Assessment of Empathy Among Undergraduate and Graduate Nursing Students in Osijek, Croatia: A Cross-Sectional Study

1. Introduction

Empathy is often recognized as a crucial element in both the education and practice of nurses and other healthcare professionals, as it is deemed vital for delivering high-quality patient care [1,2]. Four primary dimensions of empathy have been proposed: cognitive, which involves the ability to identify and comprehend the perspectives and viewpoints of others; emotional, which refers to the capacity to feel what others feel; moral, which is the motivation that encourages people to display empathy; and behavioral, which is the ability to express empathetic understanding. [3] Hojat et al. proposed the idea of empathy within the realm of patient care, emphasizing that empathy is chiefly a cognitive attribute. This involves comprehending the experiences, concerns, and viewpoints of patients, as opposed to their emotions. It also encompasses the capacity to express this understanding and a readiness to provide assistance [4]. Rogers described empathy as the capacity to perceive and understand the client's personal world as if it were your own, while still maintaining the "as if" distinction [5].

Healthcare systems, services, policies, and educational programs for healthcare professionals have all emphasized the significance of adopting an empathetic approach in medical settings [6]. Studies have shown that empathy can strengthen relationships between professionals and patients, leading to increased satisfaction for both parties [7,8,9]. For instance, increased empathy is linked to more favorable clinical results, greater satisfaction, improved communication between nurses and patients, and a decrease in burnout [10,11,12]. Nursing students, as future healthcare professionals, need to cultivate the necessary skills to deliver care that enhances patient outcomes and improves the overall quality of healthcare services [13]. Among nursing students, the development of empathy is not immediate. It is influenced by several factors, including age, gender, and experience [14,15,16]. Nurse educators should prioritize fostering empathy in future nurses, beginning at the foundational education level [17]. Assessing empathy among nursing students in education provides feedback to educators, emphasizing the importance of fostering a positive attitude towards empathy as an essential part of holistic healthcare. Examining the variations in empathy levels among students from different academic years can provide a foundation for implementing targeted strategies to enhance empathy, a crucial professional competency in the healthcare field [18].

Several tools have been created to evaluate empathy, with the 'Jefferson Scale of Empathy' (JSE) being the most utilized in healthcare environments [19,20].

Therefore, this study aimed to assess empathy levels among undergraduate and graduate nursing students and to examine differences in empathy according to demographic, educational, and professional characteristics. Additionally, the study aimed to examine the independent associations of these characteristics with empathy scores and to assess the robustness of these associations across alternative model specifications.

2. Materials and Methods

2.1. Study Design

A cross-sectional study was conducted to assess empathy levels and examine demographic, educational, and professional factors associated with empathy among nursing students in Croatia.

2.2. Participants

The research involved 201 nursing students from the Faculty of Dental Medicine and Health in Osijek, Croatia. The participants included undergraduate nursing students in their first and third years, as well as second-year graduate nursing students. The research was conducted in 2025. during the second semester, with the assumption that all students had already gained some clinical experience by that point.

2.3. Instrument

The questionnaire consisted of two parts.

Sociodemographic and professional questionnaire – This part consisted of six items developed for the purposes of this study and included gender, chronological age, highest level of education attained, year of study, employment status, and years of work experience. Gender, highest level of education attained, year of study, and employment status were collected as categorical variables, whereas chronological age and years of work experience were collected as numerical variables and subsequently categorized for selected statistical analyses.

Jefferson Scale of Empathy–Health Professions Student version (JSE-HPS) – The Jefferson Scale of Empathy is available in three versions: the Health Professions Version (JSE HP-Version), designed for physicians and other health professionals; the Medical Student Version (JSE S-Version), tailored for medical students; and the Health Professions Student Version (JSE HPS-Version), intended for students in health-related fields outside of medicine. The scale is composed of three components: perspective-taking, compassionate care, and standing in the patient's shoes. It is evaluated using a seven-point Likert scale. The set consists of 20 items, evenly split between positive and negative items. For positive items, responses are scored directly, ranging from 1 for "strongly disagree" to 7 for "strongly agree." Conversely, negative items are scored inversely, with "strongly disagree" receiving a score of 7 and "strongly agree" a score of 1. The cumulative score can reach up to 140, with higher scores signifying greater levels of empathy [4]. In the present study, the JSE-HPS demonstrated good internal consistency (Cronbach’s α = 0.825; McDonald’s ω = 0.852).

2.4. Ethical Considerations

The Asano-Gonnella Center for Research in Medical Education and Health Care at Thomas Jefferson University has granted approval for the use of the JSE-HPS.

All participants provided informed consent to participate in the study voluntarily, and had the right to withdraw at any time without any negative consequences. Their anonymity was assured in with the principles of the Declaration of Helsinki.

Approval was sought from the ethics committee of the Faculty of Dental Medicine and Health in Osijek to carry out the research. (Approval number: 2158/97-97-10-25-69). (Date of approval: November 28, 2025).

2.5. Statistical Methods

Descriptive statistical methods were used to characterize the frequency distribution of the investigated variables. Age and years of work experience were categorized according to the requirements of the statistical analysis. The normality of the distribution of the total JSE-HPS score was assessed using the Shapiro–Wilk test, where a statistically significant result (p < 0.05) indicated a deviation from a normal distribution. Examination of the homogeneity of variance showed that variances were not homogeneous in most cases; therefore, nonparametric tests were employed. Because the total JSE-HPS score deviated from normality, it is presented using both the mean (M) and standard deviation (SD), to facilitate comparison with previous JSE studies, and the median (Mdn) with the first and third quartiles (Q1–Q3), to provide a distribution-appropriate summary. For group comparisons analyzed using the Mann–Whitney U and Kruskal–Wallis tests, JSE-HPS scores are presented as median with first and third quartiles [Mdn (Q1–Q3)]. Internal consistency of the JSE-HPS was evaluated using Cronbach’s alpha and McDonald’s omega.

For comparisons among multiple independent groups, the Kruskal–Wallis test was used, followed by Dunn’s post hoc analysis with Bonferroni correction; the Mann–Whitney U test was applied for comparisons between two independent groups. Effect sizes were reported using r for the Mann–Whitney U test and epsilon squared (ε²) for the Kruskal–Wallis test. A multiple linear regression model was used to examine factors independently associated with the total JSE-HPS score. To avoid redundant representation of closely overlapping educational variables, year of study was retained in the primary model, while educational level was examined in an alternative sensitivity model. Because heteroskedasticity was detected by the Breusch–Pagan test, heteroskedasticity-consistent HC3 standard errors and 95% confidence intervals were used for inference in the primary model. Additional sensitivity analyses treated age and years of work experience as continuous variables, substituted educational level for year of study, and used 5000 bootstrap resamples with bias-corrected and accelerated (BCa) 95% confidence intervals. Model diagnostics included residual normality, homoscedasticity, independence, influential observations, and multicollinearity. Statistical significance was defined at p < 0.05. All analyses were performed in R version 4.6.1 (R Foundation for Statistical Computing, Vienna, Austria) using RStudio 2026.08.1 (Posit Software, PBC). The readxl, dplyr, psych, car, lmtest, sandwich, effect size, parameters, performance, boot, FSA, coin, and writexl packages were used for data import and processing, reliability analysis, nonparametric analyses, effect-size estimation, regression modelling and diagnostics, robust and bootstrap inference, and export of results.

3. Results

A total of 201 nursing students participated in the study, with a median age of 23 years (IQR = 21–28). The majority were female, 162 (80.6%), most commonly aged between 21 and 25 years, 96 (47.8%), and enrolled in the second year of the graduate program, 80 (39.8%). The median years of work experience were 2 years (IQR = 0–7) (Table 1).

The total JSE-HPS score was M = 106.82 ± 14.21 and Mdn = 108 (Q1–Q3 = 95–118) (Table 2).

Statistically significant differences in the overall JSE-HPS score were observed with respect to gender (U = 2127.50, p = 0.003), with a small effect size (r = 0.209), indicating that female students demonstrated higher empathy scores than male students.

A statistically significant difference was also found across chronological age groups (H (4) = 16.67, p = 0.002), with a moderate effect size (ε² = 0.065). Dunn’s post hoc analysis with Bonferroni correction showed that students aged 21–25 years had higher empathy scores than students aged 26–30 years (adjusted p = 0.020) and those aged 41 years or older (adjusted p = 0.029); the remaining pairwise comparisons were not statistically significant.

Differences with a small effect size (ε² = 0.040) were also observed with respect to educational level (H (2) = 9.85, p = 0.007). Dunn’s post hoc analysis with Bonferroni correction showed that students with a completed undergraduate degree had lower empathy scores than students with medical secondary school education (adjusted p = 0.017), while the other pairwise comparisons were not statistically significant.

Furthermore, a significant difference was found with respect to year of study (H (2) = 14.60, p < 0.001), with a moderate effect size (ε² = 0.064). Dunn’s post hoc analysis with Bonferroni correction showed that second-year graduate students had lower empathy scores than third-year undergraduate students (adjusted p < 0.001); the remaining pairwise comparisons were not statistically significant.

Regarding employment status, a significant difference was also observed (U = 2533.00, p < 0.001), with a moderate effect size (r = 0.305), indicating that unemployed students had higher empathy scores than employed students.

With respect to the categorized length of work experience, statistically significant differences in empathy scores were identified (H (4) = 11.90, p = 0.018), with a small effect size (ε² = 0.040). However, none of the pairwise comparisons remained statistically significant after Bonferroni correction.

Table 3. Differences in empathy levels with respect to general and sociodemographic variables.

		Total of JSE-HPS score	Test statistic	Effect size	p value
		Mdn (Q1–Q3)	U/H (df)	r/ε²	p value
Gender	female	111 (98–118.75)	2127.5	0.209	0.003*
	male	98.5 (92.25–108)
Chronological age	18–20	107.5 (95.5–115.75)	16.674 (4)	0.065	0.002†
	21–25	114 (102.75–118.25)
	26–30	100 (94–108.75)
	31–40	100.5 (90.5–119)
	≥ 41	96 (91.5–112)
Highest level of education attained	Medical secondary school	111 (101–118.5)	9.849 (2)	0.040	0.007†
	Grammar or vocational secondary school	114.5 (104.25–118)
	Bachelor’s degree completed	100.5 (92.75–116)
Year of study	1st year undergraduate	109 (95–117)	14.596 (2)	0.064	<0.001†
	3rd year undergraduate	115 (104–120)
	2nd year graduate	100.5 (92.75–116)
Employment status	employed	104 (94–116)	2533.0	0.305	<0.001*
	unemployed	116 (108–120.75)
Years of work experience	< 1	114 (102–120)	11.899 (4)	0.040	0.018†
	1–5	108 (94.5–117)
	6–10	103 (98–110.5)
	11–15	96 (85.5–117.5)
	≥ 16	96 (90.5–114)

Note: Mdn – median; Q1 – first quartile; Q3 – third quartile; p – statistical significance; U – Mann–Whitney U test statistic; H – Kruskal–Wallis test statistic; r – effect size for the Mann–Whitney U test; ε² – epsilon-squared effect size for the Kruskal–Wallis test; * – Mann–Whitney U test; † – Kruskal–Wallis test.

Table 3. Differences in empathy levels with respect to general and sociodemographic variables.

		Total of JSE-HPS score	Test statistic	Effect size	p value
		Mdn (Q1–Q3)	U/H (df)	r/ε²	p value
Gender	female	111 (98–118.75)	2127.5	0.209	0.003*
	male	98.5 (92.25–108)
Chronological age	18–20	107.5 (95.5–115.75)	16.674 (4)	0.065	0.002†
	21–25	114 (102.75–118.25)
	26–30	100 (94–108.75)
	31–40	100.5 (90.5–119)
	≥ 41	96 (91.5–112)
Highest level of education attained	Medical secondary school	111 (101–118.5)	9.849 (2)	0.040	0.007†
	Grammar or vocational secondary school	114.5 (104.25–118)
	Bachelor’s degree completed	100.5 (92.75–116)
Year of study	1st year undergraduate	109 (95–117)	14.596 (2)	0.064	<0.001†
	3rd year undergraduate	115 (104–120)
	2nd year graduate	100.5 (92.75–116)
Employment status	employed	104 (94–116)	2533.0	0.305	<0.001*
	unemployed	116 (108–120.75)
Years of work experience	< 1	114 (102–120)	11.899 (4)	0.040	0.018†
	1–5	108 (94.5–117)
	6–10	103 (98–110.5)
	11–15	96 (85.5–117.5)
	≥ 16	96 (90.5–114)

Note: Mdn – median; Q1 – first quartile; Q3 – third quartile; p – statistical significance; U – Mann–Whitney U test statistic; H – Kruskal–Wallis test statistic; r – effect size for the Mann–Whitney U test; ε² – epsilon-squared effect size for the Kruskal–Wallis test; * – Mann–Whitney U test; † – Kruskal–Wallis test.

A multiple linear regression analysis was conducted to examine factors independently associated with empathy scores. The primary model included gender, categorized chronological age, year of study, employment status, and categorized years of work experience. Educational level was not included simultaneously with year of study in the primary model because of their conceptual overlap and was instead evaluated in a sensitivity model. The single participant who preferred not to report gender was excluded from regression analyses, yielding n = 200.

The primary regression model was statistically significant (F (12, 187) = 3.16, p < 0.001) and explained 11.5% of the variance in empathy scores (adjusted R² = 0.115). Because the Breusch–Pagan test indicated heteroskedasticity (p = 0.022), HC3 robust standard errors were used for inference. Female gender was significantly associated with higher empathy scores (B = 6.12, HC3 SE = 2.44, p = 0.013, 95% CI [1.29, 10.94]). Employment status was not statistically significant in the primary HC3 model (B = −5.42, p = 0.176). None of the age, year-of-study, or work-experience categories were statistically significant after adjustment (Table 4). Sensitivity analyses supported the robustness of the gender association. In the model treating age and work experience as continuous variables, female gender (B = 6.79, p = 0.003) and employed status (B = −6.91, p = 0.005) were significant using HC3 inference; the model explained 12.6% of the variance (adjusted R² = 0.126). In the alternative model containing educational level instead of year of study, female gender (B = 6.75, p = 0.003) and employed status (B = −8.23, p = 0.002) were significant, with adjusted R² = 0.116. BCa bootstrap 95% confidence intervals likewise excluded zero for female gender [2.30, 10.89] and employed status [−11.45, −2.07]. Thus, the gender association was consistent across model specifications, whereas the employment-status association was sensitive to model specification.

4. Discussion

Empathy, as a cognitive trait, can potentially be cultivated through education. Ozcan et al. proposed that well-designed educational programs could enhance and strengthen empathetic abilities [23]. In the present study, the mean JSE-HPS score among nursing students was 106.82. Similar findings have been reported in studies involving nursing students from other countries, including the United Kingdom [24], Chile [25], Spain [26], and Italy [27], where mean empathy scores ranged from approximately 104 to 115. The empathy score observed in the present sample therefore falls within the range previously reported among nursing students in international studies. Research indicates that empathy levels can be enhanced and developed through education and training. Experiential learning activities [28], perspective-taking exercises [29], workshops [30], game-based learning [31], role play [32,33,34], should be considered for the purpose of enhancing empathy. This research examined the empathy levels among nursing students across various academic years. In this study, second-year graduate students showed lower levels of empathy compared with third-year undergraduate students, whereas the difference compared with first-year undergraduate students was not statistically significant after Bonferroni correction; this is broadly consistent with findings from other studies reporting differences in empathy across stages of nursing education and clinical experience [35,36,37]. Studies suggest that the causes for this can vary. Research by Sulaiman et al. suggests that the fatigue stemming from intense academic pressures and stressors experienced by students may lead to burnout [38]. Burnout, for instance, can lead to a sense of depersonalization among students in health professions, diminishing their empathy towards patients [39,40]. Furthermore, research has shown that certain stressors related to clinical training can significantly reduce the empathy levels of nursing students. These stressors are tied to academic aspects such as a heavy course load, insufficient break times, and exam pressure [41]. In this research, students between the ages of 21 and 25 exhibited greater empathy levels compared with those aged 26 to 30 and those aged 41 years or older; the difference compared with students aged 31 to 40 years was not statistically significant after Bonferroni correction. Although the overall comparison according to years of work experience was statistically significant, none of the pairwise comparisons remained statistically significant after Bonferroni correction. This highlights the importance of making empathy a key component of ongoing education and personal growth at every stage of life. There is a shared responsibility between educators and stakeholders in real-world settings to nurture and uphold the empathy levels of nurses [42,43]. Finding effective strategies to cultivate and sustain empathy from undergraduate and graduate studies through to a professional nursing career presents a significant challenge that needs to be tackled. This study used multiple linear regression to examine factors associated with empathy. Female gender showed a consistent independent association with higher empathy scores across the primary and sensitivity model specifications. Employment status showed a less consistent pattern: employed students had lower empathy scores in sensitivity analyses using continuous age and work experience and in the alternative model including educational level, whereas this association was not statistically significant in the primary model using categorized variables. Age, year of study, years of work experience, and educational level did not show consistent independent associations with empathy across the multivariable analyses. A regression analysis revealed that women exhibited greater empathy than men, which is similar to other studies [44]. Research suggests that female students tend to express their emotions more strongly than their male counterparts, which may enhance their capacity for empathy. Leppel observes that gender significantly influences students' choices when it comes to selecting degree programs. Women often choose academic fields that have historically been dominated by females, such as nursing [45]. A study led by Penprase and her team found that male nursing students demonstrate higher levels of empathy than those observed in the general student body. This heightened empathy plays a crucial role in attracting men to the nursing profession [46]. Nursing educators should prioritize nurturing empathy in male students and strengthening their connection with the nursing profession [47].

Additionally, unemployed students had higher empathy scores than employed students in the unadjusted analysis. However, the adjusted association with employment status depended on model specification and should therefore be interpreted cautiously. The lack of empathy among healthcare professionals can lead to dissatisfaction among patients and their families. Additionally, this lack of empathy can contribute to incorrect diagnoses, poor compliance with treatment plans, and decreased patient engagement [48].

Taken together, the unadjusted analyses showed differences in empathy according to age, year of study, and years of work experience, but these characteristics did not show consistent independent associations in the multivariable analyses. Female gender was the most robust adjusted correlate of higher empathy, remaining significant across the primary, sensitivity, HC3, and bootstrap analyses. The association between employment status and empathy was less stable: lower scores among employed students were supported by the sensitivity and bootstrap analyses but not by the primary categorized HC3 model. Accordingly, employment status should not be interpreted as a definitive independent determinant of empathy. The absence of significant Bonferroni-adjusted pairwise differences for years of work experience also does not support a simple conclusion that empathy decreases with increasing professional experience.

4.1. Implications for Nursing Education and Practice

The findings support continued attention to empathy throughout nursing education rather than focusing on a single stage of training. The consistent association between female gender and higher empathy suggests that educators may need to consider whether different groups of students benefit from different forms of support, while avoiding assumptions that gender itself determines empathic capacity. The tendency toward lower empathy scores among employed students, which was supported by several sensitivity analyses but was not consistent across all model specifications, warrants further investigation. The present study did not assess workload, fatigue, occupational stress, burnout, or the characteristics of students’ employment; these factors should therefore be considered possible explanations rather than mechanisms demonstrated by the present findings. Educational approaches already discussed above, including experiential learning, perspective-taking, workshops, game-based learning, and role play [28,29,30,31,32,33,34], may provide useful options for supporting empathy development, but their effectiveness in this specific population should be evaluated prospectively.

4.2. Limitations

Several limitations should be considered when interpreting these findings. First, the cross-sectional design does not allow conclusions about causality or changes in empathy over time; consequently, differences between academic years, age groups, or work-experience groups should not be interpreted as evidence that empathy increases or decreases as student progress through education or professional practice. Second, participants were recruited from a single faculty, which may limit the generalizability of the findings to nursing students in other institutions or settings. Third, some subgroups were relatively small and the distribution of participants across categories was unequal, particularly by gender and in some age and work-experience categories. Fourth, empathy was assessed using a self-report instrument and may therefore be influenced by response tendencies, including socially desirable responding. Fifth, age and years of work experience were strongly related, and the association between employment status and empathy was sensitive to model specification; although sensitivity, HC3, and bootstrap analyses were used to assess robustness, these findings require cautious interpretation and independent replication. Finally, potentially relevant factors such as workload, fatigue, burnout, occupational stress, type and intensity of employment, and specific clinical experiences were not measured. Future longitudinal and multicenter studies should examine these factors and clarify whether the observed associations persist over time and across different educational settings.

5. Conclusions

Empathy scores among nursing students varied across several demographic, educational, and professional characteristics in unadjusted analyses. In the primary HC3-adjusted model, female gender remained significantly associated with higher empathy, whereas employment status was not statistically significant. Female gender remained consistently associated with higher empathy across sensitivity and bootstrap analyses, while lower empathy among employed students was supported in several sensitivity analyses but was not consistent across all model specifications. Age, year of study, work experience, and educational level did not show consistent independent associations. These cross-sectional findings identify associations rather than causal effects and support further longitudinal and multi-institutional research on factors that may help sustain empathy throughout nursing education and the transition to professional practice.