Fields:

Select all

Archeology

Life Sciences

Medicine

Categories:

Select all

Events

In Focus

Honors

Innovations

NEWS

What are you interested in?

All topics
AI and the Digital World
Partner Research and Endeavors
VUCA/H
Socio-Cultural Determnants
Insights and Perspectives
Antifragility
In Adversity
Covid-19
Event Highlights
Complexity Science
Complementary Approaches
Climate Change
Israeli flag on soldiers shoulder

Research

Feb 26th, 2026
A longitudinal study of societal resilience and its predictors during the
  • Partner Research and Endeavors

Arielle Kaim, Maya Siman Tov, Shaul Kimhi, Hadas Marciano, Yohanan Eshel, Bruria Adini

 

First published: 21 March 2024 https://doi.org/10.1111/aphw.12539

 

Abstract

This study assesses the resilience of Israeli society during the ongoing Israel-Gaza conflict and pinpoints factors that influence this resilience in prolonged national crises. A longitudinal study was carried out with two surveys, both using the same questionnaire to gage societal, community, and individual resilience levels, along with hope, morale, distress, perceived threats, and government support. The initial survey was administered 5 days after the war escalated and the second 1 month later. The study's results reveal a decline in societal resilience over time. The regression analysis identified four major associations at both resilience measurement points. The key variables are community resilience and hope, both contributing positively. Attitudes towards government support (specifically being a government supporter vs. an opponent) also played a role. Additionally, there was a negative association with levels of religiosity, particularly distinguishing between ultra-orthodox and secular individuals. In the temporal analysis predicting future resilience (from data at the first time point to predict resilience at the second time point), societal resilience at the first measurement was the strongest forecaster of its resilience at the second measurement. Additionally, the main continuous variable from the previous analysis, community resilience, continued to be an influential and positive forecaster in the time-based analysis. The research suggests that the initial unifying effect of the conflict, similar to a “Rally around the flag” phenomenon, may be short-lived. The study underlines the importance of community strength, hope, government support, and religious considerations in shaping societal resilience in the face of conflict.

INTRODUCTION

Experiencing war ranks among the most harrowing events a person can endure. Such exposure often pushes people to the brink of their capabilities, involving numerous challenges. Wars often expose individuals to diverse vulnerabilities that impact many facets of life, from familial relationships to the risk of physical harm or even loss of life. In certain situations, individuals may find themselves obliged to give up their lives for a greater cause or the protection of their loved ones. The repercussions of war are manifold, including collateral damage, physical and psychological injuries, the destruction of homes and properties, and extensive economic and social repercussions. These are just a few of the many detrimental consequences that arise during times of conflict and war (Kimhi, Kaim, et al., 2023). The effects of war and conflict often reach beyond those directly affected, instilling a sense of threat, fear, and associated psychological distress across the broader population (Slone & Shoshani, 2022).

On October 7, 2023, Hamas, identified as a terrorist organization by numerous countries and located in the Gaza Strip, launched a significant and well-coordinated attack on the southern and central regions of Israel. This aggressive act commenced with widespread rocket fire targeting civilian populations and was coupled with attempts to infiltrate the border near Gaza. This aggressive move led to violent encounters involving the Israeli populace, police forces, and the Israel Defense Forces. The ramifications of this attack are considerable and ongoing. Recent updates reveal that the death toll has surpassed 1,400 Israelis with approximately 5,600 wounded, marking it as one of the deadliest terror attacks in modern history (Peleg & Gendelman, 2023). Moreover, a minimum of 240 persons, including 30 children, have been captured hostage by the organization. The incident has profoundly impacted the country, causing extensive mourning and leaving many people questioning how to react appropriately.

Amidst the continued aggression, orders were given for people in several areas to seek protection in or close to reinforced structures. The intensified attacks near both the southern and northern frontiers, bordering Gaza and Lebanon, led to about 200,000 people being displaced internally by the third week of the conflict, according to records by Peleg and Gendelman (2023). This disturbance has significantly weakened the evacuees' feeling of safety, diminishing their confidence in the state, law enforcement, and military's protective measures. As a result, many homes that were once places of sanctuary are no longer sources of comfort. Nonetheless, a common belief among the populace, informed by past conflict experiences, is a strong trust in the defensive capabilities of the Iron Dome missile defense system, a sentiment supported by Lahav et al. (2019).

Before the conflict erupted on October 7, 2023, Israel was experiencing considerable turmoil socially, politically, and legally. The new government, which came into power on December 29, 2022, made judicial changes a priority, initiating a contentious legal reform agenda. The proposed changes aimed to limit the Supreme Court's authority and change the judicial appointment process, eliciting extensive backlash from the opposition. This era was marked by increased public opposition, with significant protests in major cities against what was seen as an invasion of liberal democratic principles (Roznai & Cohen, 2023). The internal strife over these legal changes, which posed a fundamental challenge to the separation of powers in Israel, prepared the groundwork for a society struggling with profound division and issues of governance and justice as hostilities intensified in October 2023 (Porat, 2023).

Resilience and coping

Resilience is a term with varied definitions in scholarly research, but generally, it describes the ability of individuals, groups, or societies to effectively manage and bounce back from hardships. Métais et al. (2022) highlight this capacity for recovery post-adversity. Previous findings from Israel during periods of conflict, such as the missile attacks in 2011 (Braun-Lewensohn & Sagy, 2014) and in the aftermath of Operation Protective Edge (Elran et al., 2015), as well as during the continuous tensions in the Gaza envelope (Shapira et al., 2020), have characterized Israeli communities as exhibiting notably high resilience levels. The current research focuses on evaluating societal resilience, particularly the ability of a society to cope with the effects of the 2023 Israel-Gaza war and its recovery prospects after the conflict.

In terms of coping indicators, we consider both positive and negative variable measurements. Positive measures like hope (Germann et al., 2015; Snyder et al., 1991), well-being (Medvedev & Landhuis, 2018), and morale (Shaban et al., 2017) reflect effective adversity management and are expected to correlate positively with one another. On the other hand, negative indicators are anxiety and depression symptoms (Cullen et al., 2020), a pervasive sense of danger (Kimhi et al., 2021), and perceived threats (Kruglanski et al., 2021), which collectively reflect challenges in coping with distressing situations such as war.

The primary aim of the current research was to assess levels of societal resilience employed by the Israeli populace during the current conflict, which has an indeterminate end, and to track how these aspects change as the war evolves. Additionally, the study sought to identify what variables are associated with a society's ability to be resilient over a prolonged period, a form of resilience that becomes critical during significant national crises, like the ongoing war. In addition, the study sought to identify variables at timepoint measurement one that could predict the outcomes at the second measurement through the implementation of a longitudinal predictive framework. This study examines three central questions: initially, it seeks to determine the temporal trend of societal resilience—whether it remains constant, declines, or improves over time. Subsequently, the study aims to identify the key factors associated with societal resilience, pinpointing which contribute most significantly. The final question probes into how specific variables, measured at the first time point, can predict levels of societal resilience at a later time point. The hypotheses of this study include the following: first, we hypothesize that the level of societal resilience observed during the initial measurement will be sustained at the following measurement. Second, in line with the findings of Kimhi, Kaim, et al. (2023) in the aftermath of the Russian invasion of Ukraine, we expect that hope and governmental support will stand out as primary factors associated with societal resilience. Third, we postulate a positive correlation between higher levels of hope and governmental support with greater societal resilience across both time points. Lastly, we anticipate that hope and governmental support will act as key temporal predictors of societal resilience, illustrating their potential to forecast resilience trajectories over time.

METHODS

Data collection

The current study utilized a longitudinal design with two measurement points, employing an identical questionnaire to track changes over time. The initial measurement was conducted approximately 5 days following the unexpected Hamas assault, from October 11–15, 2023. A representative sample of 2,002 adult Hebrew-speaking Israelis was surveyed during this time. The second measurement occurred roughly 6 weeks after the war commenced and about a month following the first, spanning November 10–15, 2023. In both measurements, the questionnaire was distributed via an online panel company. This study focuses on the subset of respondents who completed all items at both measurement points (N = 1,613) that were anonymously matched using the UID code. See Table 1 for demographic information of study participants.

TABLE 1. Demographic characteristics of respondents (N = 1,613).

  Group Respondents Percent Mean ± SD
Age 18–30 394 24.4 44.21 ± 15.84
31–40 325 20.1
41–50 333 20.6
51–60 256 15.9
61–82 305 18.9
Gender 1. Men 823 51.0  
2. Women 790 49.0
Degree of religiosity 1. Secular 761 47.2  
2. Traditional 501 31.1
3. Religious 214 13.3
4. Very religious 137 8.5
Average income per family, relative to the average in Israel 1. Much lower 354 21.9 2.61 ± 1.17
2. Lower than average 383 23.7
3. Like average 504 31.2
4. Higher than average 275 17.0
5. Much higher 97 6.0
Education 1. Below high school 26 1.6 3.44 ± 1.05
2. High school 332 20.6
3. Post-secondary (without academic degree) 443 27.5
4. Bachelor's degree 524 32.5
5. Master's degree or higher 288 17.9

To ensure the study's reliability, the online panel company was tasked with administering the questionnaire and maintaining a representative sample by adhering to demographic distributions of gender, age, and geographic location, as aligned with the National Statistics Bureau's standards. Ethical approval for the study was granted by the Tel Aviv University, Israel Ethics Committee under approval number 0005985-1 dated January 16, 2023, which was initially provided for the sake of a longitudinal study on societal resilience. Informed consent was obtained from all participants before their inclusion in the study.

Measurements

The scales used in the current study were based on validated structured study tools that were previously used in various studies including during the COVID-19 pandemic (Kimhi et al., 2020) and the ongoing Russian invasion of Ukraine in 2022 (Kimhi, Kaim, et al., 2023).

Societal resilience measurement

Societal resilience is measured using a 16-item scale, refined from an original 13-item scale by Kimhi and Eshel (2019). Respondents indicate their level of agreement on a scale from 1 (strongly disagree) to 6 (strongly agree), evaluating their confidence in the government's decision-making, societal support for leadership during crises, trust in security forces, patriotism, optimism about the country's future, and trust in national institutions including the police, parliament, media, and armed forces. The Cronbach's alpha values for the initial and subsequent measurement of the Societal Resilience Index are .87 and .86, respectively.

Community resilience measurement

Community resilience was evaluated using 10 questions focused on the community where the participant lives, based on the original scale by Leykin et al. (2013). For instance, one of the items was “I believe that in a crisis, people in my community would help me.” The response options varied from 1, indicating strong disagreement, to 5, signifying strong agreement. The Cronbach's alpha values for the initial and subsequent measurement of the Community Resilience Index are .93 and .93, respectively.

Individual resilience measurement

The Connor–Davidson Resilience 10-item Scale (Connor & Davidson, 2003) was employed to gage individual resilience through a detailed 10-item questionnaire. Respondents expressed their level of concurrence with statements such as “I am capable of adapting to change” using a rating system that ranged from 1 for total disagreement to 5 for complete agreement. The Cronbach's alpha values for the initial and subsequent measurement of the Individual Resilience Index are .91 and .91, respectively.

Hope

The study's hope scale, originally designed by Jarymowicz and Bar-Tal (2006) to measure hope for peace in the Middle East, has been adapted to include five items. These items measure the respondent's hope for personal, familial, community, societal, and national strengthening post-crisis, with responses ranging from 1 (very little hope) to 5 (high hope). The Cronbach's alpha values for the initial and subsequent measurement of the Hope Index are .93 and .94, respectively.

Morale indicator

Morale is assessed with a single item querying respondents about their current morale level, with responses ranging from 1 (very poor) to 5 (very good).

Sense of danger scale

Based on Solomon and Prager (1992), this five-item scale ranges from 1 (not at all) to 5 (very much) and measures perceived personal and national existential threats due to the current war. The Cronbach's alpha values for the initial and subsequent measurement of the Sense of Danger Index are .85 and .84, respectively.

Symptoms of distress

Symptoms of distress, including anxiety and depressive symptoms, are evaluated through an eight-item scale derived from the original nine-item scale by Derogatis and Savitz (2000). Participants rate their recent experiences with nervousness, loneliness, mood, interest levels, hopelessness, tension, restlessness, and feelings of worthlessness on a scale from 1 (not at all) to 5 (extremely). Due to ethical considerations, the question concerning suicidal thoughts was not included. The Cronbach's alpha values for the initial and subsequent measurement of the Symptoms of Distress Index are .90 and .92, respectively.

Perceived threats scale

Participants rate each potential threat on how personally threatening they find it at present, including security, the Iranian nuclear threat, political, and violence in the Israeli society. Responses range from 1 (not threatening at all) to 5 (extremely threatening).

Support for government

Support for the current government was assessed via one question (scale of 1–5). The answer to this question consisted of five levels (between 1, strongly oppose, and 5, strongly support).

Statistical analysis

Descriptive statistics, such as frequency, mean, and standard deviation, were used to describe the demographic characteristics of the participants. Descriptive statistics were also utilized to determine the spread tendency and central tendency of the indexes. To evaluate the changes in societal resilience, community resilience, and hope levels over time, a paired sample t test was applied. Furthermore, analyses were conducted to discern associated factors with societal resilience at each time point. Multiple regression analyses for defining the factors associated with “societal resilience” were executed at two separate times with independent variables including community and individual resilience, hope, morale, stress levels, feelings of danger, perceived threat level concerning security matters, political views, the potential impact of a nuclear Iran, violence within Israeli society, demographic factors, and levels of governmental support. Levels of government support were entered as a dummy variable with “opponents” as the reference group. Religiosity was also dummy-coded, with “secular” as the reference. Furthermore, a supplementary linear regression analysis was conducted to assess predictors of societal resilience at the second timepoint (T2), while controlling for first measurement (T1) variables (including societal resilience, community and individual resilience, hope, morale, stress levels, feelings of danger, perceived threat level concerning security matters, political views, the potential impact of a nuclear Iran, violence within Israeli society, demographic factors, and levels of governmental support). Variables (both continuous and categorical) that displayed the top standardized β coefficients in the time-point-specific regressions were further examined. For the top-ranked categorical variables, an ANOVA was conducted with societal resilience as the dependent variable, and any significant differences between groups were explored using Bonferroni-adjusted post hoc tests. In parallel, Pearson correlations were calculated for the top continuous variables to evaluate their relationship with societal resilience. All statistical procedures were conducted using SPSS version 29, with a significance threshold of p < .05.

RESULTS

Societal resilience level

The findings show that there was a significant reduction from October (4.08 ± 0.80) to November 2023 (4.04 ± 0.76) in societal resilience levels (t[1,612] = 3.479, p < .001, Cohen's d = 0.087). See Figure 1.

Details are in the caption following the image

FIGURE 1

Open in figure viewerPowerPoint

The mean level of societal resilience across the two measurements: (4.08 ± 0.80) and (4.04 ± 0.76), respectively. Note: Societal resilience index ranges from 1 to 6. *Significant difference between the measurements. [Color figure can be viewed at wileyonlinelibrary.com]

Associations with societal resilience

The regression analyses revealed significant associations with societal resilience that were consistent across both measurement points. At the initial measurement, within the continuous variables, community resilience (β = .312) and hope (β = .300) were identified as the most influential predictors. For the categorical variables, levels of government support, specifically when comparing supporters to opponents of the government, showed a notable association (β = .168). Furthermore, for religiosity, being ultra-orthodox as opposed to secular was inversely related to societal resilience (β = −.131). At the second measurement point, the same variables maintained their significance, ranked by the strength of their association with societal resilience. Among the continuous variables, hope (β = .304) and community resilience (β = .298) were the strongest predictors. In the category of categorical variables, the level of government support again showed a substantial impact, especially when contrasting supporters with opponents (β = .205). Similarly, the degree of religiosity, with ultra-orthodox compared to secular, had a consistent inverse relationship (β = −.148) with societal resilience (refer to Table 2 for detailed regression results). These findings suggest that higher levels of community resilience and hope, as well as being a supporter (versus an opponent) of the government, are associated with increased societal resilience. Conversely, identifying as ultra-orthodox (versus secular) is associated with lower levels of societal resilience. The regression model at the first measurement accounted for 45.6% of the variance in societal resilience, while the model at the second measurement explained 44.8% of the variance.

TABLE 2. Results of regression analysis for associations with societal resilience over the two measurement times.

  Measurement 1 Measurement 2
Variables Coefficient B Std. error ß coefficient t Sig. Coefficient B Std. error ß coefficient t Sig.
Gender 0.029 0.032 .018 0.916 .360 0.039 0.030 .026 1.300 .194
Age 0.005 0.001 .104 4.918 <.001 0.005 0.001 .110 5.254 <.001
Religiosity: Traditional 0.035 0.037 .020 0.958 .338 −0.019 0.035 −.011 −0.540 .589
Religiosity: Religious −0.124 0.052 −.052 −2.391 .017 −0.142 0.050 −.062 −2.844 .005
Religiosity: Ultra-orthodox −0.382 0.065 −.131 −5.903 <.001 −0.414 0.062 −.148 −6.651 <.001
Family income −0.009 0.014 −.013 −0.664 .507 −0.015 0.013 −.022 −1.097 .273
Government support: Neutral 0.113 0.041 .061 2.763 .006 0.120 0.040 .066 3.001 .003
Government support: Supporters 0.293 0.043 .168 6.756 <.001 0.340 0.041 .205 8.211 <.001
Education −0.045 0.015 −.059 −2.939 .003 −0.051 0.015 −.069 −3.447 <.001
Individual resilience 0.002 0.027 .002 0.078 .939 0.018 0.027 .016 0.671 .502
Community resilience 0.312 0.021 .313 14.773 <.001 0.289 0.021 .298 14.004 <.001
Hope 0.259 0.021 .300 12.284 <.001 0.267 0.022 .304 12.200 <.001
Distress 0.088 0.023 .105 3.845 <.001 0.027 0.023 .034 1.204 .229
Danger −0.112 0.026 −.121 −4.216 <.001 −0.090 0.027 −.097 −3.344 <.001
Morale 0.058 0.019 .074 3.007 .003 0.014 0.021 .017 0.678 .498
Security threats 0.003 0.019 .005 0.179 .858 0.020 0.019 .029 1.085 .278
Political threats −0.066 0.016 −.106 −4.014 <.001 −0.070 0.016 −.114 −4.242 <.001
Iran nuclear threat 0.074 0.016 .110 4.639 <.001 0.048 0.016 .075 3.061 .002
Violence in Israeli society threat −0.052 0.016 −.077 −3.348 <.001 −0.030 0.016 −.044 −1.877 .061
  • Note: The R2 values for the regression models corresponding to Measurements 1 and 2 are 0.456 and 0.448, respectively.

Societal resilience and quantitative variables

Community resilience

The findings show that there was a significant reduction from October (3.66 ± 0.77) to November 2023 (3.60 ± 0.79) in community resilience levels (t[1,612] = 3.838, p < .001, Cohen's d = 0.096). The Pearson correlation between societal resilience and hope in the first measurement was r(1,612) = .504, p ≤ .001. In the second measurement, the Pearson correlation between societal resilience and hope was r(1,612) = .501, p ≤ .001.

Hope

The findings show that there was a significant increase from October (3.76 ± 0.92) to November 2023 (3.82 ± 0.87) in hope levels (t[1,612] = −3.526, p < .001, Cohen's d = −0.088). The Pearson correlation between societal resilience and hope in the first measurement was r(1,612) = .528, p ≤ .001. In the second measurement, the Pearson correlation between societal resilience and hope was r(1,612) = .526, p ≤ .001.

Societal resilience and categorical variables

Governmental support

The findings are delineated according to further analysis that probed the fluctuations between the assessments, segmented by respondents' governmental support levels. These groups were categorized as “government opponents—those that indicated 1/2” with 728 respondents in T1, “neutral—those that indicated 3” with 392 respondents, and “government supporters—those that indicated 4/5” with 493 respondents in Measurement 1. In the second measurement, “government opponents” stood at 735 respondents, “neutral” with 377 respondents, and “government supporters” with 501 respondents. Significant differences were found according to post hoc Bonferroni between all three groups (p < .001).

Religiosity

Lastly, the findings are delineated according to further analysis which probed the fluctuations between the assessments, segmented by the respondents' religiosity levels. These groups are identified across both measurements as “secular” with 761 respondents, “traditional” with 501 respondents, “religious” with 214 respondents, and “ultra-orthodox” with 137 respondents. Those in the religious group displayed the highest level of societal resilience as compared to those who identify as traditional, ultra-orthodox, and secular. However, the finding is only significant between those who identify as secular and those who identify as religious (p < .001), those who identify as secular and those who identify as traditional (p < .001), and the ultra-orthodox group and the religious group (p < .01) according to Bonferroni test in both measurements.

Temporal prediction of societal resilience

In the longitudinal analysis, the model predicting societal resilience at the second measurement point based on variables from the first measurement explained 63.1% of the variance. Societal resilience at the first measurement was the strongest forecaster of its resilience at the second measurement, with a beta coefficient of .686. Additionally, the main continuous variable from the earlier analysis, community resilience, continued to be an influential and positive forecaster in the time-based analysis, with a beta coefficient of .071. However, among the continuous variables, hope did not maintain its status as a significant forecaster. Among the categorical variables, both the degree of governmental support and religiosity were found to be non-significant. See Table 3.

TABLE 3. Longitudinal predictors of societal resilience at Time Measurement 2, controlling for measurement one variables.

Variables predicting societal resilience at T2 Coefficient B Std. error ß coefficient t Sig.
Intercept 0.837 0.144   5.828 <.001
Societal resilience (T1) 0.686 0.020 .717 34.741 <.001
Gender (T1) −0.002 0.025 −.001 −0.070 .944
Age (T1) 0.003 0.001 .066 3.770 <.001

Religiosity:

Traditional (T1)

0.000 0.029 .000 −0.007 .995

Religiosity:

Religious (T1)

0.015 0.041 .007 0.365 .715
Religiosity: Ultra-orthodox (T1) −0.048 0.052 −.017 −0.926 .355
Family income (T1) 0.008 0.011 .013 0.751 .453
Government support: Neutral (T1) 0.036 0.032 .020 1.102 .270
Government support: Supporters (T1) 0.019 0.035 .011 0.553 .580
Education (T1) −0.027 0.012 −.038 −2.274 .023
Individual resilience (T1) 0.001 0.021 .001 0.065 .948
Community resilience (T1) 0.068 0.018 .071 3.826 <.001
Hope (T1) 0.017 0.017 .021 0.996 .320
Distress (T1) −0.042 0.018 −.053 −2.320 .020
Danger (T1) 0.027 0.021 .031 1.295 .196
Morale (T1) 0.002 0.015 .003 0.144 .886
Security threats (T1) −0.001 0.015 −.002 −0.098 .922
Political threats (T1) −0.013 0.013 −.021 −0.970 .332
Iran nuclear threat (T1) 0.027 0.013 .043 2.154 .031
Violence in Israeli society threat (T1) −0.001 0.012 −.002 −0.108 .914
  • Note: The R2 value for the regression model was 0.631. The following first measurement variables (T1) were controlled for societal resilience, community and individual resilience, hope, morale, stress levels, feelings of danger, perceived threat level concerning security matters, political views, the potential impact of a nuclear Iran, violence within Israeli society, demographic factors, and levels of governmental support.

DISCUSSION

The investigative analyses have provided crucial insights that surfaced quickly with the commencement of the latest Israel-Gaza war. Comparative data from a study in review by Kaim et al. highlights a surge in societal resilience immediately following the October 7, 2023, circumstances, against a backdrop of public unrest due to proposed legal changes in Israel back in August 2023. However, this analysis has observed a significant dip in societal resilience in its subsequent assessment, contrary to the hypothesis. The initial boost in societal hardiness post-October 7 is consistent with the “rally around the flag” phenomenon, which echoes the similar public Ukrainian reaction to Russia's incursion into Ukraine, as noted by Berlinschi et al. (2022) and Kimhi, Kaim, et al. (2023). Yet, in the current study, this increase in resilience appears ephemeral, with a significant decline emerging just 1 month later. Given the unpredictable duration of the ongoing conflict, it becomes imperative to identify and address the factors leading to this erosion of societal resilience. A strategic focus on these determinants is essential to reverse the downward trend and enhance the resilience of society. Despite this finding, in the temporal analysis, societal resilience at the first measurement was the strongest forecaster of its resilience at the second measurement indicating that the initial measurement of resilience not only reflects a society's current state of robustness and adaptability but also serves as a prognostic tool, indicating its capacity to maintain these qualities over time (Bodas et al., 2022).

The analysis of data from two separate measurements has identified four key significant variables that consistently are associated with societal resilience: community resilience, level of hope, government support (specifically being a supporter of the government versus opposing it), and religiosity (specifically being ultra-orthodox versus being secular). Among these, community resilience has emerged as a particularly strong association, as well as in the temporal regression analysis, with studies from conflict zones in Ukraine and Poland (Kimhi, Baran, et al., 2023) corroborating its high correlation with societal resilience. Community resilience embodies the dynamic interplay between individuals and their communities, reflecting not just the community's capacity to fulfill the needs of its members but also the extent to which individuals draw strength from their communal ties. This has been previously discussed by Shapira (2022) during which community resilience was assessed in Israel during a period of armed conflict, a relatively calm period, and during the covid-19 pandemic. Along that line, Norris et al. (2008) cautioned against assuming that a resilient community is merely an aggregate of resilient individuals, stating that “a collection of resilient individuals does not guarantee a resilient community” (p. 128). This assertion underlines the importance of collective action and social cohesion, which extend beyond individual capacities. Drawing upon this understanding, the evidence suggests a more nuanced association: while individual resilience may not necessarily scale up to the community nor the societal level, the resilience of a community—encompassing its social networks, shared resources, and collective efficacy—can indeed propagate to influence societal resilience. Therefore, if multiple community units within a society demonstrate resilience, this collective robustness can serve as a foundation for the overall resilience of the society. This association is apparent when communities facing adversity successfully mobilize resources, provide mutual support, and maintain their functional integrity, which in turn contributes to the stability and resilience of the society at large. In this way, the resilience of communities acts synergistically, reinforcing and amplifying the resilience of society as a whole. The implication of this finding is significant for policy and intervention strategies: efforts to enhance community resilience are likely to have a cumulative effect, strengthening societal resilience. It is critical, therefore, to invest in community-level initiatives that promote social support, develop communal resources, and encourage collective efficacy.

Moreover, the data suggest that in addition to community resilience, hope stands as the next most significant association (ranked second in the first measurement and first in the second measurement) of societal resilience. This parallels findings from diverse contexts such as the COVID-19 pandemic (Demetriou et al., 2020; Flesia et al., 2023; Gallagher et al., 2021) and extends to the situation in Ukraine and surrounding nations (Kimhi, Kaim, et al., 2023). Hope, as a psychological asset, provides individuals with the motivation and pathway-oriented thinking needed to navigate through adversity and envision the resilience outcome as possible.

In addition to hope, the level of government support has been identified as an additional key associated variable with societal resilience. This influence is evidenced by the notable variance in resilience levels among those who oppose, are neutral towards, or support the government across the two observed time points as well as the regression analysis. The implications of these differences are multifaceted. First, they underscore the importance of the government's role in cultivating a sense of security and stability within a nation, particularly in times of crisis such as the current war. When citizens perceive their government as competent, their confidence in future stability can increase, thus bolstering societal resilience. Conversely, a lack of faith in governmental institutions or the current leadership can lead to a decrease in resilience, making societies more vulnerable to the negative impacts of crises (Bodas et al., 2022; Marana et al., 2019). This finding suggests that government policies, their implementation, and the public's perception of government effectiveness directly influence societal strength (Fukasawa et al., 2020). In times of crisis, visible and effective government support can provide a psychological anchor for the general public, offering reassurance and the promise of order and recovery. Moreover, the variation in resilience levels based on political stance indicates that societal resilience is not merely a byproduct of governmental action but is also shaped by the public's alignment with or trust in their leaders. This aspect becomes particularly important in diverse political landscapes, where government action may be interpreted differently across the political spectrum, affecting societal resilience in complex ways. Expanding upon this, policymakers should consider strategies to unify these disparate perceptions. Building a consensus on key issues, fostering transparent communication, and ensuring that the needs of all community segments are addressed could mitigate polarization and enhance overall societal resilience (Bodas et al., 2022). Furthermore, active community engagement and inclusion in decision-making processes may bridge the gap between government and citizens, leading to more cohesive and resilient societies.

The observed phenomenon where religiosity overall negatively is associated with societal resilience, yet religious groups in Israel display varying levels of resilience, can be understood by considering the unique sociopolitical and cultural context of the country and the current circumstances. In Israel, the term “religious” often refers to those adhering to Orthodox Jewish practices but not the more stringent practices of the ultra-Orthodox community. The religious group may have cultural and social mechanisms that contribute more positively to resilience (Goroshit & Eshel, 2013). This could include strong community support networks, a collective sense of identity, and shared values that provide psychological comfort and practical assistance during crises (Marciano et al., 2020). The ultra-Orthodox, while with high social capital within their community, in Israel are known for their insular nature, with a lifestyle that is highly focused on religious study and observance, often with limited engagement with the secular world (Rier et al., 2008). This separation can result in less access to national resources, information, and support systems that are critical for resilience at times such as the current war (Pinchas-Mizrachi et al., 2021). It might also reflect a reliance on religious leadership for guidance, which could conflict with authorities' crisis management strategies. These elements might contribute to the ultra-Orthodox community displaying lower levels of societal resilience as compared to their religious, traditional, and secular counterparts. Regarding, levels of societal resilience in the secular group may be influenced by a variety of factors, including potentially weaker community bonds or a lack of unifying narratives that can often be provided by a degree of religious belief. This is particularly relevant considering the widespread opposition within the secular community to the judicial reforms proposed as a core structural change to the current judicial institution (Klein, 2023; Porat, 2023). It is essential to recognize that these variations within the same societal context suggest that other mediating factors are at play beyond religiosity itself for societal resilience. The role of religious belief must be interpreted alongside factors such as community structure, socioeconomic status, access to resources, and the relationship between religiosity levels and governmental institutions. Understanding these complex interactions is vital for developing strategies to bolster societal resilience across all segments of Israeli society.

LIMITATIONS

While this study provides valuable insights into societal resilience during the Israel-Gaza war; however, it is important to consider the limitations inherent in its design and execution. First, the longitudinal design with two measurement points may not fully capture the nuanced and potentially rapid shifts in societal resilience that can occur in response to dynamic and evolving events. The 4-week interval between the measurements offers a snapshot of resilience yet changes that transpire outside of this timeframe remain undetected, possibly overlooking longer-term trends and immediate reactions to new developments. Second, the sample's representativeness may be compromised despite attempts to create a demographic balance. The exclusive use of an online panel for survey distribution could inadvertently bias the sample, as it is contingent on respondents having internet access and the willingness to participate in online surveys. This method might exclude those without access to technology or with limited digital literacy, potentially skewing the data towards more technologically engaged individuals. While the study presents a comprehensive analysis of the Israeli population, drawing from a wide-ranging sample across various geographic areas, which by extension includes individuals potentially affected by internal displacement from conflict zones in the South and North, the research does not specifically target or examine in depth the complex personal experiences of those who have suffered personal losses or have been part of communities directly impacted by conflict. It is also possible that individuals who have been deeply affected may choose not to participate in a study of this nature, which could introduce a bias in the results. The nuanced understanding of these personal impacts is vital for a more thorough exploration of resilience dynamics, and it is imperative that future research endeavors focus on these critical aspects to provide a more complete picture. Third, the reliance on self-report measures introduces several potential biases. Participants' responses could be influenced by social desirability, wishing to present themselves in a favorable light or recall bias, particularly when reflecting on experiences during stressful events. These biases could affect the accuracy of reported resilience and psychological states. Moreover, the study's observational design restricts the ability to establish causality. While certain factors are identified as predictors of societal resilience, it cannot be definitively concluded that these factors cause changes in resilience levels. The associations observed might be indicative of correlations rather than direct causal relationships. Finally, the generalizability of the findings is limited. The specific societal, political, and cultural context of Israel during the conflict may not reflect the circumstances of other societies, and thus, the results may not be applicable in different settings or under different stressors. In summary, while the study makes significant contributions to the understanding of societal resilience in the context of conflict, these limitations must be taken into account when interpreting its findings and considering their applicability to other scenarios or longitudinal trends.

CONCLUSIONS

The study conducted amid the Israel-Gaza war provides critical insights into the dynamics of societal resilience during times of conflict. The initial findings indicated a significant increase in societal resilience, resonant with the “Rally around the flag” effect, a phenomenon where national unity is bolstered in the face of external threats. However, a subsequent decline in resilience suggests that such unity may be short-lived, necessitating a deeper understanding of the elements that contribute to or erode societal fortitude over time. Four primary associations of societal resilience were consistently identified: community resilience, hope, government support, and religiosity. Community resilience, in particular, stands out as a vital factor, underscoring the dynamic interactions within communities that contribute to a society's overall robustness. This finding is in line with the notion that resilient communities form a resilient society, not merely as a sum of individual strengths but as a synergistic effect of collective action, social cohesion, and shared resources. Hope also emerged as a significant variable associated with societal resilience, functioning as a psychological asset that motivates individuals and communities to persist through adversity. The level of government support proved congruently critical, indicating that governments and their leadership play a pivotal role in either fostering or undermining collective strength during crises. The study also revealed complex interactions between religiosity and societal resilience. Different religious groups within Israel displayed varying levels of resilience, reflecting the intricate interplay between cultural, social, and political factors. This complexity indicates that religiosity cannot be viewed in isolation but must be considered alongside additional variables. The insights from this study highlight the importance of community initiatives, inclusive governance, and the nurturing of hope to bolster societal resilience. Recognizing the multifaceted nature of resilience, particularly in a diverse sociopolitical context like Israel's, is crucial for formulating policies and strategies that strengthen societal resilience in the face of ongoing war and future adversities.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

ETHICS STATEMENT

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation.

DATA AVAILABILITY STATEMENT

Due to ethical considerations, the raw data are not uploaded in a public repository. The data that support the findings of this study are available from the corresponding author upon reasonable request.

 

REFERENCES

 

Citing Literature

Number of times cited according to CrossRef: 19

  • Liat Shklarski, Yael Latzer, Zohar Spivak‐Lavi, Carol Tosone, Weathering the Storm Together: Therapists' Experiences Treating War Trauma Survivors While Managing Their Own Concurrent Trauma, Stress and Health, 10.1002/smi.70132, 42, 1, (2026).

    View

  • Vidmantė Giedraitytė, Ramunė Miežanskienė, Strategies for Enhancing Civil Participation in National Security: Case of Lithuania, Democratic Resilience in the Baltics, Vol. 2, 10.1007/978-3-032-10146-4_4, (69-89), (2026).

    View

  • Ieva Gajauskaite, Defining Societal Resilience as a Defensive Power, Democratic Resilience in the Baltics, Vol. 2, 10.1007/978-3-032-10146-4_1, (3-22), (2026).

    View

  • Shir Porat-Butman, Sarit Agam, Shiran Glazer, Eden Hakimi-Pour, Hanna Levenberg, Zohar Nimni, Maya Nissenhaus-Apel, Selin Simrooglu, Yael Shahar, Ariel Reuveni, Nof Vaknin, Einat Levy-Gigi, Who can best support us through cumulative trauma exposure in the media?, Acta Psychologica, 10.1016/j.actpsy.2025.105921, 262, (105921), (2026).

    View

  • Julia Brailovskaia, Sami Hamdan, Loneliness mediates the association between addictive social media use and mental health in university students in Germany and Israel, Journal of Public Health, 10.1007/s10389-025-02669-w, (2026).

    View

  • Dean Ariel, Hadas Marciano, Shaul Kimhi, Yohanan Eshel, Bruria Adini, Individual Resilience as a Mediator Between Demographic and Sociopolitical Factors, Community Resilience and Psychological Distress: A Five‐Wave Study Following October 7, Stress and Health, 10.1002/smi.70080, 41, 4, (2025).

    View

  • Dan Prat, Asaf Bloch, Maya Braun, Adi Givon, Sharon Goldman, Eldad Katorza, Shachar Shapira, Do Gunshot and Explosion Injuries Differ in Severity and Management? A Multicenter Study of Upper Extremity Trauma in the 2023 Israel-Gaza Conflict, Clinical Orthopaedics & Related Research, 10.1097/CORR.0000000000003618, 483, 11, (2047-2055), (2025).

    View

  • Tehila Kalagy, Orna Braun-Lewensohn, Sarah Abu-Kaf, Psychological distress among Israelis during crisis: A comparison between COVID-19 and the Iron Swords War, Psychiatry Research, 10.1016/j.psychres.2025.116491, 348, (116491), (2025).

    View

  • Deborah Bergman Deitcher, Raaya Alon, Special Education Preschool Teachers' Stress and Well‐Being During Wartime: Relations With Psychological Capital, Occupational Self‐Efficacy, and Social Support, Psychology in the Schools, 10.1002/pits.23584, 62, 10, (3926-3938), (2025).

    View

  • Arielle Kaim, Maya Siman Tov, Shaul Kimhi, Hadas Marciano, Yohanan Eshel, Bruria Adini, Predictors of societal and individual resilience across two and a half years of varied adversities, Scientific Reports, 10.1038/s41598-025-00854-1, 15, 1, (2025).

    View

  • Stav Shapira, Agat Sold, Tehila Refaeli, The Interplay of Personal and Collective Resilience and Mental Health During Prolonged Conflict: Insights From Young Adults in Israel, Stress and Health, 10.1002/smi.70047, 41, 3, (2025).

    View

  • Toshiya Tsujita, Facilitating and Hindering Factors in Developing National Resilience During a Crisis: The Case of Israel, “Fragile Stability” as a Political Background of October 7, 10.1007/978-981-96-2587-1_10, (169-184), (2025).

    View

  • Simon Esbit, Arielle Kaim, Shaul Kimhi, Dalia Bankauskaite, Maria Baran, Tomasz Baran, Anatolie Cosciug, Yohannan Eshel, Salome Dumbadze, Manana Gabashvili, George Jiglau, Krzysztof Kaniasty, Alice Koubova, Hadas Maricano, Renata Matkeviciene, Marius Matichescu, Mykola Nazarov, Dmitri Teperik, Nino Kochiashvili, Bruria Adini, Hope and Distress: A Cross‐Country Study Amid the Russian‐Ukrainian War, Stress and Health, 10.1002/smi.70033, 41, 2, (2025).

    View

  • Elad Mijalevich-Soker, Orit Taubman – Ben-Ari, Parents’ Experience During Wartime: Vulnerability, Complexity, and Parental Functioning, Journal of Loss and Trauma, 10.1080/15325024.2025.2465388, (1-25), (2025).

    View

  • Oleksandr SEMYKRAS, BEHAVIOURAL INSIGHTS AS A MECHANISM FOR BUILDING NATIONAL RESILIENCE IN THE CONTEXT OF HYBRID WARFARE, Bulletin of Taras Shevchenko National University of Kyiv. Public Administration, 10.17721/2616-9193.2025/22-13/14, 22, 2, (94-105), (2025).

    View

  • Chen Sharon Shmul, Baruch Berzon, Bruria Adini, Navigating crisis: exploring the links between threat perceptions, well-being, individual and workplace resilience among general hospital staff, Israel Journal of Health Policy Research, 10.1186/s13584-024-00656-2, 13, 1, (2024).

    View

  • Michael V. Joachim, Dana Atia Joachim, Liat Korn, Yair Shapiro, Amir Laviv, Avi Zigdon, Emotional resilience and sense of danger among doctors in hospitals during periods of heightened tensions and warfare in Israel, Israel Journal of Health Policy Research, 10.1186/s13584-024-00655-3, 13, 1, (2024).

    View

  • Hadas Marciano, Shaul Kimhi, Yohanan Eshel, Bruria Adini, Resilience and coping during protracted conflict: a comparative analysis of general and evacuees populations, Israel Journal of Health Policy Research, 10.1186/s13584-024-00642-8, 13, 1, (2024).

    View

  • Yuliya Lipshits‐Braziler, Moshe Tatar, Ina Ben‐Uri, Sima Amram‐Vaknin, Profiles of Psychological Capital and Work‐Related Well‐Being Among School Counselors During a Prolonged Emergency, Journal of Counseling & Development, 10.1002/jcad.70028.
Bullets on EU flag

Research

Feb 26th, 2026
Resilience and Strategic Trends in the Euro-Atlantic Space. Priorities for the
  • Partner Research and Endeavors

Resilience and Strategic Trends in the Euro-Atlantic Space

E-ARC Analytic Reports

Resilience and Strategic Trends in the Euro-Atlantic Space

Priorities for the Black Sea Region

by Valentin Ene  ·  Euro-Atlantic Resilience Centre  ·  February 2026

 
Contents
  1. Summary
  2. NATO & EU Recent Initiatives
  3. NATO and EU Foresight Reports
  4. Priorities for the Black Sea Region
  5. Conclusion
  6. Bibliography

01 — Overview

Summary

In last years, resilience became a defining priority across the Euro-Atlantic space, as both the European Union and NATO adapted to a deteriorating global landscape marked by geopolitical confrontation, increasing hybrid threats, technological disruption, resource competition and accelerating climate impacts.

Looking at future trends, the 2025 Strategic Foresight Report of the EU Commission advocates a proactive, transformative model of "Resilience 2.0," centred on technological leadership, democratic cohesion, economic security, robust infrastructures and intergenerational fairness.

At the same time, NATO Strategic Foresight Analysis identifies seven long-term global drivers, that define the strategic environment through 2040: climate collapse, resource scarcity, disruptive AI, geoeconomic fragmentation, empowered nonstate networks, competition over global commons and a transforming international order.

In this setting, the European Union launched a Preparedness Strategy, that sets a comprehensive framework for strengthening Member States' capacity to anticipate and respond to complex crises. It introduces measures to secure essential services, reinforce civil–military cooperation, raise societal preparedness, align risk assessments, and institutionalize public–private partnerships.

In parallel, with the ReArm Europe / Readiness 2030 initiative, EU seeks to mobilize up to €800 billion to expand and modernize Europe's defence industrial base, deepen joint procurement and support Ukraine.

In response to future trends, NATO placed resilience at the core of deterrence and collective defence at the 2025 Summit in The Hague, committing Allies to allocate 5% of GDP to defence by 2035, including an unprecedented 1.5% dedicated explicitly to civil resilience. NATO now pursues a layered resilience approach integrating societal, civil and military dimensions, informed by lessons from the Russia–Ukraine war.

Within this context, the Black Sea Region is positioned to evolve into a regional hub for NATO–EU coordination, resilience and strategic foresight, shaped by the deepening convergence between NATO and the EU on critical infrastructure protection, cybersecurity, hybrid threat response, climate and energy security, and civil–military cooperation.

In this environment, regional priorities should focus on strengthening societal preparedness, improving public awareness and digital literacy, countering disinformation, and consolidating the resilience of essential services and infrastructures such as energy, water, transport and communications. At the same time, enhanced public–private cooperation and the integration of private operators into the resilience architecture are indispensable, given the strategic importance and vulnerability of the region's infrastructure and information landscape.

Also, building on NATO's layered resilience concept and the EU's Preparedness Strategy, the region is positioned to expand multinational civil–military exercises, harmonize NATO–EU methodologies, and develop anticipatory tools capable of translating global strategic drivers into regional scenarios. This includes establishing the Black Sea area as a foresight and methodological hub, while strengthening structured cooperation with Ukraine and the Republic of Moldova in preparedness, crisis response and resilience assessments.

02 — Policy

NATO & EU Recent Initiatives

EU Preparedness Strategy

In March 2025, the EU presented a strategy with the objective of supporting Member States in strengthening their capacity to prevent and respond to emerging threats and complex crises. The strategy includes a detailed action plan and outlines 30 key actions, the most important for the Black Sea Region referring to:

Resilience of Essential Services

Ensuring the supply of water and other essential natural resources; Reviewing the energy security framework, adapting it to the geopolitical context; Assessing the level of preparedness in the field of financial services, especially the ability to ensure the continuity of critical functions, payments and the financing of the economy under all circumstances; Integrating the concept of preparedness into EU policies and actions; Adopting minimum preparedness requirements.

Promoting Population Preparedness

Encouraging the public to adopt practical measures, such as keeping essential supplies for a minimum of 72 hours in emergency situations; Increasing awareness of risks and threats; Promoting preparedness in youth programmes.

Crisis Response

Establishing an EU crisis centre to improve integration between existing EU crisis structures.

Strengthening Civil–Military Cooperation

Periodic organization of preparedness exercises at EU-wide level, bringing together the armed forces, civil protection, police, security, medical personnel and firefighters; Facilitating dual-use investments; Launching a platform for exchanging national best practices in civil–military interactions and the reciprocal use of civilian and military resources.

Strengthening Forecasting and Anticipation Capacities

Developing a comprehensive EU-level risk and threat assessment, contributing to the prevention of crises such as natural disasters or hybrid threats; Developing an EU training catalogue and a platform for lessons learned.

Increasing Public–Private Cooperation

Creating a public–private working group for emergency preparedness; Formulating emergency protocols together with businesses to ensure the rapid availability of essential materials, goods and services and to secure critical production lines; Developing a customized resilience-testing methodology to assess the preparedness and resilience of Member States' research and innovation sectors.

Resilience through External Partnerships

Collaboration with strategic partners such as NATO in the fields of military mobility, climate and security, emerging technologies, cyberspace, space and the defence industry; Promoting mutual resilience with candidate countries; Integrating preparedness and resilience into bilateral partnerships and multilateral institutions; Integrating preparedness and resilience into cooperation with NATO.

Since the strategy's adoption, two operational policy tracks have been launched under its umbrella:

The EU's Stockpiling Strategy

An initiative built to make sure essential items are available during big cross-border emergencies like wars, pandemics, disasters caused by climate change, or widespread infrastructure breakdowns. It signals a move away from just-in-time supply systems to a more resilient approach that values being ready, having backups, and keeping supply chains running smoothly. This plan includes necessities like food, water, fuel, medical gear, and vital civil protection tools, recognizing that crises often hit multiple areas at once.

One of the key parts of this strategy is how EU-wide stockpiles work together with national ones instead of being entirely centralized. While individual countries still manage and own most of their reserves, the EU steps in with support through guidelines, funding, and systems—mainly using the Civil Protection Mechanism and rescEU—to help quickly share and move supplies when needed. This method respects each country's control while also promoting EU-wide teamwork, so supplies can cross borders when a single country can't handle a crisis alone.

On a community level, the strategy also pushes countries to update advice about preparing households to be self-sufficient for the first 72 hours of an emergency. The idea is to help people take care of themselves during the crucial early phase, which eases the burden on emergency services and lets responders focus on those most at risk and on keeping essential services running. This reflects a bigger shift toward a culture of preparedness and shared responsibility, bringing the EU more in line with the well-established Nordic and Baltic approaches to total defence and societal resilience.

Since the strategy's adoption on 9 July 2025, the European Commission has begun shifting from policy planning toward coordination and implementation steps. One of the earliest tangible outputs has been the formation of frameworks for an EU Stockpiling Network, intended to bring national stockpile authorities together to share best practices, coordinate stock data and address overlaps or gaps in essential supplies such as food, water, medicines and fuels.

Another developing area linked to the strategy — though still evolving — is the planned establishment of a Critical Raw Materials Centre, expected in 2026, which would support coordinated purchases and strategic stockpiles of key industrial inputs (including for the energy and medical sectors). This would be one of the first concrete operational facilities created under the broader stockpiling initiative, aimed at reducing strategic dependencies and improving readiness for crises.

The EU's Medical Countermeasures Strategy

This strategy is all about protecting people's health during major health crises by making sure vaccines, treatments, tests, and vital medical gear are quickly available. It was created in direct response to the problems revealed by the COVID-19 pandemic and views health readiness as a key part of the EU's overall security and resilience—not just a healthcare issue. The strategy covers everything from research and development to production, stockpiling, purchasing, and distributing medical supplies.

At the centre of this strategy is HERA, the EU's main agency for health emergency readiness and response. HERA keeps an eye on potential threats, plans ahead, makes advance purchase deals, manages EU stockpiles, and partners with manufacturers to ensure they can ramp up production fast when needed. The goal is to avoid the kind of disorganized buying and supply shortages that happened early in the COVID-19 crisis.

This strategy also ties into the EU's bigger plans for becoming more self-sufficient and protecting its supply chains. It aims to cut back on reliance on single suppliers or non-EU countries for critical medical items, spread out production across different locations, and make regulations more flexible during emergencies. By connecting health readiness with industrial, research, and security policies, the EU is making it clear that strong healthcare systems are vital not just for saving lives, but for keeping society stable, the economy running, and politics steady during tough times.

ReArm Europe / Readiness 2030 Initiative

In parallel, the European Union launched the strategic initiative ReArm Europe / Readiness 2030, aimed at mobilizing up to €800 billion through the fiscal derogation clause, the SAFE instrument and other complementary measures, with the objective of strengthening, expanding and modernizing the defence industrial base of Member States and supporting joint procurement of modern and interoperable military equipment.

Through SAFE and the flexibilization of fiscal regulations, the EU aims to develop its capacity to react quickly and efficiently in a military or security crisis, a sign of strategic financial resilience. The initiative's focus on two essential elements of structural resilience: strengthening the defence industry aims at developing its dimensions of interoperability, efficiency and competitiveness, and at creating an ecosystem capable of rapidly supporting joint efforts. The initiative also addresses the strengthening of direct military support to Ukraine and reducing dependence on external suppliers, thereby aiming to strengthen strategic resilience and collective security in the face of threats.

Rearm Europe includes plans for the development of multimodal infrastructure (rail, road, maritime, air), facilitating rapid force deployment — a key component of military resilience — while simultaneously strengthening the resilience of transport infrastructure.

In conclusion, the ReArm Europe / Readiness 2030 Initiative represents an approach centred on increasing Europe's resilience from a military, industrial and strategic perspective. It constitutes a complementary approach to the EU Preparedness Strategy, applied in the military and financial context.

In the second half of 2025, the Council of the European Union took a decisive step by translating ReArm Europe from a political commitment into binding EU regulatory action. In December 2025, the Council adopted amendments designed to simplify and accelerate defence and dual-use investments, notably by streamlining approval procedures, shortening permitting timelines, and clarifying eligibility for EU financial instruments. Rather than establishing a new, standalone defence fund, these measures deliberately recalibrated existing EU programmes to accommodate large-scale defence investment, reducing reliance on repeated exemptions or ad-hoc derogations. Crucially, this legal shift established an important precedent by formally recognising defence readiness as a matter of European public interest, thereby justifying differentiated treatment within EU economic governance and regulatory frameworks.

By year's end, the Defence Readiness Omnibus became the main tool for putting ReArm Europe into action. Instead of starting from scratch, the Omnibus made coordinated changes to various existing EU laws. The approach was practical, as speed was seen as being more important than building a brand-new system. The Omnibus targeted bottlenecks in procurement, industrial policy, and funding. It made it easier to go from project planning to actual contracts, especially when multiple countries were working together. It also clarified how civilian programs could support defence efforts, as long as the outcomes had both civilian and military uses. Most importantly, it helped eliminate fragmentation. Defence readiness wasn't treated as a special case anymore, but it became part of mainstream EU policy, woven into various instruments and sectors.

Meanwhile, the European Commission worked on the Defence Readiness Roadmap 2030 throughout the second half of 2025. The Roadmap offered strategic guidance, pointing out which capabilities and industrial gaps required joint European action. This wasn't a detailed buying plan, but more of a coordination tool. It helped align national defence plans with broader EU goals and encouraged countries to rally around shared priorities rather than each going their own way. Key focus areas included mobility for military operations, air and missile defence, drones, ammunition production, and strengthening logistics.

By late 2025, the Roadmap became the go-to guide for how to apply SAFE loans, national defence budgets, and new EU regulatory flexibilities.

A major breakthrough also came in the second half of 2025: EU countries were now explicitly allowed to use the flexibility in EU fiscal rules to boost defence spending without facing penalties. This marked a shift in how "responsible" spending was defined, acknowledging that security demands justified increased budgets.

In tandem, the Security Action for Europe (SAFE) instrument moved from an idea to a real, ready-to-use funding tool. SAFE was created to support large-scale defence procurement and industrial investment, especially for high-cost projects that individual countries couldn't afford alone. By the end of 2025, the framework and eligibility rules were in place for SAFE to launch in 2026.

Together, SAFE and fiscal flexibility addressed the key financial problem facing European defence: the gap between ambitions and what countries could actually afford on their own.

Throughout this period, EU leaders kept reinforcing the broader political message behind Readiness 2030. Defence spending was no longer a short-term reaction to the war in Ukraine—it was now seen as a long-term necessity in a world of ongoing strategic rivalry.

European Council decisions, ministerial comments, and Commission briefings all echoed a shared view: Europe's security readiness was tightly linked to its economic resilience, tech independence, and crisis preparedness. This strong consensus helped reassure industry and investors that defence spending and military industrial growth would be sustained—not just a passing phase.

By December 2025, ReArm Europe had matured from a politically sensitive idea into a coherent EU policy framework, with supporting laws, funding tools, and strategic direction all in place.

NATO Summit in The Hague (2025)

In the context of an increasingly dynamic international security environment, characterized by geopolitical confrontation, high-intensity armed conflicts and the multiplication of hybrid and conventional threats, the 2025 NATO Summit in The Hague enshrined resilience as the foundation of deterrence and collective defence, establishing the integration of the seven baseline requirements into national planning.

All 32 Member States (with the exception of Spain, which received a temporary exemption) committed to reaching 5% of GDP allocated annually to defence and related expenditures by 2035, with 3.5% dedicated to "effective defence" (equipment, salaries, ammunition, etc.) and 1.5% dedicated to civil resilience (energy networks, telecommunications, transport), critical infrastructure and civil crisis-support capabilities, as well as strategic stocks and preparedness for hybrid crises.

Thus, NATO includes for the first time civil and societal resilience as an explicitly budgeted element within the defence target. Through this decision, NATO confirmed that resilience is not an auxiliary dimension, but an integral part of the defence architecture, which must be planned and financed with the same rigour as military capabilities.

Furthermore, the more recent but still expanding concept of layered resilience, introduced to reflect lessons identified from the Russia–Ukraine war, emphasizes that institutional and military preparedness must be combined with the robustness and flexibility of civilian infrastructures and societal cohesion to generate an integrated, efficient and adaptable defence system.

The Hague Declaration mentions that NATO and the EU must align their resilience and preparedness strategies, including for energy security; protection of critical infrastructure (ports, submarine cables, space, digital networks); joint response to hybrid and cyber attacks. The need for NATO–EU complementarity on resilience was emphasized: NATO for collective defence, the EU for civil infrastructure and crisis response.

Additionally, leaders agreed to reduce barriers to defence trade among allies and to develop transatlantic industrial cooperation, emphasising resilient supply chains for ammunition, digital technology, chips, energy and critical materials.

In terms of societal resilience and strategic communication, the Summit linked societal resilience to education, population preparedness and partnership with the private sector (technology, media, energy), emphasizing the fight against disinformation and malign foreign influence.

NATO leaders committed at The Hague to strengthening deterrence and defence, with particular emphasis on the eastern flank. In the months following the summit, this commitment translated into continuity rather than disruption: existing force posture and forward presence were maintained, large-scale exercises continued as planned, and NATO's operational planning cycle remained on track. From an Alliance management perspective, this signalled steadiness and reliability, reassuring Allies that agreed defence plans were being upheld without delay or confusion.

At the same time, there was no major post-summit escalation or structural overhaul of NATO's military posture. No significant new permanent deployments were announced, nor were there substantial changes to NATO's command arrangements that could be directly traced to decisions taken in The Hague. This absence of dramatic moves indicates that NATO deliberately chose not to redefine deterrence through visible force expansion, opting instead to preserve an already heightened baseline established in previous years.

Taken together, this outcome suggests that NATO delivered on stability and reassurance but stopped short of bold or transformative deterrence initiatives. The Alliance demonstrated that it could sustain readiness and coherence under pressure, but it did not seek to signal a new phase of military escalation. In that sense, the post-summit period reflects continuity rather than transformation, reinforcing existing commitments rather than reshaping them.

On defence industrial capacity, the momentum that NATO highlighted at The Hague shifted decisively toward the European Union. While the summit underscored the importance of defence production, stockpiles, and industrial resilience, most tangible progress since then has occurred through EU initiatives such as ReArm Europe, Readiness 2030, and the Defence Readiness Omnibus. NATO has continued to play a role in coordinating requirements, standards, and interoperability, but it has not positioned itself as the main driver of industrial scaling or financing.

As a result, NATO did not itself deliver the industrial outcomes it emphasised at the summit, but it relied on parallel EU action to fill that gap. Strategically, this arrangement is coherent, even if institutionally indirect.

Finally, the summit's broader political messages have produced mixed but telling results. Pressure—particularly from the United States—for greater European responsibility has clearly worked at the level of narrative and planning, as reflected in EU-level defence investment frameworks and national budgetary signals. Yet uncertainty about the long-term U.S. force posture in Europe remains unresolved, with no post-summit clarity beyond reaffirmations of Article 5. Support for Ukraine has continued consistently, and Russia remains framed as a long-term threat, but without any qualitative escalation such as new membership steps or NATO-led security guarantees. Overall, NATO has largely done what it said it would do in terms of alignment, planning, and coordination, while postponing most hard delivery to the medium term and, in practice, to other institutions—above all, the EU.

NATO–EU Common Perspective

NATO–EU cooperation has seen significant expansion in recent years, confirmed by the 2025 joint report ("Tenth progress report on the implementation of the common set of proposals endorsed by EU and NATO Councils on 6 December 2016 and 5 December 2017"), which highlights convergent areas of action such as the protection of critical infrastructures, cyber security, military mobility, public health, climate change and combating hybrid threats.

NATO sets the political-military framework and the seven baseline requirements on civil preparedness, while the EU provides normative and financial tools through CER, NIS2, SAFE and the EDF, a situation that turns resilience into an area of practical complementarity.

In this context, of increasing NATO-EU convergence on the topic of resilience, the Black Sea area stands out as a key testing ground for the application of this shared view. This is because the area is home to a large number of the vulnerabilities that are increasingly being addressed by both organizations: military pressure, hybrid threats, critical infrastructures, and interdependencies.

From a NATO point of view, the Black Sea is an essential part of the Eastern Flank and is closely connected to collective defence, deterrence, and crisis management. The security context is characterized by the proximity of active and frozen conflicts, the militarization of the sea and airspace, and the constant hostile actions below the threshold of armed conflict. This creates a high demand for civil preparedness and resilience, in accordance with NATO's baseline requirements, since military effectiveness in the region cannot be separated from the continuity of civilian activities.

However, the European Union has its own approach to the Black Sea, which is mainly that of strategic interdependence. This is because the EU is faced with the Black Sea as an area where any kind of disturbance in energy, transport, food, or digital infrastructure has immediate spillover effects within the Union. The EU, therefore, uses its instruments to address vulnerabilities that are of a structural nature, as opposed to those that are episodic. This is because the EU policies ensure that resilience is translated into enforceable standards.

The Black Sea region is thus a particularly good example of the functional complementarity between NATO and the EU. While NATO sets the strategic context and the level of readiness necessary to resist dramatic security shocks, the EU offers the legal, economic, and technological infrastructure necessary to implement resilience on a day-to-day basis. In a context where there is a lot of hybrid pressure and ambiguity, this division of labor becomes a force multiplier rather than a weakness, as long as the coordination mechanisms are effective.

03 — Analysis

NATO and EU Foresight Reports

European Commission's 2025 Strategic Foresight Report

In September 2025, the European Commission published a new strategic foresight report, Resilience 2.0: strengthening the EU's capacity to thrive in conditions of turbulence and uncertainties, which introduces the concept of "Resilience 2.0," emphasising a shift to a proactive, transformative, future-oriented approach that ensures a decisive advantage in the new geopolitical reality marked by unpredictability. The report identifies both global and EU-specific challenges and proposes areas of action meant to ensure the Union's resilience and enable it to fully benefit from its transformative power in a changing world. These areas include:

  • Developing a coherent global vision for the EU – Defining a clear European strategic concept based on values and interests; Accelerating the enlargement process and gradual integration of candidate countries.
  • Enhancing internal and external security – Civil-military synergies and an integrated approach to defence and security; Robust European critical infrastructures (digital, energy, transport, space); Societal preparedness and rapid response capacity; Strengthened EU–NATO cooperation.
  • Harnessing the power of technology and research – Leadership in global governance of high-impact technologies (AI, clean tech, biotechnologies); Developing strategic autonomy in essential tech value chains; Setting global standards for AI and promoting a European ethical, human-centred model; Responsible approaches to controversial technologies (superintelligence, human augmentation, solar geoengineering).
  • Strengthening long-term economic resilience and preparing for labour-market changes – Strengthening strategic industries and supply chains; Developing the circular economy and internal resources (critical raw materials); Adapting the labour market to technological and demographic transformations.
  • Supporting sustainable and inclusive well-being – Reforming taxation systems (shifting the burden from labour to negative externalities); Strengthening medical supply chains and health prevention.
  • Reimagining education – Adapting curricula to future skills (STEM, AI, creativity, adaptability); Investing in retraining and upskilling to respond to automation and AI.
  • Strengthening the foundations of democracy as a common good – Combating polarization, information manipulation and disinformation; Involving local communities and civil society; Promoting democratic deliberation and trust in European institutions.
  • Anticipating demographic transformation and intergenerational fairness – Creating a European framework for intergenerational equity; Promoting solidarity and social cohesion between generations; Ensuring long-term sustainability of the welfare state and public services.

The 2025 Strategic Foresight Report concludes that the European Union must shift from reactive crisis response to proactive, forward-looking resilience — labelled "Resilience 2.0" — to ensure it can anticipate, absorb, adapt to, and shape future disruptions and opportunities through to 2040 and beyond. This approach positions resilience not just as survival, but as transformative capacity that bolsters competitiveness, security, democratic values and societal well-being in an uncertain and rapidly changing world.

NATO Strategic Foresight Analysis 2023 (SFA23)

The document provides a common understanding of the evolving security environment up to 2043, serving as the foundation for the Alliance's strategic reflection.

SFA23 concludes that rivalry and adversarial intentions of major state actors and non-state terrorist actors will persist in a context marked by disruptions. They will seek to influence and challenge the Alliance, as well as to question the rules-based international order. To this end, they will strengthen their power and seek to expand their influence, exploiting instabilities and resorting to digital, socio-economic and hybrid means.

The report identified 170 global trends and synthesized the most influential into seven drivers shaping the future security environment:

  • Climate collapse and biodiversity loss – considered the most significant long-term existential factors.
  • Resource scarcity – fuelling instability and regional conflicts.
  • The era of AI and disruptive technologies – rapidly reshaping states, societies and armed forces.
  • Geoeconomics fuelling polarization – the fragmentation of the global system into economic blocs, with major implications for trade, demography and financial security.
  • Powerful human networks – non-state actors becoming more influential through urbanization, technologization and the avalanche of information/disinformation.
  • Competition for global commons – intensified by strategic demand and technological progress (e.g., space, polar regions).
  • An international order in transition – challenging the rules-based order, global fragilization, new alliances and intensified strategic competition.

The NATO Strategic Foresight Analysis 2023 (SFA23) highlights that the Alliance will be operating in the next two decades in a more contested, fragmented, and volatile security environment, which will be marked by strategic rivalry, systemic disruption, and the degradation of the rules-based international order. The state and non-state actors will continue to challenge the Alliance in the next two decades in various domains, which will be below the threshold of armed conflict.

The seven drivers of change that have been identified in SFA23 show that the future of security will be one of interconnected, cumulative, and nonlinear challenges, where climate collapse, disruptive technologies, and geopolitical fragmentation will be the force multipliers of instability.

Taken together, SFA23 finds that NATO must be able to continuously adapt its tools of power, decision-making, and partnerships in order to remain credible and effective. This involves building resilience, sustaining technological and military superiority, enhancing anticipation and early warning, and sustaining unity of purpose among Allies. Strategic foresight thus becomes not just an analysis tool, but an essential tool for NATO's long-term deterrence, defence, and shaping of the security environment through 2043.

NATO–EU Similarities in Foresight

Both NATO and the European Union foresee a future marked by greater instability, strategic competition, and fragmentation. They agree that the international environment will become increasingly contested over the next two decades, with rising geopolitical tensions and the weakening of multilateral norms challenging the rules-based global order.

A shared concern is the proliferation of hybrid threats. Both institutions highlight that state and non-state actors are leveraging tactics below the threshold of open conflict—such as cyberattacks, disinformation, and economic coercion—to destabilize societies and weaken institutional trust. Addressing these threats requires coordinated, cross-domain responses.

Technological transformation is another critical area of convergence. NATO and the EU emphasize the importance of retaining a competitive edge in emerging and disruptive technologies, such as artificial intelligence, quantum computing, and cybersecurity. Both foresee technology as a double-edged sword—offering opportunities for resilience and innovation but also new vulnerabilities.

Climate change is identified as a major threat multiplier by both organizations. The reports link environmental degradation to increased conflict, migration, and economic disruption. They stress that climate-related challenges will increasingly intersect with security, demanding integrated responses that combine defence, environmental, and social policy tools.

Resilience emerges as a central theme in both foresight strategies. NATO emphasizes civil preparedness and societal resilience as vital to military effectiveness, while the EU integrates resilience into policy planning, infrastructure protection, and crisis management. Both view resilience as key to absorbing shocks and sustaining operational continuity.

Finally, NATO and the EU stress the importance of strategic foresight as more than a planning tool—it is a critical enabler of long-term security, governance, and preparedness. Both call for enhanced partnerships, shared intelligence, and closer coordination to effectively navigate the complex challenges of the coming decades.

04 — Regional Focus

Priorities for the Black Sea Region

In this context of growing geopolitical rivalry, the Black Sea Region stands out as a region where the global strategic trends manifest themselves with particular intensity. The overlap of military pressure, hybrid threats, critical infrastructure interdependencies, and societal vulnerabilities puts the region at the nexus of the NATO deterrence and defense strategy and the European Union resilience and preparedness strategy.

Thus, the Black Sea is no longer a marginal theater but rather a central arena for the testing of the coherence and effectiveness of the emerging NATO-EU common view on resilience. The strategic foresight analysis of both NATO and the European Union highlights that the future security challenges will be more and more interconnected, transboundary, and nonlinear. The effects of climate change, technological disruption, geoeconomic fragmentation, and the rise of hybrid threats are already being felt in the Black Sea region, which is further aggravating the vulnerabilities in the region. In this scenario, the concept of resilience cannot be dealt with in a sectoral manner or through a national approach.

Defining clear regional priorities becomes essential for translating shared assessments and policy frameworks into practical action. The following priorities, if pursued by the Black Sea Region countries, would do much to operationalize NATO–EU convergence on resilience, focusing on areas where coordinated efforts can deliver the greatest strategic impact, reduce vulnerabilities and strengthen the region's capacity to anticipate, withstand and adapt to complex crises.

Priority 01

Societal and Civil Preparedness

A first overarching priority is the strengthening of societal and civil preparedness as a foundation for deterrence and crisis response. In line with NATO's baseline requirements and the EU's Preparedness Strategy, the Black Sea Region must move beyond a reactive approach to crises and develop a culture of preparedness that encompasses public authorities, critical infrastructure operators and the population at large. This includes improving risk awareness, promoting basic household preparedness, strengthening digital and media literacy, and reinforcing trust in public institutions. Given the region's exposure to disinformation and malign influence, societal resilience is not only a social objective but a core security requirement.

Priority 02

Critical Infrastructures Resilience

A second key priority concerns the protection and resilience of critical infrastructures and essential services, particularly in energy, transport, water, digital networks and ports. The Black Sea is a major hub for energy transit, maritime trade and digital connectivity, dynamics that are further intensified by the persistent use of hybrid instruments by state actors, notably Russia, including cyber operations, disinformation activities, economic and energy leverage, and actions targeting critical and civilian infrastructure, conducted predominantly below the threshold of armed conflict.

These activities exploit structural vulnerabilities and institutional gaps, undermine societal cohesion and trust, and complicate collective prevention and response mechanisms, reinforcing the need for integrated resilience approaches that combine civil, societal and military preparedness across the region. NATO's emphasis on continuity of civilian services and the EU's regulatory frameworks under CER and NIS2 should be applied in a complementary manner, ensuring that regional infrastructures are designed, regulated and stress-tested against complex, multi-domain crises. Particular attention should be given to cross-border interdependencies, as disruptions in the Black Sea have immediate spillover effects across the wider Euro-Atlantic space.

Priority 03

Extending Dimensions of Resilience

A third priority is the integration of public–private actors into the regional resilience architecture and deepening of civil-military cooperation. Much of the Black Sea's critical infrastructure and information environment is owned or operated by private entities, making their involvement indispensable. Building on EU initiatives promoting public–private cooperation and NATO's recognition of the private sector as a resilience stakeholder, the region should advance structured mechanisms for information sharing, joint preparedness planning and coordinated crisis response. This approach is essential for reducing vulnerabilities, accelerating recovery and ensuring the continuity of essential economic and social functions during crises.

The convergence of NATO's layered resilience concept and the EU's Preparedness Strategy create a unique opportunity to harmonize methodologies, align planning assumptions and reduce duplication. Expanding multinational exercises that simultaneously test NATO civil preparedness requirements and EU regulatory compliance would help translate political alignment into operational readiness. Such exercises should increasingly focus on hybrid scenarios, infrastructure disruptions and cross-border crises, reflecting the realities of the regional threat environment.

Priority 04

Hub for Cooperation and Foresight

A fourth priority is the development of the Black Sea Region as a hub for strategic foresight, anticipation and scenario-based planning, in cooperation with partners in the region. Given the concentration of long-term drivers identified in NATO and EU foresight reports—ranging from climate impacts and resource pressures to disruptive technologies and geopolitical fragmentation—the region is particularly suited for piloting anticipatory tools and methodologies. Strengthening foresight capacities would support early warning, improve decision-making and enable policymakers to link global strategic trends with regional vulnerabilities and response options.

With regional partners, particularly Ukraine and the Republic of Moldova, cooperation must be deepened in the fields of preparedness, resilience assessment and crisis response. The security of the Black Sea cannot be separated from the resilience of its immediate neighbourhood. Supporting partner countries in aligning with NATO and EU resilience standards, sharing best practices and participating in joint exercises contributes directly to regional stability and to the broader objective of mutual resilience.

Taken together, these priorities reflect a shift from viewing the Black Sea primarily as a frontline or buffer zone to treating it as a strategic space for integrated resilience-building. By aligning NATO's defence-oriented approach with the EU's regulatory, financial and societal instruments, the Black Sea Region can evolve into a cornerstone of the Euro-Atlantic resilience architecture, capable not only of withstanding shocks, but of adapting to and shaping a rapidly changing strategic environment.

05 — Final Remarks

Conclusion

Taken together, the recent strategic documents adopted by the European Union and NATO point to a clear and lasting shift in the Euro-Atlantic security paradigm. Resilience is no longer treated as a supporting concept, but as a central organizing principle for deterrence, preparedness and long-term stability. The EU's Preparedness Strategy and Resilience 2.0 agenda, alongside ReArm Europe / Readiness 2030, demonstrate an effort to institutionalize resilience through regulation, investment and industrial capacity. In parallel, NATO's decisions at the 2025 Summit in The Hague and its Strategic Foresight Analysis embed civil and societal resilience directly into collective defence planning. Together, these documents provide a coherent strategic framework for addressing systemic and hybrid risks across the Euro-Atlantic space.

Within this framework, the Black Sea Region emerges as a focal area where the assumptions and priorities of these strategic documents converge most visibly. The region reflects many of the long-term drivers identified in NATO and EU foresight—geopolitical rivalry, hybrid pressure, technological disruption, climate-related stress and infrastructure interdependence—while also carrying immediate operational relevance for both organisations. As a result, the Black Sea functions not only as a security frontier, but as a practical testing ground for the implementation of NATO's baseline requirements, the EU's preparedness measures and the alignment between civil, military and societal dimensions of resilience.

In this context, articulating clear priorities for the Black Sea Region becomes essential to bridging strategic intent and operational reality. By anchoring regional action in the shared strategic guidance provided by NATO and EU documents, these priorities aim to ensure coherence, reduce fragmentation and maximize the added value of NATO–EU complementarity.

Strengthening resilience in the Black Sea is therefore not a regional end in itself, but a critical contribution to the credibility, adaptability and long-term effectiveness of the broader Euro-Atlantic resilience and security architecture.

06 — Sources

Bibliography

  • European Commission. Resilience 2.0: Strengthening the EU's Capacity to Thrive in Conditions of Turbulence and Uncertainty. Strategic Foresight Report 2025. Brussels, European Commission, 2025.
  • European Commission. EU Preparedness Strategy. Communication from the Commission to the European Parliament, the Council, the European Economic and Social Committee and the Committee of the Regions. Brussels, 2025.
  • European Commission. Stockpiling Strategy for Crisis Preparedness and Response. Brussels, 2025.
  • European Commission. Medical Countermeasures Strategy. Brussels, 2025.
  • European Commission. Defence Readiness Roadmap 2030. Brussels, 2025.
  • Council of the European Union. Defence Readiness Omnibus: Amendments to EU Regulatory Frameworks Supporting Defence and Dual-Use Investments. Brussels, December 2025.
  • European Council. Conclusions on ReArm Europe / Readiness 2030. Brussels, 2025.
  • European Commission. Security Action for Europe (SAFE) Instrument – Framework and Eligibility Rules. Brussels, 2025.
  • NATO. Strategic Foresight Analysis 2023 (SFA23). Brussels, NATO Headquarters, 2023.
  • NATO. Vilnius Summit Communiqué. Brussels, 2023.
  • NATO. The Hague Summit Declaration. Brussels, NATO Headquarters, 2025.
  • NATO. Resilience and Civil Preparedness: NATO's Baseline Requirements. Brussels, NATO Headquarters.
  • NATO and European Union. Tenth Progress Report on the Implementation of the Common Set of Proposals Endorsed by the EU and NATO Councils on 6 December 2016 and 5 December 2017. Brussels, 2025.
  • European Union. Directive (EU) 2022/2557 on the Resilience of Critical Entities (CER Directive). Official Journal of the European Union.
  • European Union. Directive (EU) 2022/2555 on Measures for a High Common Level of Cybersecurity across the Union (NIS2 Directive). Official Journal of the European Union.
  • European Defence Agency. Defence Data and Industrial Outlook. Brussels.
  • European External Action Service. EU Approach to Hybrid Threats. Brussels.
  • NATO. Countering Hybrid Threats. NATO Review and policy documents, Brussels.
  • European Commission & High Representative of the Union for Foreign Affairs and Security Policy. Joint Communication on a Strategic Approach to Resilience in the EU's External Action. Brussels.

Published by the Euro-Atlantic Resilience Centre

52 Vasile Lascăr Street, Sector 2, Bucharest  ·  www.e-arc.ro  ·  contact@e-arc.ro  ·  +40 21 369 54 30

February 2026

Research

Feb 25th, 2026
Precision prevention network: new pathway for supporting women victims of

Precision prevention network:   new pathway for supporting women  victims of violence

  • Partner Research and Endeavors

Precision prevention network: new pathway for supporting women victims of violence

Authors

Anna Carannante , Marco Giustini , Emanuele Caredda , Simona Gaudi

Abstract

Introduction. Violence against women (VAW) is a persistent global public health problem that runs across all social classes and ethnicities with a considerable negative influence on women’s health and behaviour. Early detection, appropriate interventions and multidisciplinary cooperation are crucial factors in tackling gender violence.
Objectives. This note describes “The Violence against women: long-term health effects for precision prevention” transdisciplinary and multicenter project that aims to implement the National Guidelines with two sets of questions: the European Injury Database (EU-IDB) violence module and the Post-Traumatic Stress Disorder (PTSD) questionnaire for improving innovative approaches to limit the long-term health effect of VAW.
Furthermore, the analysis of epigenetic profile in women’s DNA may contribute to the knowledge of molecular mechanisms underlying PTSD and other non-communicable diseases. Epigenomic research in parallel with rigourous guidelines and social, educational, clinical and community interventions could accomplish innovative precision prevention protocols.
Conclusions. Public health plays essential role in identifying risk factors and strengthening the support for women victims of violence.

Keywords: violence against women (VAW), intimate partner violence (IPV), post traumatic stress disorder (PTSD), long-term effec, precision prevention

INTRODUCTION

Violence against women (VAW) may determine higher physical health morbidity and mortality [1]. It is one of the most devastating plagues worldwide with a considerable negative influence on women’s health and behaviour [2].

The United Nations defines VAW as “any act of gender-based violence that results in, or is likely to result in, physical, sexual, or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life” [3].

Furthermore, the Council of Europe Convention on preventing and combating VAW and domestic violence, the so-called Istanbul Convention (2011), defines gender-based violence as any violence directed against a woman as such, or that affects women disproportionately (art. 3) [4].

A data analysis conducted from 2000 to 2018, across 161 countries, by WHO and UN Interagency Working Group on Violence against Women, found the prevalence of nearly 30% of women subjected to physical and/or sexual violence by an intimate partner or non-partner sexual violence or both [1].

In addition, the Italian National Institute of Statistics reported that about 31.5% of women have experienced some form of violence at least once in their life [5].

Current data confirm the very high prevalence of all types throughout the world [67]: 35% of women worldwide have experienced either physical and/or sexual violence, 7% have been sexually assaulted by someone other than a partner, and 200 million have experienced female genital mutilation/cutting [8].

Worldwide, almost one-third (27%) of women aged 15-49 years, who have been in a relationship, reported that they have been subjected to some form of physical and/or sexual violence by their intimate partner [1]. An increasing research demonstrates the associations between intimate partner violence (IPV) and women’s mental health problems, in particular, depression and stress related disorders [9] affecting woman’s physical and mental health, reducing sexual autonomy, and increasing the risk for unintended pregnancy and multiple abortions [10].

According to the European Injury DataBase (EU-IDB) [11], the two most common forms of VAW are IPV and violence by acquaintances or friends (39% and 17% respectively).

Thus, violence has long-term consequences even if the violence has stopped or has been limited to a single abuse episode making the victims vulnerable to many diseases and conditions [10] (Figure 1). Among the mental health and behavioural disorders, the most prevalent is the Post Traumatic Stress Disorder (PTSD), a stress-related disorder triggered by sudden traumatic events and multiple genomic factors [112].

In analogy to the Istanbul Convention, the current Italian National Strategic Plan on male violence against women [13] includes 4 pillars: i) prevention, ii) protection and support, iii) prosecution and punishment, iv) assistance and promotion.

The Decree of the President of the Council of Ministers (November 24, 2017) introduced the National Guidelines for Health Authorities and Hospitals concerning rescue and socio-medical assistance to women victims of violence, adopted in accordance with the objectives of the Italian National Strategic Plan [14]. The aim of the National Guidelines is to provide an adequate and integrated intervention in the treatment of the physical and psychological consequences of violence starting from timely care of women victims of violence up to accompaniment to local services. This pathway encompasses both the Emergency Department (ED) and the dedicated medical services in the territory (Figure 2).

MEASURES TO IMPROVE THE PATHWAY FOR SUPPORTING WOMEN VICTIMS OF VIOLENCE

National Guidelines path provides a triage code (for confirmed or suspected violence) and, according to the severity of the trauma, an ad hoc protocol, as the result of the activation of fast track to psychological assessment in case of less serious health conditions; otherwise, in the case of hospitalization, the psychological assessment will be performed when the health conditions improve. In order to better understand the context of violence, our project proposes to collect information concerning: i) sex of the perpetrator, ii) age of the perpetrator, iii) setting of the assault iv) relationship victim/perpetrator (see Supplementary Material available online in italian version, in order to meet the objectives of the project; Figure 2) through the EU-IDB violence module [11].

In addition to the physical and medical examination, a psychological interview is submitted for assessing re-victimization risk. If, following the psychological assessment, as already suggested by National Guidelines (e.g. with the Brief Risk Assessment for ED-DA-5; see Supplementary Material available online) [15], a medium/high risk of relapse emerges, the woman is entrusted to an emergency shelter or similar facilities, otherwise she is discharged. In both cases, the objective is the activation of her entry into the territorial anti-violence network.

Finally, the PTSD assessment is carried out when patient has established a relationship with the psychologist. After the discharge from hospital to her place to an emergency shelter, the PTSD assessment can be performed using the International Trauma Questionnaire-ITQ (see Supplementary Material available online; Figure 2) [16].

One of the new tasks of the Central Actions Area (Centro Nazionale per la Prevenzione e il Controllo delle Malattie, CCM) “Violence against women: long-term health effects for precision prevention” requires the integration of EU-IDB violence module and ITQ in the National Guidelines [14].

This integration is part of a multicentric and transdisciplinary project, “The Violence against women: long-term health effects for precision prevention”, aiming at defining new strategies and models for supporting women and at creating new territorial models to counteract long-term health effects. In fact, most epidemiological studies on VAW focus on short-term effects, while long-term ones are neglected or marginally included even if they involve serious and complex consequences.

Early detection of chronic and non-communicable diseases that originate from the trauma is crucial to face their onset.

EPIGENETICS OF VIOLENCE AGAINST WOMEN

Violence, as a negative “socio-environmental” factor, is able to influence and modify the functionality of our genome through epigenetic modifications. Studying the genome and identifying epigenetic markers is an innovative approach to understanding the effects of violence on women’s psychophysical health. In fact, the consequences of violence remain in the psyche and can also affect the structure and functionality of the DNA (deoxyribonucleic acid) compromising women’s health.

It has already been demonstrated that violence interferes with genome plasticity and gene expression through epigenetic mechanisms [17]. Differentially regulated methylation levels of genes associated with Hypothalamic-Pituitary-Adrenal (HPA) axis, neurotransmission and inflammation genes were found to be linked to PTSD [1819]. Among long-term psychiatric disorders, PTSD is the most prevalent and is triggered by sudden traumatic events and multiple genomic factors and influenced by duration and severity of violence [112].

In 2016, the Italian National Institute of Health (Istituto Superiore di Sanità, ISS) in collaboration with the University of Milan and the Cà Granda Foundation of the Ospedale Maggiore Policlinico di Milano, conducted the pilot study “Epigenetics for women” (EpiWE) that highlighted the presence of epigenetic markers associated with PTSD arising from violence in the relational and/or sexual environment compared to the control population.

The EpiWe study represented a preliminary attempt to link PTSD and stress relatated disorders in women who have been exposed to IPV or sexual violence to epigenetic changes detected in their DNA samples [20]. In particular, three genes brain-derived neurotrophic factor (BDNF), dopamine receptor D2 (DRD2), and insulin-like growth factor 2 (IGF2) have been found to be differentially expressed (hypermethylated) indicating that violence can interfere with genome plasticity and gene expression regulation. This finding, although preliminary, is promising in revealing epigenetic markers in genes mediators of brain plasticity, which can modulate learning and memory in response to stress associated with IPV and violence-induced PTSD. By contributing to the knowledge of epigenetic signature underlying PTSD and stress-related disorders in the context of VAW, we could derive clues about better treatments and innovative protocols of precision medicine for limiting the long-term effects [20].

The EpiWe pilot project developed into a multicentric project, “Violence against women: long-term health effects for precision prevention”, that intends to collect biological samples for a follow-up study to detect the epigenetic signature of the entire genome.

DISCUSSION AND CONCLUSIONS

VAW has different dimensions in different cultures and, clearly, encompasses very different levels of traumatic injuries. This leads to the need of a unescapable systematic multidisciplinary approach.

The “Violence against women: long-term health effects for precision prevention”, a transdisciplinary and multicenter project, aims to implement the National and Territorial Health Services for tackling the long-term health consequences by means of dedicated health and social services. It is necessary to build up the entire health history of women to correlate violence and the early onset of some non-communicable diseases.

In our project, a substantial premise is represented by the creation of a unique individual personal code that will enable to set up the personal clinical history of the patient (DMdS 262 of 7 December 2016).

Moreover, during our pilot study we faced various problems in particular, the patient dropout, which means the abandon of the care pathway. This results in the lack of DNA samples acquisition, necessary to the follow-up study (2 years, at least). The epigenomic analysis of the samples could be of use as a biomarker of the consequences of the violence that sometimes could emerge even many years after the event.

The implementation of the ViVa biobank within the ISS, ensures the first collection of biological samples of women who have survived violence, and violence for the first time is considered as a social health determinant that causes diseases.

The earlier is the detection of PTSD in association with the epigenetic markers, the faster will be the development of resilience.

Our objective consists in improving Public Health research by creating and interconnecting innovative strategies to ensure long-term care and limit the costs of violence weighing heavily both on women for women who have suffered violence and on the National Health Service (NHS).

Other Information

Acknowledgments

The Authors thank the Italian Ministry of Health for the technical and financial support: CCM - Azione Centrale Project “Violenza sulle donne: effetti a lungo termine sulla salute per una prevenzione di precisione”. Furthermore, the Authors thank all participants of the Operational Units (Unità Operativa, UOs) that are involved in this project: UO1- Alessia Borzi (Dipartimento Ambiente e Salute, Istituto Superiore di Sanità); UO2 - Loredana Falzano (Centro per la Salute Globale, Istituto Superiore di Sanità), Sara Mellano (Servizio Relazioni Esterne Centro Rapporti Internazionali, Istituto Superiore di Sanità), Antonella Pilozzi (Centro Nazionale Prevenzione delle Malattie e Promozione della Salute, Istituto Superiore di Sanità), Mariella Nocenzi, (Dipartimento di Comunicazione e Ricerca Sociale, La Sapienza Università di Roma); UO3 - Andrea Piccinini (Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano), Paolo Bailo (Sezione di Medicina Legale, Università degli Studi di Camerino), Giussy Barbara, Edgardo Somigliana (Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano), UO4 - Paolo Cremonesi, Pierluigi Daniela, Fabio Pastorelli, Enzio Berbessi, Elena Cazzulo (Ente ospedaliero “Ospedali Galliera”, Dipartimento funzionale Emergenza Accettazione - DEA), UO5 - Patrizia Magliocchetti, Sabrina Pizzulo, Cinzia Tellarini, Maria D’Alessandro, Giovanna Savarese (Unità Operativa Complessa, Tutela della Salute della Donna e dell’Età Evolutiva della ASL Roma 2), UO6 - Giuseppina Cersosimo, Paola Iovino (Dipartimento di Studi Politici e Sociali, Università degli Studi di Salerno), UO7 - Maria Grazia Foschino Barbaro, Giulia Sannolla (Gruppo di lavoro per la governance della rete socio-sanitaria per il contrasto della violenza all’infanzia della Regione Puglia).

The Authors would like to thank Giuseppina Mandarino for editorial assistance on the manuscript.

Authors’ contributions

AC, MG and SG conceived and designed the study and wrote the manuscript. EC revised and edited the manuscript. All Authors revised the manuscript for important intellectual content, and agreed with this article’s contents.

Conflict of interest statement

The Authors declare no competing interests.

Address for correspondence: Simona Gaudi, Dipartimento Ambiente e Salute, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy. E-mail: simona.gaudi@iss.it

*These Authors contributed equally to this work

Figures and tables

Figure 1. Behavioural and health consequences of violence (adapted from WHO. Global status report on violence prevention 2014. Available from: https://www.who.int/publications/i/item/9789241564793, last access August 2024. WHO is not responsible for the content or accuracy of this adaptation).

Figure 2. The pathway for supporting women victims of violence. In the circle the assessment tools are shown: EU-IDB violence module revised; Brief Risk Assessment (DA-5) and PTSD questionnaire (International Trauma Questionnaire-ITQ). (Modified from “Linee guida nazionali per le Aziende sanitarie e le Aziende ospedaliere in tema di soccorso e assistenza socio-sanitaria alle donne vittime di violenza. Gazzetta Ufficiale della Repubblica Italiana, Serie generale - n. 24 del 30.01.2018).

References

  1. Violence against women prevalence estimates, 2018. Global, regional and national prevalence estimates for intimate partner violence against women and global and regional prevalence estimates for non-partner sexual violence against women. Geneva: WHO; 2021.
  2. Forms of violence. 2019;.
  3. Declaration on the elimination of violence against women. New York: UN; 1993.
  4. Council of Europe Convention on preventing and combating violence against women and domestic violence. Istanbul. 2011;.
  5. Indagine sulla sicurezza delle donne. Anno 2014. ISTAT; 2015.
  6. Department of Economic and Social Affairs, Statistics Division. World population prospects: The 2019 revision.
  7. World development indicators.
  8. Gender-based violence (Violence against women and girls). 2019;.
  9. Stewart D, Vigod S. Update on mental health aspects of intimate partner violence. Med Clin North Am. 2019;103(4):735-49.
  10. Sarkar N. The impact of intimate partner violence on women’s reproductive health and pregnancy outcome. J Obstet Gynaecol. 2008;28(3):266-71.
  11. Giustini M, Fondi G, Bejko D, Bauer R, Valkenberg H, Pitidis A. European Injury Data Base (EU-IDB): data analysis 2020. Roma: Istituto Superiore di Sanità; 2023.
  12. Castro-Vale I, Carvalho D. The pathways between cortisol-related regulation genes and PTSD psychotherapy. Healthcare (Basel). 2020;8(4).
  13. Piano strategico nazionale sulla violenza maschile contro le donne 2021-2023.
  14. Italia. Decreto del presidente del consiglio dei ministri 24 novembre 2017. Linee guida nazionali per le Aziende sanitarie e le Aziende ospedaliere in tema di soccorso e assistenza socio-sanitaria alle donne vittime di violenza. Gazzetta Ufficiale, Serie Generale - n. 24. 2018;.
  15. Snider C, Webster D, O’Sullivan C, Campbell J. Intimate partner violence: development of a brief risk assessment for the emergency department. Acad Emerg Med. 2009;16(11):1208-16.
  16. Cloitre M, Shevlin M, Brewin C, Bisson J, Roberts N, Maercker A, Karatzias T, Hyland P. The International Trauma Questionnaire: development of a self-report measure of ICD-11 PTSD and complex PTSD. Acta Psychiatr Scand. 2018;138(6):536-46.
  17. Daskalakis N, Rijal C, King C, Huckins L, Ressler K. Recent genetics and epigenetics approaches to PTSD. Curr Psychiatry Rep. 2018;20(5).
  18. Rusiecki J, Chen L, Srikantan V, Zhang L, Yan L, Polin M, Baccarelli A. DNA methylation in repetitive elements and post-traumatic stress disorder: a case-control study of US military service members. Epigenomics. 2012;4(1):29-40.
  19. Smith A, Ratanatharathorn A, Maihofer A, Naviaux R, Aiello A, Amstadter A, Ashley-Koch A, Baker D, Beckham J, Boks M, Bromet E, Dennis M, Galea S, Garrett M, Geuze E, Guffanti G, Hauser M, Katrinli S, Kilaru V, Kessler R, Kimbrel N, Koenen K, Kuan P, Li K, Logue M, Lori A, Luft B, Miller M, Naviaux J, Nugent N, Qin X, Ressler K, Risbrough V, Rutten B, Stein M, Ursano R, Vermetten E, Vinkers C, Wang L, Youssef N, Uddin M, Nievergelt C. Epigenome-wide meta-analysis of PTSD across 10 military and civilian cohorts identifies novel methylation loci. BioRxiv. 2019;.
  20. Piccinini A, Bailo P, Barbara G, Miozzo M, Tabano S, Colapietro P, Farè C, Sirchia S, Battaglioli E, Bertuccio P, Manenti G, Micci L, La Vecchia C, Kustermann A, Gaudi S. Violence against Women and Stress-Related Disorders: Seeking for Associated Epigenetic Signatures, a Pilot Study. Healthcare (Basel). 2023;11(2).

Research

Feb 25th, 2026
Nurses during war: Profiles- based risk and protective factors

Nurses during war: Profiles- based risk and protective factors

  • Partner Research and Endeavors

Liat Hamama PhDInbal Amit RN, MAMichal Itzhaki RN, PhD

 

Abstract

Introduction

Nurses in southern Israel's public hospitals were exposed to unusual traumatic events following the October 7, 2023, Hamas attack on Israel, and the ensuing Swords of Iron War. This study aimed to clarify the complexity of wartime nursing by identifying profiles based on risk factors (i.e., psychological distress and adjustment disorders) and protective factors (i.e., positive affect (PA), resilience, and perceived social support [PSS]).

Design

This study utilizes a cross-sectional design.

Method

Two hundred nurses at a major public hospital in southern Israel completed self-report questionnaires. A latent profile analysis (LPA) was conducted to identify distinct profiles based on nurses' risk and protective factors. Differences in profiles were examined alongside sociodemographic and occupational variables and traumatic event exposure. The LPA was conducted using MPlus 8.8 Structural Equation Modeling (SEM) software.

Findings

Two distinct profiles were identified: “reactive” and “resilient.” The “reactive” group included nurses who had higher risk factor scores (psychological distress and adjustment disorder), whereas the “resilient” group included nurses who had higher protective factor scores (PA, resilience, and PSS). Furthermore, nurses in the “reactive” group were younger, with greater seniority, worse self-rated health, and a higher frequency of kidnapped family members compared to nurses from the “resilient” group.

Conclusion

Nurses in wartime are at risk if identified as “reactive.” Identifying these profiles can assist in developing effective support practices to help nurses cope with wartime challenges and maintain their mental well-being.

Clinical Relevance

Healthcare organizations should tailor interventions to prepare and support nurses of various ages and experience levels, during and after conflicts. This approach aims to reduce risk factors and promote protective factors among nurses during wartime.

INTRODUCTION

The practice of nursing in a hospital environment is significantly affected by both acute and cumulative workplace conditions (Ganz et al., 2019). As frontline responders during wartime and other conflicts, nurses play a pivotal role in delivering immediate medical care and support to those injured or impacted (Sberro-Cohen et al., 2023). Additionally, nurses can experience direct threats to their safety and the safety of their loved ones during wartime (Ben-Ezra et al., 2011; Sberro-Cohen et al., 2023). These challenges and conditions might create a confluence of primary and secondary trauma (i.e., direct threat versus being a witness to someone else's trauma), which may affect nurses' mental health (Ben-Ezra & Bibi, 2016; Sberro-Cohen et al., 2023). As such, there is a need to focus on nurses' coping strategies and resources (both personal and environmental), which are essential for navigating such difficult times and sustaining optimal mental and psychological health (Ben-Ezra & Bibi, 2016).

The focus of the current study was on Israeli hospital nurses following an armed conflict between Israel and Hamas-led Palestinian militant groups that has been raging, primarily in and around the Gaza Strip, since October 7, 2023. The conflict began with a surprise attack by Hamas on southern Israel from the Gaza Strip, dubbed “Operation Al Aqsa Flood.” This operation involved an extensive rocket assault across the nation and the infiltration into Israel by a significant number of terrorists, leading to the deaths of approximately 1300 civilians. Additionally, 252 individuals—including Israelis and foreigners, infants, children, women, and elderly people—were taken captive and held in the Gaza Strip (https://www.gov.il/en/pages/swords-of-iron-war-in-the-south-7-oct-2023). In response, on October 27, 2023, Israel began its own operation—the Swords of Iron War. These chain events are considered traumatic events: “actual or threatened death, serious injury, or sexual violence” (American Psychiatric Association, 2013, p. 271). As such, nurses at public hospitals have been at risk of combined exposure to traumatic events, including events that pose a risk both to their own lives and to those of their family members (Ben-Ezra & Bibi, 2016; Sberro-Cohen et al., 2023). In this study, we aimed to identify distinct profiles based on a combination of risk factors (i.e., psychological distress and adjustment disorder) and protective factors (i.e., positive affect [PA], perceived social support [PSS], and resilience). We also sought to explore the differences between these profiles in relation to participants' exposure to threatening events and their background variables (i.e., sociodemographic and occupational).

The transactional theory by Lazarus and Folkman (1984) proposes that the intensity of a stress reaction is influenced by the mediating role of appraisal—a cognitive process through which meaning is ascribed to events. This process stimulates emotions considered threatening, challenging, or harmful, and prompts the use of coping strategies to manage emotions or directly contend with the stressors. These coping efforts lead to an outcome, altering the interaction between the individual and their environment, which is then evaluated as positive, negative, or unresolved (Biggs et al., 2017). A positive resolution of stressors brings about positive emotions, whereas unresolved or negative resolutions cause distress, leading the individual to explore additional coping mechanisms to address the stressor (Biggs et al., 2017). Drawing on the transactional theory, we focused on two negative outcomes: psychological distress and adjustment disorder (risk factors). Psychological distress is described as an uncomfortable emotional experience in response to a specific stressor or demand that leads to harm, whether temporary or permanent, to the individual (Ridner, 2004). An adjustment disorder represents a maladaptive response to a stressful event, ongoing psychosocial challenges, or a response to a combination of stressful life circumstances. The nature and severity of an adjustment disorder can be shaped by the characteristics and duration of the stressor (e.g., single, repeated, cumulative, or long-term events), past experiences, and environmental factors (Maercker & Lorenz, 2018).

In addition, we examined the positive resolution of the stressors—positive affect—which concerns daily life experiences and includes the experiential evaluation of one's positive emotions, such as satisfaction, happiness, energy, joy, and relaxation (Keyes, 2006). Individuals with high levels of PA exhibit a stronger sense of control over their lives, manage stress more effectively, engage in more active and open thinking, and set personal life goals (Keyes & Ryff, 2000). In addition to PA, we focused on resources as another protective factor. According to Hobfoll's Conservation of Resources (COR) theory (Hobfoll, 1989), stress arises from three scenarios: the actual depletion of resources, the potential risk of losing them, or the inability to obtain resources following a significant investment (Hobfoll, 19892002). According to Hobfoll's (1989) theory, people attempt to acquire, conserve, and protect their resources. In this study, we focused on resilience (personal resource) and PSS (interpersonal resource). Resilience represents a personal characteristic: “the personal qualities that enable one to thrive in the face of adversity” (Connor & Davidson, 2003, p. 76). Individuals who demonstrate psychological resilience are likely to exhibit effective coping strategies (Fletcher & Sarkar, 2013). PSS concerns beliefs about the availability of various types of support from one's social networks (Gottlieb & Bergen, 2010), including family (extended or nuclear), friends (individuals who are not family), and significant others (partners or others considered particularly close; Zimet et al., 1988).

Finally, we strove to examine nurses' distinct profiles based on risk and protective factors, alongside background variables (i.e., sociodemographic and occupational), and exposure to various October 7th/Swords of Iron-related traumatic events (i.e., direct exposure, witnessing the trauma, learning that the trauma happened to a close relative or close friend, indirect exposure to aversive details of the trauma in the course of professional duties; American Psychiatric Association, 2013). Regarding background variables, a previous meta-analysis (Kisely et al., 2020) of 59 papers on the psychological reactions of healthcare staff during virus outbreaks (e.g., SARS, MERS, Ebola, H1N1, and COVID-19) revealed that being female, young, and less experienced (in terms of seniority) could render individuals more vulnerable to psychological distress. Conversely, Godifay et al. (2018) demonstrated that Ethiopian healthcare workers (nurses and physicians) who had work experience of ≥5 years had 4.1 times higher odds of developing work-related stress than those who had ≤5 years of experience.

Given the above, our study could potentially add innovative knowledge to the empirical literature about nurses during wartime, specifically regarding risk and protective factors, offering a clearer picture of the complexity of being a nurse during such periods. Identifying distinct profiles might enable the development of more effective support practices to maintain nurses' mental health.

METHODS

Participants

The sample comprised 200 nurses working at a major public hospital in Israel's south, aged 23–66 years (M = 42.62, SD = 9.17). Of the participants, 182 (91%) were female; 167 (84%) were either married or in a partnership; 175 (88%) identified as Jewish; and 187 (94%) assessed their health as either good or excellent (see Table 1).

TABLE 1. Nurses' sociodemographic and occupational characteristics (n = 200).

Variables N (%) Mean (SD)
Gender
Male 16 (8.0)  
Female 182 (91)  
Other 2 (1.0)  
Marital status
Married 167 (84)  
Not married 33 (17)  
Education
Registered nurse (RN) certification without an academic degree 10 (5.0)  
RN with a bachelor's degree 101 (51)  
RN with a master's degree 87 (44)  
RN with a PhD 2 (1.0)  
Religion
Jewish 175 (88)  
Muslim 6 (3.0)  
Christian 9 (4.5)  
Druze 10 (5.0)  
Religiosity
Secular 130 (65)  
Traditional 47 (24)  
Religious 18 (9.0)  
Orthodox 5 (2.5)  
Health
Bad 1 (0.5)  
Not so good 12 (6.0)  
Good 127 (64)  
Excellent 60 (30)  
Role
Staff nurse 132 (66)  
Nurse in a managerial position 68 (34)  
Years of job seniority   14.34 (10.46)
Years of tenure at the hospital   4.45 (2.17)

In terms of occupational characteristics, 64 nurses (34%) held administrative positions; the range of nursing seniority spanned 3 months to 36 years (M = 14.34, SD = 10.46); and the average tenure at the hospital was reported as 4.45 years (SD = 2.17; Table 1).

Regarding nurses' exposure to October 7th-related threatening events, 33% (n = 39) reported having a family member who was injured in the Hamas attack. Additionally, 7.5% (n = 15) reported having a family member who was kidnapped or missing. At the occupational level, 19% (n = 38) of the nurses reported treating victims who had been at the Nova Music Festival (i.e., one of the massacre sites at which 364 civilians were killed, many were wounded, and another 40 abducted); 46% (n = 91) treated victims from the attacked communities of the Gaza envelope (an area that encompasses the populated areas in the Southern District of Israel that are within 7 km of the Gaza Strip border); 33% (n = 66) treated civilians suffering from anxiety; and 25% (n = 50) treated wounded soldiers who arrived at the hospital.

Measures

Participants completed standardized self-report questionnaires that had previously been employed among Israeli populations and demonstrated robust psychometric properties.

Background data included sociodemographic and occupational characteristics. The former comprised details about participants' age, biological sex, marital status, number of children, education level, religion, and religiosity. Additionally, participants' self-rated health was assessed by a single question: “In general, how do you rate your health?” Responses were given on a scale ranging from 1 (poor) to 4 (excellent). This metric was previously validated with objective health indicators (Benyamini et al., 2003). Concerning occupational characteristics, participants were asked about their years of nursing experience, tenure at their current workplace, type of position (e.g., full-time, part-time), and their role within the workplace, such as being a departmental nurse or holding a managerial position.

Exposure to threatening events was assessed through questions that gauged participants' exposure to victims who had undergone various October 7th-related experiences. This exposure was evaluated within the framework of vulnerability circles, either personal (i.e., having a family member injured/kidnapped) or professional (i.e., Nova Music Festival attendees, residents of the attacked Gaza envelope communities, and civilians suffering from anxiety).

Adjustment disorder (ADJ) was assessed using the International Adjustment Disorder Questionnaire (IADQ; Shevlin et al., 2020), divided into three main sections. The first section, the psychosocial stressor checklist, requires responses in a binary format (yes = 1, no = 0). The second section includes a symptom list with three items each for measuring preoccupation symptoms and failure to adapt symptoms—for example, “Since the stressful event(s), I often feel afraid about what might happen in the future”; “Since the stressful event(s), I find it difficult to achieve a state of inner peace.” Responses for these items are provided on a 5-point Likert scale, ranging from 0 (not at all) to 4 (extremely). Participants are also asked, “Did these symptoms begin within one month of the stressful event?” with answers given in a binary format (yes = 1, no = 0). The third and final section evaluates functional impairment in social, occupational/educational, and other important domains caused by the symptoms (e.g., “In the past month, have the above symptoms affected any other important part of your life?”), using three items on a 5-point Likert scale that ranges from 0 (not at all) to 4 (extremely). In the current study, only the second and third sections—comprising 10 items—were applied. The Hebrew validation for the IADQ was provided by Levin et al. (2022), and the reliability (Cronbach's alpha) for the total score scale was 0.92. In the present study, Cronbach's alpha was 0.80.

Psychological distress was assessed by the Kessler Psychological Distress Inventory (K-6; Kessler et al., 2002) via a six-item questionnaire “intended to yield a global measure of distress based on questions about anxiety and depressive symptoms” that a person has experienced in the last month (e.g., “How frequently have you felt nervous during the last month?”). Each item is scored on a 5-point Likert-type scale from 0 (none of the time) to 4 (all the time). The total score ranges from 0–24. A cutoff point of 13+ is the optimal cutoff point for assessing the prevalence of serious mental illness, and scores of 19 or higher indicate elevated psychological distress. Cronbach's alpha for the original scale was 0.83 (Kessler et al., 2002). The Hebrew adaptation (Ben-Ezra & Bibi, 2016) was shown to have a reliability of 0.88, and in the present study, Cronbach's alpha was 0.82.

Positive affect was measured by the Positive and Negative Affect Schedule (I-PANAS-SF; Thompson, 2007) via five items composing the PA scale (e.g., inspired, attentive). Higher scores on PA items indicate the tendency to experience a good mood. Respondents were requested to rate the statement on a 5-point scale (never to always) by comparing themselves during the past 2 weeks with their “usual selves.” The Cronbach's alpha in this study was 0.79.

Perceived social support was measured by the Multidimensional Scale of Perceived Social Support (MSPSS; Zimet et al., 1988). The scale consists of 12 items distinguishing PSS from three different sources: family (4 items, e.g., “My family is willing to help me make decisions”); friends (4 items, e.g., “My friends really try to help me”); and a significant other (4 items, e.g., “There is a special person who is around when I am in need”). Participants answered on a 7-point Likert-type scale, from 1 (very strongly disagree) to 7 (very strongly agree). The mean score was calculated; a high score indicated greater levels of PSS. The internal reliability of the original MSPSS for the total scale was α = 0.91 (Zimet et al., 1988), and in the current study, it was 0.95.

Resilience was measured using the Connor–Davidson Resilience Scale (CD-RISC 10; Campbell-Sills & Stein, 2007), a brief version of the CD-RISC 25 (Connor & Davidson, 2003). Participants were asked to rate the 10 items (e.g., “I believe I can achieve my goals, even if there are obstacles”) on a 5-point scale, ranging from 0 (not true at all) to 4 (true nearly all the time), resulting in a possible score range of 0–40. Higher scores on this scale indicate a greater level of resilience. In the current study, Cronbach's alpha was 0.89. [Permission for use of the Hebrew CD-RISC-10 was granted by Jonathan Davidson on November 8, 2023.]

Procedure

The present study was conducted in January–February 2024 (4 weeks) at a general hospital in Israel's south that provides healthcare for about 400,000 civilians as well as for soldiers. The study protocol was approved by the Assuta Ashdod Hospital Institutional Review Board and Helsinki Committee (approval no. 0142-23-AAA) and by Tel Aviv University's Institutional Ethics Committee (approval no. 0007542-1). After approvals, the second author provided, via the hospital's internal email system and WhatsApp, a direct link to an electronic questionnaire run on QUALTRICS. Informed consent was obtained. Participants were informed of the purpose of the study and the eligibility criteria—namely, nurses who could read and speak Hebrew fluently—and they provided their consent electronically (by clicking “I agree to participate”). Respondents took approximately 12 min to complete the questionnaire. Of the 670 potential participants (i.e., all the hospital's nurses), 200 returned the fully completed questionnaires (response rate 29.85%). Thirteen questionnaires were excluded as they were not complete.

Data analysis

We first applied latent profile analysis (LPA) to estimate distinct profiles in nurses' psychological distress, adjustment disorder, PA, PSS, and resilience (risk and protective factors). To do so, we followed the guidelines of Nylund-Gibson and Choi (2018) using MPlus 8.8 (Muthén & Muthén, 2023) Structural Equation Modeling (SEM) software. We examined one to four possible profiles using unconditional LPA. To decide on the number of profiles, we used the following information (summarized in Table 1): (i) information criteria (IC)—including the Bayesian Information Criterion (BIC), sample-size adjusted Bayesian Information Criterion (SABIC), Consistent Akaike Information Criterion (CAIC), and Approximate Weight of Evidence Criterion (AWE)—which are approximate fit indices where lower values indicate superior fit. These ICs were also plotted (see Figure 1) to inspect for an “elbow” point of “diminishing returns” in model fit (equivalent to a scree plot in factor analysis); (ii) we also used likelihood-based tests—the Vuong–Lo–Mendell–Rubin adjusted likelihood ratio test (VLMR-LRT) and the bootstrapped likelihood ratio test (BLRT)—which provide p-values assessing whether adding a class leads to a statistically significant improvement in model fit. The BLRT has been shown to be one of the most robust methods across a diversity of modeling conditions (Nylund et al., 2007); and (iii) finally, we employed the Bayes factor (BF) indices used as a pairwise comparison of fit between two neighboring class models with values >10 suggesting “strong” support for the more complex model, and the correct model probability (cmP) that provides an estimate of each model being “correct” out of all models considered. We also considered how the selected models related to each other (e.g., theoretically different) as well as the relative sizes of the emergent profiles. Here, we decided on a minimum profile size of 20 participants. Overall, 200 participants were profiled in this phase. Missing data were handled with Multiple Imputation (Rubin, 2009).

Details are in the caption following the image

FIGURE 1

Open in figure viewerPowerPoint

Scree plot of fit indices of the LPA. An elbow is indicated in 2 profiles.

Upon deciding on the ideal number of profiles, we identified and examined the consequences of latent profile membership using distal variables. To do that, we employed the Bolck, Croon, and Hagenaars (BCH) method (Bakk & Kuha, 2021; Bolck et al., 2004). Specifically, we separated the profile enumeration step from subsequent structural analyses, such that profiles were enumerated solely with the chosen latent class indicators measuring the substantive domain of interest (psychological distress, adjustment disorder, PA, PSS, and resilience). Using the selected profile solution, BCH weights were saved alongside the distal variables—treating civilians with anxiety (yes, no), Nova survivors (yes, no), and Gaza envelope survivors (yes, no); having a family member injured (yes, no) or kidnapped (yes, no); age; number of children; religiosity; self-rated health; and nursing seniority in years. In the 3rd step, the measurement parameters of the latent classes were held fixed while accounting for classification error. Distal variables were included, and their relation to the latent class variable was estimated.

RESULTS

The pattern of associations between LPA measures (psychological distress, adjustment disorder, PA, PSS, and resilience) and exposure measures is presented in Figure S1, and between LPA measures and background measures in Figure S2.

Latent profile analysis

Results are summarized in Table 2. Fit indices did not converge on a single solution, which is generally the rule rather than the exception in applied practice (Nylund-Gibson & Choi, 2018). The ICs and cmP suggested a 4-profile solution, whereas the likelihood tests and BF supported a 2-profile solution. In addition, as plotted in Figure 1, an elbow in the ICs was already observed at the 2-profile solution. Given that the likelihood tests have been shown to be robust across a diversity of modeling conditions (Nylund et al., 2007), we selected the 2-profile solution in Step 1. The entropy score of 0.74 and the average posterior probabilities (AvePP) scores >0.80 reflect well-separated profiles (Nagin, 2005). The profiles are presented in Figure 2, comprising “reactive” (n = 44) and “resilient” (n = 156). The reactive group had significantly higher psychological distress scores and frequency of adjustment disorders than did the resilient group. The reactive group also had lower PA, resilience, and PSS.

TABLE 2. Fit indices of LPA.

  1 profile 2 profiles 3 profiles 4 profiles
BIC 2055.44 1982.22 1968.30 1962.43
SABIC 2023.76 1934.70 1901.77 1876.89
CAIC 2040.63 1960.00 1937.19 1922.43
AWE 2045.63 1967.50 1947.69 1935.93
VLMR-LRT   91.19 (0.015) 44.31 (0.302) 36.51 (0.651)
BLRT   94.06 (<0.0001) 45.71 (0.292) 37.66 (0.592)
BF   38.91 2.01 1.34
cmP 0.00 0.17 0.35 0.47
Entropy 1.00 0.74 0.77 0.83
LL −1001.23 −951.37 −928.52 −909.69
% smallest n   0.22 0.12 0.08
  • Note: The best scores in each category are marked in bold.

Details are in the caption following the image

FIGURE 2

Open in figure viewerPowerPoint

The relative scores of the variables comprise the two profiles. ADJ, adjustment disorder; Distress, psychological distress; PA, positive affect; PSS, perceived social support.

Differences between profiles in distal variables

In the third step of the model, significant differences between the profiles were found in exposure to threatening events (specifically, a family member was kidnapped on October 7) and background variables (age, self-rated health, and seniority). Intercepts and residual standard deviations are presented in Table 3. We found that the “reactive” group had a significantly greater frequency of kidnapped family members (18% vs. 4%), younger age, greater job seniority, and worse self-rated health as compared with the “resilient” group. The frequency of treating civilians with anxiety, Nova survivors, Gaza envelope survivors, and/or having a family member injured was not related to the differences between the “reactive” and “resilient” groups.

TABLE 3. Differences between profiles in the distal variables.

  Reactive Resilient p
M/% SD M/% SD
Took care of anxiety patients (yes) 0.34   0.33   0.862
Took care of Nova survivors (yes) 0.23   0.18   0.496
Took care of Gaza envelope survivors (yes) 0.45   0.46   0.995
Family member injured (yes) 0.47   0.36   0.291
Family member kidnapped (yes) 0.18   0.04   0.043
Age 38.98 8.58 43.75 9.02 0.011
Number of children 2.99 1.38 3.43 1.21 0.116
Religiosity 1.50 0.85 1.49 0.73 0.927
Self-rated health 3.01 0.69 3.30 0.51 0.031
Job seniority 28.30 13.70 22.42 14.42 0.048
  • Note: Significant differences are marked in bold.

DISCUSSION

This study is the first study in which distinct profiles based on risk factors (psychological distress and adjustment disorder) and protective factors (PA, resilience, and PSS) among nurses in wartime were examined. The findings offer a clear picture of the way nurses have coped in the aftermath of October 7, 2023, terrorist attack on Israeli civilians and during the ongoing Swords of Iron War. Based on LPA, two distinct profiles were revealed: “reactive” and “resilient.” The reactive group consisted of nurses who had higher scores of psychological distress and adjustment disorder and lower scores of PA, resilience, and PSS. Although we attempted to identify relevant studies for each group, the singular characteristics of the October 7th attack and the ensuing Swords of Iron War made it difficult to rely on previous research. Furthermore, studies addressing the consequences of a sequence of traumatic events (Katsoty et al., 2024; Levi-Belz et al., 2024) have focused on civilian populations rather than on “first responders,” such as nurses.

As stated above, nurses in the “reactive” group were characterized by high scores of psychological distress and frequency of adjustment disorder. Studies have demonstrated a high prevalence of psychological distress among nurses (Belay et al., 2021) in general and particularly during wartime (Ben-Ezra et al., 2011). Adjustment disorder, for its part, has not yet been examined in the arena of nursing (as per the ICD-11, adjustment disorder is a stress response syndrome with core symptoms of preoccupations and failure to adapt to the stressor; Shevlin et al., 2020). In this context, a recent study (Ring et al., 2018) on mortality salience after the Sarona terror attack (in Tel Aviv, Israel) revealed that mortality salience served as a predictor associated with adjustment disorder. Karatzias et al. (2021) suggested that there might be a high degree of comorbidity between the latent structures of adjustment disorder and post-traumatic stress disorder (PTSD), while also noting that their symptom profiles were unique and distinct. Going forward, researchers should consider exploring the latent structure of adjustment disorder, particularly among nurses exposed to war-related stress. Indeed, nurses are highly susceptible to psychological distress and adjustment disorder due to the nature of their work, which involves witnessing patients' suffering and death, meeting demanding job expectations, managing progressively heavier workloads, and adjusting to evolving work settings, while at the same time receiving minimal professional support (Hsiao-Yean, 2022). Likewise, Kenny and Hull (2008) concluded that providing care to patients who have sustained multiple traumas and injuries (e.g., soldiers) presents significant challenges. They noted that these injuries create stress not only for the patients and their families but also for the nurses responsible for their care.

A possible explanation for the two risk factors identified in the “reactive” profile can be explained by Terror Management Theory (TMT; Greenberg et al., 1997). Specifically, TMT posits that humanity has developed a range of coping mechanisms to fend off thoughts related to death and to support daily functioning. Consequently, the awareness of our own mortality triggers extreme stress levels, which may lead to overwhelming anxiety. This potential anxiety can be mitigated by adhering to cultural worldviews, maintaining self-esteem, and fostering close relationships—referred to as anxiety-buffering systems (Pyszczynski et al., 2015). In this scenario, nurses exposed to various October 7th-related incidents may have perceived their anxiety-buffering systems (i.e., worldview, self-esteem, and relationships) as having been disrupted and actively threatened. Their thoughts of death became a central focus and attempts to entirely erase these thoughts from their minds proved to be futile. As such, their vulnerability to psychological disorders, such as psychological distress and adjustment disorder, increased.

Furthermore, the “reactive” group profile included lower PA, resilience, and PSS. Concerning PA, Palgi et al. (2012) reported that hospital personnel (nurses and physicians) with a positive congruent (high PA and low negative affect) had a lower level of peritraumatic symptoms during exposure to the Second Lebanon War (2006) and Israel's Operation Cast Lead (2008–2009). According to Fredrickson's (1998) broaden-and-build theory, positive emotions temporarily expand individuals' attention and thinking, allowing them to access higher-level connections and a broader range of perceptions or ideas than usual. These expanded perspectives enable individuals to identify and develop significant personal resources, become better equipped to manage stressful situations, think in a more active and open manner, and effectively seize opportunities (Keyes & Ryff, 2000).

Resilience (i.e., “the personal qualities that enable one to thrive in the face of adversity”; Connor & Davidson, 2003 p. 76) and PSS (from family, friends, and significant others) have both been reported to protect nurses from stress by mitigating or counterbalancing the negative effects of the stressful events they encounter (e.g., Henshall et al., 2020; Sberro-Cohen et al., 2023). Hobfoll's COR theory (Hobfoll, 1989) underscores the importance of personal, social, and material resources that individuals strive to acquire, maintain, and protect in times of stress and adversity. In this context, resilience and PSS can be seen as resources that may have enabled the nurses to cope with the heightened October 7th-related demands they faced. Thus, possessing these resources (protective factors) may be linked to acquiring additional resources that are beneficial in tackling stressful situations, whereas a lack of resources may be linked to being vulnerable to resource loss, with initial losses potentially leading to further losses (Hobfoll, 2002). In line with COR theory, it might be that the hospital nurses categorized in the “reactive” group may have failed to acquire resources and, as a result, were more vulnerable to psychological distress and adjustment disorder.

The study findings regarding the differences between the profiles in distal variables revealed that the “reactive” group (i.e., nurses who reported higher scores of psychological distress and adjustment disorder, and lower scores of PA, resilience, and PSS) were younger, had greater nursing seniority, had worse self-rated health, and had a higher frequency of kidnapped family members. Regarding seniority, as mentioned earlier, previous studies (Belay et al., 2021; Godifay et al., 2018) have shown that nurses with more work experience face higher odds of developing work-related stress and psychological distress compared to those with fewer years of experience. Furthermore, concerning age, research on older adults during stressful events has shown that they develop psychological resilience by utilizing coping strategies gained from past life challenges and experiences (Lind et al., 2021). A possible explanation for the differences in nurses' age and seniority as related to the two groups (reactive/resilient) may be attributed to the nature of nursing work in wartime, the workplace environment, the social context, and the occupational hazards encountered during military conflicts (Fink & Milbrath, 2023). Specifically, younger nurses might not yet have a comprehensive understanding of the nursing profession's complexities and may lack the psychological robustness needed to handle the various challenges associated with their roles. Conversely, more experienced nurses often encounter increased stress due to their supervisory duties and their more frequent interactions with injured patients, potentially amplifying their psychological distress.

Regarding the differences in self-rated health among the nurses in the two groups, Martin et al. (2022) found that a better-rated health status was a major predictor of being more self-compassionate, happier, more satisfied with life, and less stressed among undergraduate nursing students. Furthermore, worse self-rated health was found to be associated with negative psychosocial job characteristics (i.e., inadequate social support and low sense of coherence) among Lithuanian hospital nurses (Malinauskiene et al., 2011). It thus appears that these background variables (age, nursing seniority, and self-rated health) may have acted as antecedents in the “reactive” group profile and contributed to their vulnerability.

Lastly, a significantly higher frequency of exposure to threatening events, especially having kidnapped family members, was found in the “reactive” group profile. Nurses routinely encounter a variety of potentially psychologically traumatic events as part of their daily work activities, and cumulative exposure to these potentially traumatic events can lead to clinically significant symptoms of mental disorders, including PTSD, depression, anxiety, and panic disorder symptoms (Stelnicki et al., 2021). However, on and post-October 7th, nurses in Israel came face to face with the largest mass casualty incident and the largest terror attack in Israel's history (Codish et al., 2024). They were exposed to events that directly threatened them, including the kidnapping of their own relatives, while treating and caring for wounded civilians and soldiers. In this vein, it appears that the nurses in the “reactive” group were subjected to cumulative stressors, including the traumatic events of their daily work, as well as the October 7th-related events that directly and indirectly threatened them. Researchers in the field should continue to explore how life-threatening events directly experienced by, witnessed by, or learned about by nurses in their occupational practice and personal lives are related to the “reactive” group profile.

Limitations

Several study limitations should be noted. First, the cross-sectional approach offers a limited snapshot of the long-term effects of trauma, not accounting for possible recovery or delayed symptoms. Nevertheless, it should be mentioned that the checklist for reporting cross-sectional studies, based on the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines, provides a comprehensive framework to ensure clarity, transparency, and completeness in reporting (Von Elm et al., 2014). Second, the “reactive” group was relatively small and was identified at a single public hospital in southern Israel, limiting the study's broader applicability. Third, this study relied on self-reported data. Self-reporting can be limited by issues, such as memory bias, reporting bias, common method variance, and social desirability bias (Paulhus & Vazire, 2007). Furthermore, it is possible that self-report questionnaires do not fully capture internal experiences, as well as excluding potential pre-existing risk factors or the additional stress of war-related occupational, economic, and personal challenges. Fourth, we did not examine differences in research variables between nurses working in acute wards (such as intensive care and operating rooms), chronic wards (e.g., rehabilitation departments), or outpatient clinics. Future research should include in-depth interviews to explore risk and protective factors more comprehensively, and longitudinal studies to uncover factors affecting nurses' psychological well-being amid ongoing trauma (e.g., the Israel–Hamas conflict). Despite these limitations, the findings highlight the importance of identifying at-risk nurses facing cumulative stress. Furthermore, these findings—which suggest that researchers should focus on risk and protective factors for those in high-stress frontline roles—can be generalized, especially to conflict zones.

Implications for health policy

During wartime, hospital nurses face significant challenges. Healthcare organizations need to develop strategies to prepare and support nurses of various ages and levels of experience, especially targeting younger nurses or those with longer tenures who have been identified as susceptible to psychological distress and adjustment disorders. Implementing programs that boost nurses' resilience during and after conflicts could reduce the risks of post-traumatic stress, burnout, and workforce turnover. Segev (2023) highlighted the importance of emotional and professional support for critical care nurses in wartime to help them process traumatic experiences and develop effective coping mechanisms. Moreover, it is crucial for policymakers to officially recognize nurses' contributions during wartime and document their experiences in professional journals and public media. Such recognition not only honors their service but also offers valuable lessons for handling future crises.

CONCLUSIONS

Following the events of October 7, 2023, and the ensuing Swords of Iron War in Israel, this study is the first study in which distinct profiles were investigated, based on risk and protective factors, among nurses working at a public hospital in southern Israel. These nurses encountered highly unusual incidents in their personal lives (e.g., having a family member injured, kidnapped, or otherwise unaccounted for post-October 7th) and in their professional role (e.g., treating injured victims from the Nova Music Festival and from the communities that were attacked, civilians suffering from anxiety attacks, and wounded soldiers upon their arrival at the hospital). We identified two distinct profiles—“reactive” and “resilient”—differentiated by levels of psychological distress, adjustment disorder, PA, resilience, and PSS. Additionally, nurses in the “reactive” group exhibited a higher frequency of having kidnapped family members, poorer self-rated health, younger age, and greater nursing seniority. Identifying these profiles can aid in developing effective support practices to help nurses cope with wartime challenges and maintain their mental well-being. Future studies should consider a comparative analysis of nurses' coping mechanisms and challenges during wartime across different countries. Such research would provide a broader understanding of the varied experiences and strategies nurses employ globally, offering valuable insights and enhancing the overall relevance and applicability of the findings.

ACKNOWLEDGMENTS

The authors thank the nurses who willingly participated in this study.

FUNDING INFORMATION

This research received no specific grant from any funding agency.

CONFLICT OF INTEREST STATEMENT

The authors declare no potential conflicts of interest concerning the research, authorship, and/or publication of this study.

IRB STATEMENT

The study protocol was approved by the Assuta Ashdod Hospital Institutional Review Board and Helsinki Committee (approval no. 0142-23-AAA) and by Tel Aviv University's Institutional Ethics Committee (approval no. 0007542-1).

CLINICAL RESOURCES

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

 

REFERENCES
American Psychiatric Association. (2013). Diagnostic and statistical man
ual of mental disorders (5th ed.). American Psychiatric Publishing.
Bakk, Z., & Kuha, J. (2021). Relating latent class membership to ex
ternal variables: An overview. British Journal of Mathematical and 
Statistical Psychology, 74(2), 340–362. h t t p s : / / d o i . o r g / 1 0 . 1 1 1 1 / 
bmsp. 12227 
Belay, A. S., Guangul, M. M., Asmare, W. N., & Mesafint, G. (2021). 
Prevalence and associated factors of psychological distress among 
nurses in public hospitals, southwest, Ethiopia: A cross- sectional 
study. Ethiopian Journal of Health Sciences, 31(6), 1247–1256. 
h t t p s : / / d o i . o r g / 1 0 . 4 3 1 4 / e j h s . v 3 1 i 6 . 2 1
Ben- Ezra, M., & Bibi, H. (2016). The association between psychological 
distress and decision regret during armed conflict among hospital 
personnel. Psychiatric Quarterly, 87, 515–519. h t t p s : // d o i . o r g / 1 0 . 
1 0 0 7/ s 1 1 1 2 6-  0 1 5-  9 4 0 6-  y
Ben- Ezra, M., Palgi, Y., Wolf, J. J., & Shrira, A. (2011). Psychiatric symp
toms and psychosocial functioning among hospital personnel 
during the Gaza war: A repeated cross- sectional study. Psychiatry 
Research, 189(3), 392–395. h t t p s : // d o i . o r g / 1 0 . 1 0 1 6 / j . p s y c h r e s . 
2011. 02. 004
Benyamini, Y., Blumstein, T., Lusky, A., & Modan, B. (2003). Gender dif
ferences in the self- rated health–mortality association: Is it poor 
self- rated health that predicts mortality or excellent self- rated 
health that predicts survival? The Gerontologist, 43(3), 396–405. 
h t t p s : / / d o i . o r g / 1 0 . 1 0 9 3 / g e r o n t / 4 3 . 3 . 3 9 6
Biggs, A., Brough, P., & Drummond, S. (2017). Lazarus and Folkman's 
psychological stress and coping theory. In C. Cooper & J. C. Quick 
(Eds.), The handbook of stress and health: A guide to research and prac
tice (pp. 349–364). John Wiley & Sons.
Bolck, A., Croon, M., & Hagenaars, J. (2004). Estimating latent structure 
models with categorical variables: One- step versus three- step esti
mators. Political Analysis, 12(1), 3–27. h t t p s : / / d o i . o r g / 1 0 . 1 0 9 3 / p a n / 
mph001
Campbell- Sills, L., & Stein, M. B. (2007). Psychometric analysis and re
finement of the Connor- Davidson Resilience Scale (CD- RISC): 
Validation of a 10- item measure of resilience. Journal of Traumatic 
Stress, 20(6), 1019–1028. h t t p s : // d o i . o r g / 1 0 . 1 0 0 2 / j t s . 2 0 2 7 1 
Codish, S., Frenkel, A., Klein, M., Geftler, A., Dreiher, J., & Schwarzfuchs, 
D. (2024). October 7th 2023 attacks in Israel: Frontline experience 
of a single tertiary center. Intensive Care Medicine, 1- 3, 308–310. 
h t t p s : / / d o i . o r g / 1 0 . 1 0 0 7 / s 0 0 1 3 4-  0 2 3-  0 7 2 9 3 -  4
Connor, K. M., & Davidson, J. R. (2003). Development of a new resilience 
scale: The Connor- Davidson resilience scale (CD- RISC). Depression 
and Anxiety, 18(2), 76–82. h t t p s : / / d o i . o r g / 1 0 . 1 0 0 2 / d a . 1 0 1 1 3 
Fink, A. M., & Milbrath, G. R. (2023). A concept analysis of nurses in con
flicts after World War II. Journal of Advanced Nursing, 79(1), 31–47. 
h t t p s : / / d o i . o r g / 1 0 . 1 1 1 1 / j a n . 1 5 4 5 4 
Fletcher, D., & Sarkar, M. (2013). Psychological resilience: A review 
and critique of definitions, concepts, and theory. European 
Psychologist, 18(1), 12–23. h t t p s : / / d o i . o r g / 1 0 . 1 0 2 7 / 1 0 1 6-  9 0 4 0 / 
a000124
Fredrickson, B. L. (1998). What good are positive emotions? Review of 
General Psychology, 2, 300–319. h t t p s : // d o i . o r g / 1 0 . 1 0 3 7/ 1 0 8 9-  
2 6 8 0 . 2 . 3 . 3 0 0
Ganz, F. D., Margalith, I., Benbenishty, J., Hirschfeld, M., Wagner, N., & 
Toren, O. (2019). A conflict of values: nurses' willingness to work 
under threatening conditions. Journal of Nursing Scholarship, 51(3), 
281–288. h t t p s : // d o i . o r g / 1 0 . 1 1 1 1 / j n u . 1 2 4 6 6 
Godifay, G., Worku, W., Kebede, G., Tafese, A., & Gondar, E. (2018). Work 
related stress among health care workers in Mekelle city adminis
tration public hospitals, North Ethiopia. Journal of Health, Medicine, 
and Nursing, 46, 189–195. h t t p s : // c o r e . a c . u k / d o w n l o a d / p d f / 2 3 4 6 9 
2 4 4 8 . p d f
Gottlieb, B. H., & Bergen, A. E. (2010). Social support concepts and mea
sures. Journal of Psychosomatic Research, 69(5), 511–520. https:// 
d o i . o r g / 1 0 . 1 0 1 6 / j . j p s y c h o r e s . 2 0 0 9. 1 0 . 0 0 1
Greenberg, J., Solomon, S., & Pyszczynski, T. (1997). Terror management 
theory of selfesteem and social behavior: Empirical assessments 
and conceptual refinements. In M. P. Zanna (Ed.), Advances in exper
imental social psychology (Vol. 29, pp. 61–139). Academic.
Henshall, C., Davey, Z., & Jackson, D. (2020). The implementation and 
evaluation of a resilience enhancement programme for nurses 
working in the forensic setting. International Journal of Mental Health 
Nursing, 29(3), 508–520. h t t p s : // d o i . o r g / 1 0 . 1 1 1 1 / i n m . 1 2 6 8 9 
Hobfoll, S. E. (1989). Conservation of Resources: A new attempt at con
ceptualizing stress. American Psychologist, 44, 513–524. h t t p s : // d o i . 
o r g / 1 0 . 1 0 3 7/ 0 0 0 3-  0 6 6 X . 4 4 . 3 . 5 1 3
Hobfoll, S. E. (2002). Social and psychological resources and adaptation. 
Review of General Psychology, 6(4), 307–324. h t t p s : // d o i . o r g / 1 0 . 
1 0 3 7/ 1 0 8 9-  2 6 8 0 . 6 . 4 . 3 0 7
Hsiao- Yean, C. H. I. U. (2022). Psychological distress among nurses: A 
concern that cannot be disregarded. Journal of Nursing Research, 
30(4), e216. https:// doi. org/ 10. 1097/ jnr. 00000 00000 000507
Karatzias, T., Shevlin, M., Hyland, P., Fyvie, C., Grandison, G., & Ben- Ezra, 
M. (2021). ICD- 11 posttraumatic stress disorder, complex PTSD and 
adjustment disorder: The importance of stressors and traumatic life 
events. Anxiety, Stress, and Coping, 34(2), 191–202. h t t p s : // d o i . o r g / 
1 0 . 1 0 8 0 / 1 0 6 1 5 8 0 6 . 2 0 2 0 . 1 8 0 3 0 0 6
Katsoty, D., Greidinger, M., Neria, Y., Segev, A., & Lurie, I. (2024). A pre
diction model of PTSD in the Israeli population in the aftermath 
of October 7th, 2023, terrorist attack and the Israel- Hamas war. 
MedRxiv. 2024- 02 h t t p s : // d o i . o r g / 1 0 . 1 1 0 1 / 2 0 2 4 . 0 2 . 2 5 . 2 4 3 0 3 2 3 5
Kenny, D. J., & Hull, M. S. (2008). Critical care nurses' experiences car
ing for the casualties of war evacuated from the front line: Lessons 
learned and needs identified. Critical Care Nursing Clinics of North 
America, 20(1), 41–49. h t t p s : / / d o i . o r g / 1 0 . 1 0 1 6 / j . c c e l l . 2 0 0 7. 1 0 . 0 1 3
Kessler, R. C., Andrews, G., Colpe, L. J., Hiripi, E., Mroczek, D. K., 
Normand, S. L., Walters, E. E., & Zaslavsky, A. M. (2002). Short 
screening scales to monitor population prevalence and trends in 
non- specific psychological distress. Psychological Medicine, 32, 
959–976. h t t p s : // d o i . o r g / 1 0 . 1 0 1 7/ S 0 0 3 3 2 9 1 7 0 2 0 0 6 0 7 4
Keyes, C. L. (2006). Subjective well- being in mental health and human 
development research worldwide: An introduction. Social Indicators 
Research, 77(1), 1–10. h t t p s : / / d o i . o r g / 1 0 . 1 0 0 7 / s 1 1 2 0 5-  0 0 5-  5 5 5 0-  3
Keyes, C. L. M., & Ryff, C. D. (2000). Subjective change and mental 
health: A self- concept theory. Social Psychology Quarterly, 63(3), 
264–279. h t t p s : // d o i . o r g / 1 0 . 2 3 0 7/ 2 6 9 5 8 7 3
Kisely, S., Warren, N., McMahon, L., Dalais, C., Henry, I., & Siskind, D. 
(2020). Occurrence, prevention, and management of the psycho
logical effects of emerging virus outbreaks on healthcare workers: 
Rapid review and meta- analysis. BMJ, 369, m1642. h t t p s : // d o i . o r g / 
1 0 . 1 1 3 6 / b m j . m 1 6 4 2 
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. Springer.
Levi- Belz, Y., Groweiss, Y., Blank, C., & Neria, Y. (2024). PTSD, depres
sion, and anxiety after the October 7, 2023 attack in Israel: A na
tionwide prospective study. eClinicalMedicine, 68, 102418. https:// 
d o i . o r g / 1 0 . 1 0 1 6 / j . e c l i n m . 2 0 2 3 . 1 0 2 4 1 8
Levin, Y., Bachem, R., Hyland, P., Karatzias, T., Shevlin, M., Ben- Ezra, M., 
& Maercker, A. (2022). Validation of the international adjustment 
disorder questionnaire in Israel and Switzerland. Clinical Psychology 
& Psychotherapy, 29(4), 1321–1330. h t t p s : // d o i . o r g / 1 0 . 1 0 0 2 / c p p . 
2710
Lind, M., Bluck, S., & McAdams, D. P. (2021). More vulnerable? The life 
story approach highlights older people's potential for strength 
during the pandemic. The Journals of Gerontology: Series B, 76(2), 
e45–e48. h t t p s : // d o i . o r g / 1 0 . 1 0 9 3 / g e r o n b / g b a a 1 0 5
Maercker, A., & Lorenz, L. (2018). Adjustment disorder diagnosis: 
Improving clinical utility. The World Journal of Biological Psychiatry, 
19(sup1), 
S3–S13. 
1449967
h t t p s : / / d o i . o r g / 1 0 . 1 0 8 0 / 1 5 6 2 2 9 7 5 . 2 0 1 8 . 
Malinauskiene, V., Leisyte, P., Romualdas, M., & Kirtiklyte, K. (2011). 
Associations between self- rated health and psychosocial condi
tions, lifestyle factors and health resources among hospital nurses 
in Lithuania. Journal of Advanced Nursing, 67(11), 2383–2393. 
h t t p s : / / d o i . o r g / 1 0 . 1 1 1 1 / j . 1 3 6 5-  2 6 4 8 . 2 0 1 1 . 0 5 6 8 5 . x
Martin, S. D., Urban, R. W., Johnson, A. H., Magner, D., Wilson, J. E., & 
Zhang, Y. (2022). Health- related behaviors, self- rated health, and 
predictors of stress and well- being in nursing students. Journal of 
Professional Nursing, 38, 45–53. h t t p s : / / d o i . o r g / 1 0 . 1 0 1 6 / j . p r o f n u r s . 
2 0 2 1 . 1 1 . 0 0 8
Muthén, L. K., & Muthén, B. O. (2023). Muthén, & Muthén (Eds.), Mplus 
user's guide (8th ed.). Muthén & Muthén. h t t p s : // d o i . o r g / 1 0 . 1 1 1 1 / j . 
1 6 0 0-  0 4 4 7. 2 0 1 1 . 0 1 7 1 1 . x
Nagin, D. (2005). Group- based modeling of development. Harvard 
University Press.
Nylund, K. L., Asparouhov, T., & Muthén, B. O. (2007). Deciding on the 
number of classes in latent class analysis and growth mixture mod
eling: A Monte Carlo simulation study. Structural Equation Modeling: 
A Multidisciplinary Journal, 14(4), 535–569. h t t p s : // d o i . o r g / 1 0 . 
1080/ 10705 51070 1575396
Nylund- Gibson, K., & Choi, A. Y. (2018). Ten frequently asked ques
tions about latent class analysis. Translational Issues in Psychological 
Science, 4(4), 440–461. h t t p s : // d o i . o r g / 1 0 . 1 0 3 7 / t p s 0 0 0 0 1 7 6 
Palgi, Y., Ben- Ezra, M., & Shrira, A. (2012). The effect of prolonged expo
sure to war- related stress among hospital personnel with different 
affect types: Lessons from the second Lebanon war and the Gaza 
"Cast Lead" operation. European Journal of Psychotraumatology, 3, 
1–10. h t t p s : // d o i . o r g / 1 0 . 3 4 0 2 / e j p t . v 3 i 0 . 7 1 6 5
Paulhus, D. L., & Vazire, S. (2007). The self- report method. In R. W. 
Robins, R. C. Fraley, & R. F. Krueger (Eds.), Handbook of research 
methods in personality psychology (pp. 224–239). Guilford Press.
Pyszczynski, T., Solomon, S., & Greenberg, J. (2015). Thirty years of ter
ror management theory: From genesis to revelation. In J. M. Olson 
& M. P. Zanna (Eds.), Advances in experimental social psychology (Vol. 
52, pp. 1–70). Academic Press. h t t p s : // d o i . o r g / 1 0 . 1 0 1 6 / b s . a e s p . 
2 0 1 5 . 0 3 . 0 0 1
Ridner, S. H. (2004). Psychological distress: Concept analysis. Journal of 
Advanced Nursing, 45(5), 536–545. h t t p s : // d o i . o r g / 1 0 . 1 0 4 6 / j . 1 3 6 5-  
2 6 4 8 . 2 0 0 3 . 0 2 9 3 8 . x
Ring, L., Lavenda, O., Hamama- Raz, Y., Ben- Ezra, M., Pitcho- Prelorentzos, 
S., David, U. Y., Zaken, A., & Mahat- Shamir, M. (2018). Evoked death- 
related thoughts in the aftermath of terror attack: The associations 
between mortality salience effect and adjustment disorder. The 
Journal of Nervous and Mental Disease, 206(1), 69–71. h t t p s : // d o i . 
org/ 10. 1097/ NMD. 00000 00000 000738
Rubin, D. B. (2009). Multiple imputation for nonresponse in surveys (Vol. 
81). John Wiley & Sons, Inc.
Sberro- Cohen, S., Amit, I., Barenboim, E., & Roitman, A. (2023). Resilience, 
sense of danger, and reporting in wartime: A cross- sectional study 
of healthcare personnel in a general hospital. Human Resources for 
Health, 21, 81. h t t p s : / / d o i . o r g / 1 0 . 1 1 8 6 / s 1 2 9 6 0-  0 2 3-  0 0 8 6 6 -  w
Segev, R. (2023). Learning from critical care nurses' wartime experiences 
and their long- term impacts. Nursing in Critical Care, 28(2), 253
260. h t t p s : // d o i . o r g / 1 0 . 1 1 1 1 / n i c c . 1 2 8 1 9 
Shevlin, M., Hyland, P., Ben- Ezra, M., Karatzias, T., Cloitre, M., Vallières, 
F., Bachem, R., & Maercker, A. (2020). Measuring ICD- 11 adjustment 
disorder: The development and initial validation of the International 
Adjustment Disorder Questionnaire. Acta Psychiatrica Scandinavica, 
141(3), 265–274. h t t p s : // d o i . o r g / 1 0 . 1 1 1 1 / a c p s . 1 3 1 2 6 
Stelnicki, A. M., Jamshidi, L., Ricciardelli, R., & Carleton, R. N. (2021). 
Exposures to potentially psychologically traumatic events among 
nurses in Canada. Canadian Journal of Nursing Research, 53(3), 277
291. h t t p s : // d o i . o r g / 1 0 . 1 1 7 7/ 0 8 4 4 5 6 2 1 2 0 9 6 1 9 8 8
Thompson, E. R. (2007). Development and validation of an internation
ally reliable short- form of the positive and negative affect sched
ule (PANAS). Journal of Cross- Cultural Psychology, 38(2), 227–242. 
h t t p s : / / d o i . o r g / 1 0 . 1 1 7 7 / 0 0 2 2 0 2 2 1 0 6 2 9 7 3 0 1
Von Elm, E., Altman, D. G., Egger, M., Pocock, S. J., Gøtzsche, P. C., 
Vandenbroucke, J. P., & Strobe Initiative. (2014). The strength
ening the reporting of observational studies in epidemiology 
(STROBE) statement: Guidelines for reporting observational stud
ies. International Journal of Surgery, 12(12), 1495–1499. h t t p s : / / d o i . 
o r g / 1 0 . 1 0 1 6 / j . i j s u . 2 0 1 4 . 0 7. 0 1 3
Zimet, G. D., Dahlem, N. W., Zimet, S. G., & Farley, G. K. (1988). The multi
dimensional scale of perceived social support. Journal of Personality 
Assessment, 52(1), 30–41

Tel Aviv University makes every effort to respect copyright. If you own copyright to the content contained
here and / or the use of such content is in your opinion infringing Contact the referral system >>