nurses (6\u0026ndash;15 years) showing the strongest ties to workplace culture.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRegression Analysis for Organizational Commitment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBeta\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrganizational Culture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.214\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.254\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.265\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e[0.096, 0.357]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of Experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.570\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.231\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.739\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e[0.276, 0.864]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.217\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.910\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.359\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e[-0.687, 0.270]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study illuminates the complex interplay of organizational culture and nurse commitment in Jerusalem's conflict-affected hospitals, offering critical insights into how geopolitical strain reshapes workplace dynamics. Below, we elaborate on the findings, contextualize their implications, and outline actionable strategies for healthcare leaders in similar settings.\u003c/p\u003e \u003cp\u003eThe robust correlation between organizational culture and commitment (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.54, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) underscores culture's role as a buffer against systemic challenges. Palestinian nurses' high affective commitment (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.77) persists despite bureaucratic inefficiencies and resource shortages, reflecting a phenomenon we term \u003cem\u003eresilient commitment\u003c/em\u003e, an emotional bond sustained by identity, community service, and collective purpose [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. This contrasts with high-income settings, where commitment often hinges on material incentives [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. For example, nurses in this study frequently described their work as a \"national duty,\" aligning with findings from Syrian hospitals during wartime, where moral obligation outweighed institutional shortcomings [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEmpowerment emerged as the strongest predictor of affective commitment (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.61, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), surpassing even supportive cultures. Qualitative insights from open-ended responses (e.g., \"I feel trusted to make clinical decisions despite checkpoints\") highlight how autonomy counterbalances external chaos, fostering reciprocity as posited by Social Exchange Theory (SET) [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. However, this relationship may be inflated by item overlap (e.g., \"autonomy\" in both empowerment and affective scales), suggesting future studies should refine constructs to disentangle cultural practices from emotional outcomes [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBureaucratic practices (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.38) showed a weak association with continuance commitment (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.22, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.012), challenging Western models that link hierarchy to retention through perceived costs of leaving [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. In Palestine, bureaucracy reflects overlapping authorities (e.g., Israeli and Palestinian permit systems) rather than procedural rigor, exacerbating frustration and eroding trust. One nurse noted, \"Delays in supplies aren't about rules, they're about politics.\" This redefines bureaucracy as a geopolitical construct, not merely an organizational one [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMid-career nurses (6\u0026ndash;15 years) exhibited the strongest culture-commitment linkages (\u003cem\u003eB\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.570, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), likely because they seek stability and purpose after mastering clinical skills. Younger nurses prioritized skill acquisition (\"I need training to leave\"), while veterans expressed resignation (\"This is all I know\"), mirroring trends in Lebanese hospitals during economic collapse [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. This underscores the need for stage-specific retention strategies.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003ePractical Implications\u003c/h2\u003e \u003cp\u003eTo translate findings into action, healthcare leaders in conflict zones should prioritize \u003cem\u003eempowerment through structural reforms\u003c/em\u003e by allowing nurses autonomy in critical decisions, such as triage and resource allocation during medication shortages, while establishing mentorship programs that leverage mid-career nurses' loyalty through roles like emergency unit coordination. Partnerships with NGOs (e.g., M\u0026eacute;decins Sans Fronti\u0026egrave;res) can further bypass bureaucratic barriers, such as expediting supply chains for essential medicines. Concurrently, \u003cem\u003ebureaucratic inefficiencies\u003c/em\u003e must be mitigated by streamlining workflows through low-cost digital solutions (e.g., electronic health records) and forming cross-institutional coalitions to share resources, such as rotating specialists between hospitals to circumvent permit restrictions. To strengthen \u003cem\u003econtinuance commitment\u003c/em\u003e, economic incentives like competitive salaries aligned with regional benchmarks (e.g., UAE or Jordanian standards) and hardship allowances for high-risk areas (e.g., East Jerusalem conflict zones) are critical. Retention strategies should also be \u003cem\u003etailored to career stages\u003c/em\u003e: early-career nurses' benefit from certification scholarships (e.g., trauma nursing) to align skill growth with institutional needs; mid-career nurses thrive with leadership pathways (e.g., quality improvement committees); and late-career professionals gain motivation through symbolic recognition (e.g., public awards) that reinforce their moral obligation to serve.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe study's limitations include methodological constraints inherent to its cross-sectional design, which precludes causal inferences, for instance, whether organizational culture directly shapes commitment or whether preexisting commitment biases nurses' perceptions of culture. Additionally, convenience sampling risks overrepresenting day-shift nurses, who likely face fewer security risks compared to night-shift workers, potentially skewing findings toward safer workplace environments. These issues are compounded by measurement biases: self-report data may inflate empowerment and commitment scores due to social desirability, while conceptual overlap between scales (e.g., \"autonomy\" in empowerment and \"emotional attachment\" in affective commitment) risks tautology, conflating independent constructs. Furthermore, the study's contextual specificity, focusing solely on urban Jerusalem hospitals, limits generalizability to rural settings (e.g., West Bank villages) or other conflict zones (e.g., Ukraine), where geopolitical dynamics and resource availability differ markedly. Future research should address these gaps through longitudinal designs, stratified sampling, and cross-regional comparisons.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eFuture Directions\u003c/h2\u003e \u003cp\u003eFuture research should prioritize \u003cem\u003emethodological innovations\u003c/em\u003e, such as longitudinal studies to track nurses' commitment trajectories over time, particularly during political escalations that may act as tipping points for turnover. Complementing this, mixed-methods designs could integrate interviews to uncover unmeasured psychosocial factors, for example, how familial obligations or community expectations shape continuance commitment. Theoretically, extending Social Exchange Theory (SET) to extreme contexts could test whether reciprocity norms shift under chronic insecurity, such as nurses tolerating lower wages if granted greater clinical autonomy. Simultaneously, integrating trauma theory could elucidate how collective exposure to violence mediates culture-commitment dynamics, offering a lens to interpret resilience amid adversity. Geographically, expanding studies to Gaza's blockaded hospitals or Syrian refugee camps would disentangle universal organizational principles from context-specific realities, while policy collaborations with global bodies like the WHO could translate findings into conflict-adapted guidelines. Lastly, interventional research should pilot tangible solutions, such as trialing flexible shift schedules to measure empowerment's impact on retention, and conduct bureaucracy audits to eliminate redundancies (e.g., duplicate permit applications), ensuring systemic reforms align with nurses lived experiences.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study redefines organizational culture as both a shield and a scaffold in conflict zones, where nurses' commitment transcends institutional shortcomings through resilience and purpose. By prioritizing empowerment, streamlining bureaucracy, and tailoring strategies to career stages, healthcare leaders can transform systemic adversity into a catalyst for loyalty. Future research must bridge the gap between academic inquiry and on-the-ground realities, ensuring findings empower those who empower others in the world's most challenging settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIRB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInstitutional Review Board\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSET\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSocial Exchange Theory\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eP-O Fit\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePerson-Organization Fit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNGOs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon-Governmental Organizations\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUAE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited Arab Emirates\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eWe would like to express our thanks to all the nurses who participated in the study.\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eApproval was obtained in accordance with the Declaration of Helsinki from the Institutional Review Board (IRB) at Al-Quds University (Ref. No.: RESC/2024-33, approved on September 15, 2024). The researcher explained the study\u0026apos;s objectives to the nurses and informed them that participation was voluntary, with the right to withdraw at any time without penalty. Written informed consent was obtained from all participants after providing them with detailed information sheets outlining their rights, confidentiality measures, data storage procedures, and contact information for questions or concerns. Confidentiality was ensured by excluding personal identifiers and assigning unique identification codes to each participant.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author (Dr. Ibrahim Aqtam) upon reasonable request.\u003c/p\u003e\n\u003cp\u003eClinical trial\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eF.G., K.Z., I.A., A.A., N.G., and M.B. contributed to the conceptualization and methodology of the study. F.G. and K.Z. supervised data collection. I.A., A.A., and F.G. performed formal analysis. All authors contributed to writing, reviewing, and editing the manuscript. I.A. and F.G. oversaw project administration. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eYadegary MA, Aghajanloo A, Negarandeh R. Challenges of professional self-regulation in Iranian nursing. Hayat. 2017;23(1):1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDwivedi S, Kaushik S, Luxmi. Impact of organizational culture on commitment of employees: An empirical study of BPO sector in India. Vikalpa. 2014;39(3):77\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeyer JP, Allen NJ, Smith CA. Commitment to organizations and occupations: Extension and test of a three-component conceptualization. J Appl Psychol. 1993;78(4):538\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKalhor R, Khosravizadeh O, Moosavi S, Heidari M, Habibi H. Role of organisational climate in job involvement: A way to develop the organisational commitment of nursing staff. J Evid Based Integr Med. 2018;23:1\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWahyuni E, Darsono R. The effect of organizational culture on employee commitment: The mediating role of job satisfaction. Jurnal Ilmu Manajemen (JIM). 2021;9(1):109\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMosadeghrad AM, Ashrafi E. The impact of quality management on patient satisfaction in a hospital: Brief report. Tehran Univ Med Sci J. 2017;75(3):228\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMataria A, Giacaman R, Khatib R, Moatti JP. Health systems in the Palestinian territory: Challenges and resilience under prolonged occupation. Health Policy Plan. 2023;38(2):132\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhatib R, Daoud A, Abu-Rmeileh NME, Mikki N, Giacaman R. Health system challenges in Jerusalem: The case of healthcare access for Palestinians. Lancet Glob Health. 2022;10(3):e388\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlau PM. Exchange and power in social life. New York: Wiley; 1964.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO'Reilly CA, Chatman J, Caldwell DF. People and organizational culture: A profile comparison approach to assessing person-organization fit. Acad Manage J. 1991;34(3):487\u0026ndash;516.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchein EH, Schein P. Organizational culture and leadership. 5th ed. San Francisco: Jossey-Bass; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCameron KS, Quinn RE. Diagnosing and changing organizational culture: Based on the competing values framework. 3rd ed. San Francisco: Jossey-Bass; 2011.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeyer JP, Allen NJ. A three-component conceptualization of organizational commitment. Hum Resour Manage Rev. 1991;1(1):61\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLund DB. Organizational culture and job satisfaction. J Bus Ind Mark. 2003;18(3):219\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAktas E, Cicek I, Kiyak M. The effect of organizational culture on organizational efficiency: The moderating role of organizational environment. Int J Org Lead. 2011;1(1):1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpreitzer GM. Psychological empowerment in the workplace: Dimensions, measurement, and validation. Acad Manage J. 1995;38(5):1442\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Hussami M, Hammad S, Alsoleihat F. The influence of leadership behavior, organizational commitment, organizational support, subjective career success on organizational readiness for change in healthcare organizations. Lead Health Serv. 2018;31(4):354\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBahrami MA, Montazeralfaraj R, Tafti AD. The mediating role of organizational learning in the relationship of organizational intelligence and organizational agility. Osong Public Health Res Perspect. 2016;7(3):190\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEkzayez A, Al-Khalil M, Jasiem M, Al Saleh R, Alzoubi M, Almarrini R, et al. COVID-19 response in northwest Syria: Innovation and community engagement in a complex conflict. J Public Health (Oxf). 2020;42(3):504\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbu-El-Noor NI, Aljeesh YI, Radwan AS, Al Ashqar AF. The impact of hospital workers' organizational commitment on their organizational performance at the European Gaza hospital. Public Policy Adm. 2016;15(4):562\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiacaman R, Khatib R, Shabaneh L, Ramlawi A, Sabri B, Sabatinelli G, et al. Health status and health services in the occupied Palestinian territory. Lancet. 2009;373(9666):837\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHofstede G, Hofstede GJ, Minkov M. Cultures and organizations: Software of the mind. 3rd ed. New York: McGraw-Hill; 2010.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHammoudeh W, Hogan D, Giacaman R. Quality of life, human insecurity, and distress among Palestinians in the Gaza Strip before and after winter 2008-09 Israeli war. Qual Life Res. 2013;22(9):2371\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrislin RW. Back-translation for cross-cultural research. J Cross Cult Psychol. 1970;1(3):185\u0026ndash;216.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCropanzano R, Mitchell MS. Social exchange theory: An interdisciplinary review. J Manage. 2005;31(6):874\u0026ndash;900.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKristof AL. Person-organization fit: An integrative review of its conceptualizations, measurement, and implications. Pers Psychol. 1996;49(1):1\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrivellas P, Reklitis P, Platis C. The effect of job related stress on employees' satisfaction: A survey in health care. Procedia Soc Behav Sci. 2013;73:718\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Health conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan. Geneva: WHO. 2023. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://apps.who.int/gb/ebwha/pdf_files/WHA77/A77_18-en.pdf\u003c/span\u003e\u003cspan address=\"https://apps.who.int/gb/ebwha/pdf_files/WHA77/A77_18-en.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [Accessed December 2024].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhamis K, Seduced M, Ziv A, Admi H, Mann M. Palestinian nurses' experience of workplace violence. Int Nurs Rev. 2016;63(2):284\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbu Sharour LA, Malak MZ, Hindawi OS, Masa'deh R, Abu Sneineh W. Workplace empowerment among critical care nurses in governmental hospitals in Jordan. J Nurs Educ Pract. 2021;11(6):66\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMansour H, Obaid M, Tubaishat A. The effect of structural empowerment on intent to stay among intensive care unit nurses in Jordan. Am J Nurs Res. 2018;6(6):370\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRaosoft Inc. Sample size calculator. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.raosoft.com/samplesize.html\u003c/span\u003e\u003cspan address=\"http://www.raosoft.com/samplesize.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [Accessed December 2024].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWallach EJ. Individuals and organizations: The cultural match. Train Dev J. 1983;37(2):28\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlnuaimi AS. Organizational culture and organizational commitment in Jordanian hospitals. Int J Bus Manage. 2013;8(21):103\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeyer JP, Allen NJ. Testing the side-bet theory of organizational commitment: Some methodological considerations. J Appl Psychol. 1984;69(3):372\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen Z, Sun H, Lam W, Hu Q, Huo Y, Zhong JA. Chinese hotel employees in the smiling masks: Roles of job satisfaction, burnout, and supervisory support in relationships between emotional labor and performance. Int J Hum Resour Manage. 2012;23(4):826\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Mailam FF. The effect of nursing care delivery systems on nurses' job outcomes. Aust J Adv Nurs. 2005;23(1):30\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIBM Corp. IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiacaman R, Shannon HS, Saab H, Arya N, Boyce W. Individual and collective exposure to political violence: Palestinian adolescents coping with conflict. Eur J Public Health. 2007;17(4):361\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaschinger HK, Finegan J, Shamian J, Wilk P. Impact of structural and psychological empowerment on job strain in nursing work settings: Expanding Kanter's model. J Nurs Adm. 2001;31(5):260\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFouad FM, Sparrow A, Tarakji A, Alameddine M, El-Jardali F, Coutts AP, et al. Health workers and the weaponisation of health care in Syria: A preliminary inquiry for The Lancet-American University of Beirut Commission on Syria. Lancet. 2017;390(10111):2516\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGouldner AW. The norm of reciprocity: A preliminary statement. Am Sociol Rev. 1960;25(2):161\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePodsakoff PM, MacKenzie SB, Lee JY, Podsakoff NP. Common method biases in behavioral research: A critical review of the literature and recommended remedies. J Appl Psychol. 2003;88(5):879\u0026ndash;903.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTett RP, Meyer JP. Job satisfaction, organizational commitment, turnover intention, and turnover: Path analyses based on meta-analytic findings. Pers Psychol. 1993;46(2):259\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTamari S. The role of NGOs in the development of Palestinian civil society. Middle East J. 2000;54(3):389\u0026ndash;404.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl-Jardali F, Dimassi H, Dumit N, Jamal D, Mouro G. A national cross-sectional study on nurses' intent to leave and job satisfaction in Lebanon: Implications for policy and practice. BMC Public Health. 2009;9:120.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Organizational commitment, empowerment, conflict-affected healthcare, Jerusalem, cultural adaptation, nursing retention","lastPublishedDoi":"10.21203/rs.3.rs-6743797/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6743797/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn conflict-affected regions such as Palestine, nurses' organizational commitment is critical for sustaining healthcare resilience. While organizational culture shapes such commitment, its dynamics remain understudied in settings marked by geopolitical strain. This study, the first in Palestine to empirically link empowerment to affective commitment using culturally adapted instruments, examines these relationships in Jerusalem hospitals, integrating geopolitical realities into organizational frameworks.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo assess how organizational culture dimensions (bureaucratic, innovative, supportive, empowerment) predict commitment types (affective, continuance, normative) in Palestinian hospitals, with a focus on empowerment's role in mitigating systemic challenges unique to conflict zones.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA cross-sectional study was conducted across five Jerusalem hospitals (October 2024–January 2025) using convenience sampling. Data from 302 nurses (94.4% response rate) were collected via validated scales culturally adapted through translation, back-translation, and pilot testing (N = 40). The 36-item Organizational Culture Scale and 24-item Organizational Commitment Scale employed 5-point Likert responses (1 = strongly disagree; 5 = strongly agree). Analyses included Pearson's correlations and regression modeling.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOrganizational culture significantly predicted commitment (B = 0.214, p = 0.001), explaining 57.8% of variance. Empowerment emerged as the strongest cultural driver of affective commitment (M = 3.63), while bureaucratic practices showed the weakest association (M = 3.38). Years of experience significantly predicted commitment (B = 0.570, p \u0026lt; 0.001), with mid-career nurses (6–15 years) exhibiting the strongest ties to workplace culture.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHospitals should prioritize empowerment (e.g., autonomy in decision-making) and reduce bureaucratic barriers through digital tools to strengthen affective bonds. Retention strategies must address career-stage needs, particularly for mid-career nurses. These findings advocate for context-specific retention strategies tailored to the unique challenges of conflict-affected healthcare systems. Future studies should employ longitudinal designs to unravel causal pathways and validate conflict-specific adaptations of organizational frameworks.\u003c/p\u003e","manuscriptTitle":"Organizational Culture and Nurse Commitment in Conflict-Affected Hospitals: A Focus on Empowerment in Jerusalem","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-20 10:28:00","doi":"10.21203/rs.3.rs-6743797/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"85ffcc36-25da-4b1b-af5c-b94de10efe09","owner":[],"postedDate":"June 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-08T05:54:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-20 10:28:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6743797","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6743797","identity":"rs-6743797","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}