When war erupts, the world watches for bombs and bullets, but the quieter wound often goes uncounted. In conflict-affected regions, the health professionals standing closest to the psychological wreckage are frequently not psychiatrists or trauma counselors at all. They are nurses, and in many hospitals across the Middle East they are very young ones: interns and early-career clinicians with less than a year of experience, suddenly responsible for calming terrified families, supporting the bereaved, and delivering what humanitarian agencies call psychological first aid. A new multi-country survey has now measured, for the first time at this scale, how prepared that frontline generation actually is, and the numbers suggest a significant gap between what novice nurses are asked to do and what they have been taught.

The study, a cross-sectional survey published in BMC Nursing, recruited 465 novice nurses from six Middle Eastern countries: Iraq, Syria, Yemen, Palestine, Saudi Arabia, and Lebanon. The researchers defined novice narrowly, including only nursing interns and nurses with under twelve months of clinical experience, a deliberate choice that targets the exact population most likely to be deployed to the front lines of patient contact without specialized training. Participants completed a knowledge and competency questionnaire adapted from the World Health Organization’s Psychological First Aid Facilitator’s Manual for Orienting Field Workers, the standard international reference for teaching the technique. Psychological first aid is not psychotherapy; it is a structured, non-intrusive approach built on supportive communication, grief support, and trauma-informed care, designed to reduce acute distress and connect people to practical help in the immediate aftermath of crisis.

The headline result is stark. On a knowledge test scored from 0 to 15, the overall mean was 7.61, with a standard deviation of 1.75. In other words, the average novice nurse in the sample answered roughly half of the psychological first aid knowledge items correctly. Self-perceived competence told a different and more encouraging story: on a scale from 1 to 5, participants rated their own ability to deliver psychological first aid at a mean of 3.52. That mismatch, moderate confidence paired with roughly fifty percent knowledge, is the study’s central tension, and it is a familiar pattern in emergency care research. Confidence without corresponding knowledge can be dangerous in a crisis, because a clinician who believes they are helping may not recognize when their approach drifts into harmful territory, such as forcing a survivor to talk about traumatic events before they are ready.

Geography mattered. Self-perceived competence differed significantly across the six countries, with the analysis producing an F statistic of 7.083 and a p-value below .001, an effect size of eta squared equal to 0.072. Nurses in Palestine reported the highest competence, averaging 3.83 out of 5, followed closely by Syria at 3.76. At the other end, Lebanon averaged 3.26 and Saudi Arabia 3.18. Knowledge scores also differed across countries in the omnibus analysis, with an F of 2.850 and p equal to .018, though the effect was smaller at eta squared of 0.037. Palestine again led with a mean knowledge score of 8.25, while Saudi Arabia recorded the lowest at 7.00. The pattern is intuitively compelling: the countries where armed conflict is a lived, daily reality produced the most confident novices, suggesting that exposure to crisis conditions, whether through formal training or sheer necessity, shapes how ready these young nurses feel.

Yet the researchers are careful about how far that interpretation can be pushed. When they applied Bonferroni corrections to the pairwise comparisons between countries, no individual country difference remained statistically significant in the adjusted model. The omnibus tests flagged real variation, but the study cannot say with confidence that Palestinian nurses know more than Saudi nurses, or that Syrian nurses feel more competent than Lebanese ones, once the statistical penalty for multiple comparisons is paid. This is a common and often misunderstood feature of multi-group survey research: an overall test can detect that the groups are not identical while the corrected pairwise tests, with their stricter thresholds, cannot pinpoint exactly which pairs differ. The honest reading is that country-level variation exists in self-perceived competence, but its precise boundaries remain unresolved.

There is a second methodological caution, and the authors flag it prominently. The knowledge scale’s reliability, measured by the KR-20 coefficient, was low. KR-20 is a measure of internal consistency for dichotomous test items, analogous to Cronbach’s alpha, and a low value means the individual items on the test are not measuring a single coherent underlying construct with precision. Because of this, the researchers interpreted their knowledge findings primarily at the item level rather than leaning on the aggregate score. That decision matters for anyone hoping to use the 7.61 figure as a precise benchmark. What the study can credibly support is the identification of specific item-level knowledge gaps, particular concepts or procedures within psychological first aid that novice nurses across all six countries consistently got wrong, and those gaps become concrete targets for curriculum design.

The practical implications reach beyond the region. Psychological first aid has become a cornerstone of international emergency response, endorsed by the WHO and embedded in disaster-preparedness frameworks worldwide, yet capacity in many conflict-affected countries remains limited. Nurses are often the main providers of this support in crisis settings, not by design but by arithmetic: they outnumber mental health specialists by orders of magnitude, and they are physically present when survivors arrive. If the newest members of the nursing workforce, those most likely to be staffing emergency departments and field hospitals, hold only partial command of the technique, then the first psychological contact a war survivor receives may rest on an uneven foundation. The study’s authors argue that their findings support the further development and evaluation of psychological first aid education specifically tailored to novice nurses in conflict-affected settings.

The survey’s design carries its own trade-offs, which shape how the results should be used. It relied on convenience sampling, meaning participants were recruited by accessibility rather than drawn randomly from national registries of novice nurses, so the sample may overrepresent certain hospitals, cities, or training backgrounds within each country. The cross-sectional design captures a single moment in time; it cannot show whether competence grows with experience, whether confidence precedes knowledge or follows it, or whether the country differences reflect training systems, cultural norms around expressing confidence, or the intensity of local conflict exposure. Self-perceived competence, moreover, is a subjective measure. A nurse who rates themselves 4 out of 5 may be genuinely skilled or simply unaware of what skilled looks like, which is precisely why the knowledge test, despite its reliability limitation, is the more objective half of the instrument.

The ethics of conducting such research across active conflict zones deserve note. The multicountry protocol received institutional review board approval from Vision Colleges in Saudi Arabia, Taiz University in Yemen, Tishreen University in Syria, and the American University of Beirut in Lebanon, with the central approval explicitly covering Iraq and Palestine as participating sites where local co-investigators confirmed no additional review was required under their institutions’ procedures. All participants gave electronic informed consent, no personal identifiers were collected, and the study adhered to the Declaration of Helsinki. Running a coordinated survey across six countries, several of them in or recovering from armed conflict, is itself a logistical achievement, and the transparency of the ethical documentation strengthens confidence in the data’s provenance.

What remains is the gap the study exposes. Half of fifteen is not a passing grade for the psychological frontline of war, and 3.52 out of 5 confidence does not close it. The researchers did not receive external funding for the work, and they frame their contribution as diagnostic rather than curative: a baseline measurement of where novice nurses stand, with item-level knowledge gaps identified and country-level variation in self-perceived competence documented. The next step they point toward is concrete, developing and evaluating psychological first aid education built for this specific population, then measuring whether knowledge and confidence converge at a level the situation demands. Until that happens, the young nurses of Iraq, Syria, Yemen, Palestine, Saudi Arabia, and Lebanon will keep doing the work, improvising half of it, and hoping the half they know is the half that matters.

Subject of Research: Psychological first aid preparedness among novice nurses in conflict-affected Middle Eastern countries

Article Title: Novice nurses’ preparedness for psychological first aid in conflict-affected Middle Eastern Countries: a cross-sectional survey

Article References: Innab, A., Taleb, F., Altaheri, A. T. A., Noureddine, S., Elfayoumy, R., Adra, M., Massouh, A., Avedissian, T., Shurafi, S. O., Albakour, E. J., Hallaj, F. A., Hermis, A. H., Jumaa, Z. Y., & Mani, Z. A. (2026). Novice nurses’ preparedness for psychological first aid in conflict-affected Middle Eastern Countries: a cross-sectional survey. BMC Nursing. https://doi.org/10.1186/s12912-026-05331-2

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05331-2

Keywords: psychological first aid, novice nurses, armed conflict, Middle East, cross-sectional survey, WHO, nursing education, trauma-informed care, competence, BMC Nursing, Iraq, Syria