Introduction
Empathy is a fundamental component of effective healthcare, especially for nurses who must connect with patients on a personal level. This compassion includes understanding and communicating patients’ subjective experiences and perspectives, essential to providing individualized care [1]. Empathy is characterized as a cognitive-emotional process that allows healthcare providers to become aware of another person’s emotional state, allowing for deeper connection and understanding [2]. This dual nature of empathy includes cognitive empathy, which involves recognizing and understanding the emotions of others, and emotional or affective empathy, which allows individuals to experience the feelings of others psychologically [3]. However, the interplay of these cognitive and emotional components has remained a subject of ongoing debate.
The development of empathy begins in early childhood and relies on complex interactions within brain networks that enable individuals to recognize and respond to the emotions of others [4]. The early social environment significantly impacts a child’s ability to empathize, with primary caregivers playing a crucial role in promoting this ability [5, 6]. While some argue that empathy is an innate quality, it is increasingly recognized as a skill that can be taught and developed through structured educational approaches. In nursing education, educators explore effective teaching strategies that promote student empathy [7]. Empathy training often includes behavioral listening techniques and related micro-skills to improve students’ empathy [8].
Several factors influence the level of empathy among nursing students, including interpersonal relationships, gender differences, self-efficacy, self-esteem, attachment styles, and satisfaction with their academic program. Research shows that interpersonal relationships are the most predictive factor of nursing students’ empathy levels [9]. Additionally, studies have shown that female nursing students tend to demonstrate greater empathy than their male counterparts [2]. Interestingly, first-year master’s students often demonstrate lower levels of empathy than sixth-semester students, likely due to the latter’s greater exposure to educational environments that emphasize empathic practices [10].
Empathy is critical to the patient-provider relationship and significantly impacts patient satisfaction, adherence to treatment plans, and overall clinical outcomes [11]. Despite the recognized importance of empathy in nursing education and practice, there is a notable lack of comprehensive reviews specifically addressing empathy in nursing students. A systematic review by Levett-Jones et al. (2019) examined the effectiveness of teaching empathy to undergraduate nursing students; however, it did not focus on reporting current studies on the topic [12]. Similarly, a scoping review by Zhou et al. (2021) identified efforts to promote and assess empathy, but these efforts focused primarily on physicians and medical students. Therefore, it is critical to address this gap by focusing on nursing students and evaluating the existing literature on their empathic development [13].
Holistic care emphasizes providing patients with care that addresses their physical, emotional, mental, and spiritual needs [14]. This approach promotes a partnership between caregivers and patients, facilitating shared decision-making regarding health needs [14, 15]. Empathy is essential to authentic presence in holistic care [16], which involves building positive interpersonal communication within therapeutic relationships. This connection helps nurses better understand patients’ perceptions and needs while assisting them to overcome challenges or resolve problems [17]. Therefore, enhancing empathy among nursing students is essential to improving patient care outcomes and promoting effective relationships between nurses and patients.
This narrative review aims to identify and analyze key factors influencing hospital students’ empathy and provide insights for educational strategies to improve empathic abilities. The logic behind this study lies in understanding the critical role of empathy in patient-centered care, which enables the development of effective educational interventions. Fostering empathy is vital because of the crucial role of nurses in healthcare and its impact on patient’s quality of life. Increased empathy improves relationships between caregiver and patient and improves health outcomes. The results will benefit educators and policymakers and guide them to develop more effective interventions. By incorporating potential factors such as attachment styles, we offer a comprehensive perspective on developing empathy, ultimately contributing to better patient care and health outcomes [18]. 

Materials and Methods
This study is a narrative review based on he preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. It aims to explore factors that influence nursing students’ empathy. Although we took a narrative approach, our search strategy was systematic and comprehensive. The search was carried out by a team of two with nursing knowledge using the keywords “empathy”, “nursing student”, and “review” in several databases, including PubMed, Scopus, Noormags, Scientific Information Database (SID), Magiran and Google Scholar, in both Persian and English, with no time limits. Boolean operators were used to ensure thorough research in the literature. The inclusion criteria included original research studies focused on nursing students’ empathy. The exclusion criteria included inaccessible full-text articles and secondary reviews. In particular, we examined studies that used quantitative or qualitative designs involving samples of nursing students. The interventions or comparisons were not limited but focused on factors that influenced the empathy levels of these students. The results examined included empathy measurements, such as self-defined scales. Data extraction was carried out using a standardized form that included demographic variables (e.g. authors, year), study design (e.g. quantitative or qualitative), and key findings on the empathy level of hospital students. Because of the narrative nature of this review, no formal quality assessment was carried out. However, only peer-reviewed articles were selected to ensure the results were based on solid evidence. The search process began with identifying 884 potentially relevant studies, with no time restrictions during the search phase. After removing duplicates and applying inclusion and exclusion criteria in title/abstract screening and full-text evaluation (Figure 1), 17 studies were selected for the final analysis.

Results
This narrative review comprehensively analyzed the factors that influence empathy among nursing students. A total of 17 studies were identified and included in the review. Seven articles were published in English, offering valuable insights into the various elements influencing empathic development in nursing education. The selected studies used various qualitative, quantitative, and mixed-method approaches to provide a comprehensive perspective. The sample population consisted of nursing students from various universities in Iran (such as Tehran and Mashhad) and from other countries such as Italy and Greece. The age range was generally between 18 and 25 years. The gender distribution varied between studies. The results of these studies underscore the complexity of empathy among nursing students and highlight personal characteristics, educational environment, clinical experiences, and social influences as key factors. Table 1 summarizes the reviewed studies and provides details of their authors, year of publication, study design, population characteristics, and key findings related to empathy among nursing students.




This review is intended to illustrate the breadth of research in this area and highlight the importance of promoting empathy in nursing education. 
Table 1 summarizes the key contributions of each study and provides a foundation for understanding the complex dynamics that shape empathy in nursing students. These factors can be divided into three main groups: Demographic, psychological, spiritual, educational, and interventional factors:

Demographic characteristics
These encompass inherent personal and demographic traits:
• Age: Studies show mixed effects. Some indicate higher empathy with age [19, 20], while others suggest empathy declines during academic years [21, 22]. 
• Gender: Studies have shown that women typically score higher on empathy than men [20, 23]. 

Psychological and spiritual factors
This category highlights intrinsic attitudes and psychological constructs:
• Emotional intelligence (EI): A strong positive correlation exists between EI and empathy [23]. 
• Attachment style: Secure attachment correlates positively with empathy [24]. 
• Spiritual attitude: A positive spiritual attitude enhances empathy [25]. 
• Religious beliefs: They are positively correlated with prosocial behaviors, mediated by empathy [26]. 
• Forgiveness: Increased capacity for forgiveness links to greater empathy [24]. 
• Alexithymia: Factors affecting alexithymia can impact empathy and communication skills [19].

Educational and interventional factors
This domain focuses on formal training and clinical experiences:
• Context-based learning (CBL): CBL significantly improves empathy in psychiatric settings [27]. 
• Spiritual care training: It enhances empathy [28]. 
• Psychiatric clerkship: It improves empathy toward mental disorders [29].
• Empathy skills training: It increases responsibility and caring behaviors [30]. 
• Exposure to clinical environments: This may lead to decreased empathy in later academic years due to increased stress and workload [21, 22].
The results of this review underline the complex interplay of factors that influence nursing students’ empathy. The level of empathy is significantly influenced by demographic characteristics such as gender, with female students generally having higher empathy scores than their male colleagues [1, 9]. Psychological factors such as emotional intelligence and attachment styles also play a crucial role, positively correlating with empathic abilities [9, 31]. Educational experiences, including clinical experiences and training programs that focus on spiritual care and contextual learning, can promote empathy but also lead to its decline due to increased stress and workload [19, 21]. The decreased empathy observed over academic years underscores the need for targeted educational interventions to maintain empathic abilities throughout nursing education [19]. These findings emphasize the importance of integrating diverse educational strategies to promote compassionate healthcare professionals. 

Discussion
Empathy, an essential component of social intelligence, has been extensively studied in various academic disciplines, including nursing. This study examined previous research on nursing students that aimed to promote empathy, identify factors contributing to their empathic abilities, and assess their levels of empathy. Because empathy is integral to compassion and kindness, it improves holistic nursing [32]. In addition, nurses show empathy through their presence, which is essential for holistic care practices [33]. By comparing the results of various research papers, we can identify common topics and significant discrepancies that shed light on the complexity of developing empathy in nursing education.
Demographic characteristics such as age, gender, academic year, and employment status have often been highlighted as significant factors influencing empathy levels. For example, Hajibabaee et al. found that female nursing students generally had higher empathy scores than male students [23], consistent with Mardani-Hamooleh’s results, which also suggested gender differences in empathy levels [25]. In addition, the studies by Kesbakhi and Rohani [21] and Saeidi et al. [22] found that empathy tends to decline as students progress throughout their academic years, suggesting that increased exposure to clinical stressors may negatively impact empathic responses. This decline highlights the need for educational interventions to maintain and strengthen empathy throughout the nursing curriculum.
Psychological and spiritual factors such as emotional intelligence, spiritual attitude, and forgiveness influenced empathy. Atta et al. emphasized the mediating role of emotional intelligence in promoting empathic behavior in nursing students. They suggested that those with higher emotional intelligence can better empathize with patients [34]. Similarly, Mardani-Hamooleh found a positive association between spiritual attitudes and levels of empathy, suggesting that promoting spiritual perspectives could improve empathic responses in clinical settings [25]. These findings highlight the importance of integrating emotional and spiritual education into nursing programs to encourage more empathetic healthcare workers.
The influence of educational and interventional experiences on empathy development was a recurring theme across studies. Lashgari et al. showed that CBL during psychiatric internships significantly improved nursing students’ empathy skills, reinforcing that practical experiences are essential for developing empathic skills [27]. Additionally, Mohammadi Nasab pointed out that training focusing on professional ethics and spiritual care can lead to higher levels of empathy, suggesting that educational institutions should prioritize these areas in their curricula [30].
Several similarities emerge when comparing studies on factors that influence empathy in nursing students. Gender differences consistently indicate that female students tend to demonstrate higher levels of empathy than their male counterparts. This finding suggests that targeted strategies are needed to support male nursing students in developing their empathic skills. This result is consistent with the results of various studies, including those indicating lower emotional intelligence scores in male students, which may contribute to their reduced empathic responses [23, 25]. Additionally, the influence of academic progress shows a troubling decline in empathy observed in high school students across multiple studies [21, 22]. This decline is likely due to increased stress and emotional exhaustion associated with clinical training, indicating a critical area for intervention. Finally, the role of emotional intelligence proves to be an essential factor. A positive association between emotional intelligence and empathy highlights the need for educational programs to improve nursing students’ emotional intelligence [34]. 
Compared to previous studies on empathy in nursing education, our findings are primarily consistent but also highlight essential nuances regarding the impact of academic experience on empathic development. While many studies highlight the benefits of clinical exposure for promoting empathy [35], our analysis suggests that increased stress associated with clinical education may decrease empathy levels among hospital students. This discrepancy highlights the need for nuanced interventions that balance practical experience with effective stress management techniques. 
In summary, while our findings are generally consistent with existing literature on factors that influence nursing students’ empathy levels, they also highlight critical areas where action is needed — particularly concerning gender differences and the academic decline in empathy. These findings can serve as a basis for targeted educational initiatives to maintain and improve empathic skills throughout nursing education.

Conclusion
Addressing the factors influencing empathy through targeted educational strategies is critical to effectively preparing nursing students to interact compassionately with patients. The research highlights the importance of fostering empathy, especially as studies indicate that female students generally exhibit higher levels of empathy than their male counterparts. This disparity highlights the need for specialized support to help male students improve their empathic skills. Additionally, the decline in students’ empathy observed over the academic years suggests that increased stress and emotional fatigue due to clinical training may negatively impact their ability to engage with patients. Addressing these factors through targeted educational strategies can better prepare nursing students to interact effectively and compassionately with patients. 
Further research is essential to explore innovative methods for sustaining empathy throughout nursing education and practice, ultimately leading to better patient care outcomes and a more empathetic healthcare workforce. By prioritizing empathy development in nursing curricula, educational institutions can prepare future nurses to be competent practitioners and compassionate caregivers.
The study has notable strengths and limitations. A key strength is the comprehensive analysis of the factors that influence empathy in nursing students, which improves understanding of this complex topic. Additionally, it offers practical recommendations for improving empathy training through emotional intelligence and context-based learning. However, the study’s limited sample diversity may limit the generalizability of its findings. Additionally, reliance on self-reported measures may introduce bias as students overestimate their empathic abilities.

Ethical Considerations
Compliance with ethical guidelines
This article is a review with no human or animal sample.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
Conceptualization and study design: Atefe Esmailpour Moalem; Data analysis and interpretation: Fereshteh Araghian Mojarad; Writing the original draft: Vida shafipour; Review and editing: Atefe Esmailpour Moalem,   and Leila Shafipour; Final approval: All authors.

Conflict of interest
The authors declared no conflict of interest.

References

1. Juniarta, Eka NGA, Ferawati Sitanggang Y. Empathy in nursing students: a scoping review. J Holist Nurs. 2024; 42(2 S):S59-86. [DOI:10.1177/08980101231163966] [PMID]
2. Cunico L, Sartori R, Marognolli O, Meneghini AM. Developing empathy in nursing students: a cohort longitudinal study. J Clin Nurs. 2012; 21(13-14):2016-25. [DOI:10.1111/j.1365-2702.2012.04105.x] [PMID]
3. Moudatsou M, Stavropoulou A, Philalithis A, Koukouli S. The role of empathy in health and social care professionals. Healthcare (Basel). 2020; 8(1):26. [DOI:10.3390/healthcare8010026] [PMID]
4. Riess H. The science of empathy. J Patient Exp. 2017; 4(2):74-7. [DOI:10.1177/2374373517699267] [PMID]
5. Decety J, Meidenbauer KL, Cowell JM. The development of cognitive empathy and concern in preschool children: A behavioral neuroscience investigation. Dev Sci. 2018; 21(3):e12570. [DOI:10.1111/desc.12570] [PMID]
6. Pashevich E. Can communication with social robots influence how children develop empathy? Best-evidence synthesis. AI & Soc. 2022; 37:579-89. [DOI:10.1007/s00146-021-01214-z]
7. Mennenga HA, Bassett S, Pasquariello L. Empathy development through case study and simulation. Nurse Educ. 2016; 41(3):139-42. [DOI:10.1097/NNE.0000000000000226] [PMID]
8. Williams J, Stickley T. Empathy and nurse education. Nurse Educ Today. 2010; 30(8):752-5. [DOI:10.1016/j.nedt.2010.01.018] [PMID]
9. Kim J. Factors influencing nursing students' empathy. Korean J Med Educ. 2018; 30(3):229-36. [DOI:10.3904/kjm.2017.92.3.53.e1] [PMID]
10. Håkansson Eklund J, Holmström IK, Ollén Lindqvist A, Sundler AJ, Hochwälder J, Marmstål Hammar L. Empathy levels among nursing students: A comparative cross-sectional study. Nurs Open. 2019; 6(3):983-9. [DOI:10.1002/nop2.280] [PMID]
11. Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians' empathy and clinical outcomes for diabetic patients. Acad Med. 2011; 86(3):359-64. [DOI:10.1097/ACM.0b013e3182086fe1] [PMID]
12. Levett-Jones T, Cant R, Lapkin S. A systematic review of the effectiveness of empathy education for undergraduate nursing students. Nurse Educ Today. 2019; 75:80-94. [DOI:10.1016/j.nedt.2019.01.006] [PMID]
13. Zhou YC, Tan SR, Tan CGH, Ng MSP, Lim KH, Tan LHE, et al. A systematic scoping review of approaches to teaching and assessing empathy in medicine. BMC Med Educ. 2021; 21(1):292. [DOI:10.1186/s12909-021-02697-6] [PMID]
14. Jasemi M, Valizadeh L, Zamanzadeh V, Keogh B. A concept analysis of holistic care by hybrid model. Indian J Palliat Care. 2017; 23(1):71-80. [DOI:10.4103/0973-1075.197960] [PMID]
15. Frisch NC, Rabinowitsch D. What's in a definition? Holistic nursing, integrative health care, and integrative nursing: Report of an integrated literature review. J Holist Nurs. 2019; 37(3):260-72. [DOI:10.1177/0898010119860685] [PMID]
16. Kinchen E. Development of a quantitative measure of holistic nursing care. J Holist Nurs. 2015; 33(3):238-46. [DOI:10.1177/0898010114563312] [PMID]
17. Mercer SW, Reynolds WJ. Empathy and quality of care. Br J Gen Pract. 2002; 52(S):S9-12. [PMID]
18. Mohammadi A,  Kamali K. Measuring patients’ perceived empathy of clinical nurses. J Iran Med Counc. 2021; 4(2):64-71. [DOI:10.18502/jimc.v4i2.6459]
19. Sharafkhani R, Nukpezah RN, Lathabhavan R, Kallmen H, Fournier A, Hosseini Marznaki Z. Factors that affect levels of alexithymia, empathy and communication skills of nursing students in northern Iran. Nurs Open. 2023; 10(6):3936-45. [DOI:10.1002/nop2.1652] [PMID]
20. Ashghali Farahani M, Salehi T, Arab Ameri Z, Hajibabaee F, Hosseini AF, Ghaffari F. [Empathy among undergraduate nursing students in Tehran University of Medical Sciences (Persian)]. Iran J Med Ethics Hist Med. 2016; 9(4):56-67. [Link]
21. Sedaghati Kesbakhi MS, Rohani C. Changes in the level of nursing students’ empathy during four years education. Research Square. 2019. [Link]
22. Saeidi S, Reza-Masouleh S, Chehrzad MM, Kazem Nejad Leili E. Empathy with patients compared between first and final year nursing students. J Holist Nurs Midwifery. 2017; 27(1):79-85. [DOI:10.18869/acadpub.hnmj.27.1.79]
23. Hajibabaee F, A Farahani M, Ameri Z, Salehi T, Hosseini F. The relationship between empathy and emotional intelligence among Iranian nursing students. Int J Med Educ. 2018; 9:239-43. [DOI:10.5116/ijme.5b83.e2a5] [PMID]
24. Khodabakhsh MR. [Relationship between attachment style and empathy in nursing students (Persian)]. Iran J Nurs. 2012; 25(77):40-9. [Link]
25. Mardani-Hamooleh M, Ahmadi M, Seyedfatemi N, Haghani H. [Relationship between empathy and spiritual attitude among nursing students in Tehran (Persian)]. Iran J Med Ethics Hist Med. 2018; 11:176-88. [Link]
26. Naami A, Mehrabizadeh Honarmand M, Bassak Nejad S, Hassanvand Amouzadeh M, Asadi A, Sanaeenasab N. [Relationship between religious attitude and prosocial behavior considering the mediating role of empathy and altruism in nursing and medical students (Persian)]. J Mazandaran Univ Med Sci. 2020; 29(182):73-81. [Link]
27. Lashgari E, Vaghee S,  Karimi Moonaghi H, Vashani HB. [The effect of context-based learning in psychiatric nursing internship on empathy skills with the patient of nursing students (Persian)]. J Fundam Ment Health. 2018; 20(5):299-305. [DOI:10.22038/jfmh.2018.11402]
28. Rezaei R, Vagharseyyedin SA, Taheri F, Nikkhah Beidokhti A. [The effect of spiritual care training on the empathy among nursing students (Persian)]. Faslnāmah-I akhlāq-I Pizishkī. 2021; 14(45):1-11. [DOI:10.22037/mej.v14i45.34313]
29. Vaghee S, salarhaji A, Kashani Lotfabadi M, Vaghei N, Zarvandi R. [The effect of psychology clerkship on empathy toward mental disorders in nursing students (Persian)]. J Med Educ Dev. 2017; 12(1 & 2):40-50. [Link]
30. Mohammadi Nesbat P, Parchebafieh S, Fatah Moghadam L. [The effectiveness of learning empathy skills on the responsibility of nursing students (Persian)]. J Nurse Physician War. 2023; 11(38):28-35. [Link]
31. Dulay MCB, Domingo JEA, Domingo KFR, Domondon HOF, Dumangon LG, Duran RAD, et al. An exploratory study of factors influencing student nurses' empathy. J Nurs Healthcare. 2018; 3(2):1-9. [DOI:10.33140/JNH.03.02.05]
32. Taleghani F, Ashouri E, Memarzadeh M, Saburi M. Barriers to empathy-based care: Oncology nurses' perceptions. Int J Health Care Qual Assur. 2018; 31(3):249-59. [DOI:10.1108/IJHCQA-12-2016-0185] [PMID]
33. Boeck PR. Presence: A concept analysis. Sage open. 2014; 4(1). [DOI:10.1177/2158244014527990]
34. Atta MHR, Hammad HA, Elzohairy NW. The role of Empathy in the relationship between emotional support and caring behavior towards patients among intern nursing students. BMC Nurs. 2024; 23(1):443. [DOI:10.1186/s12912-024-02074-w] [PMID]
35. Cabataña PGE, Dacayana YLA, Jabagat JB, Palompon DR. Exploring empathy of nursing students and the extent of their clinical experiences: A cross-case analysis. J Ners. 2024; 19(4):412-23. [DOI:10.20473/jn.v19i4.56238]
36. Larti N, Jamshidi M, Tondro A. [Investigating the relationship between empathy for patients and ethics in nursing profession among nursing students at Kermanshah University of Medical Sciences: A case study (Persian)]. J Relig Health. 2023; 1(3):7-10. [Link]
37. Madani M, Lashkrdoosr H, Tabatabaei M. [Investigating the effect of role-playing scenarios on changing mood and empathy in nursing students in the psychiatric ward (Persian)]. Strides Dev Med Educ J. 2013; 10(4):313-20. [Link]
38. Khodabakhsh MR,  Mansuri P. [Relationship of forgiveness and empathy among medical and nursing students (Persian)]. Intern Med Today. 2012; 18(2):45-54. [Link]