The aim of this study was to determine the level of empathy and its changes in undergraduate nursing students across different academic education years. The overall results showed that the average reported empathy by nursing students in all the years of education was 91.8 ± 28.7 (range: 20-140). The changes in empathy level showed that nursing students reported the highest level of empathy with patients during the first year of education. While in the fourth year of education, the level of empathy was less than the percentile 50, in more than 76 percent of students. The average empathy of nursing students in our study was different from other studies with similar scales. The research results with nursing students in US showed that their average empathy was 114 ± 11.5 (18). In a similar study with the purpose of psychometric analysis of the JSE- NS version R in 598 American nursing students, their average empathy was 114.5 ± 10.9 (19). In addition, the mean level of midwifery students’ empathy was reported 107.3 ± 13.7 at a university in Australia (20). While the average empathy of nursing students in Greece was reported 88.6 ± 8.9 (21)). Also in another study, the mean level of empathy among medical students was reported 100.5±14.8. (22). Perhaps the difference between average empathy of nursing students in the current research with reported studies, can be related to reasons like the different social context and cultural backgrounds in students, students' clinical experience, students experiences across different years of education, accessing to good role models in the clinical settings, having tutors with higher levels of emotional perception, as well as receiving inherent or acquired empathy in the family. The results of this study showed that with increasing students' academic year, their empathy declined. These results were in line with a study which was longitudinally conducted from the first to the fourth year of education at the University of Thomas Jefferson. The results of the study showed that with the passage of time and more interaction of nursing students with patients, their empathy decreased. The authors reported that the reason can be related to continuous communication of students with patients at a clinical environment, having more autonomy and less supervision by clinical faculties in the second and third years of education, compared to the first year (10). In another study in UK, it was found that the empathy of third year nursing students was lower than the first year (23). Also, contradictory results was found in earlier studies. In a study which was conducted at Medical University of Guilan-Iran with nursing students, the results showed that there was no statistically significant difference between the level of empathy of first year students with fourth year (14). Nevertheless, nursing students in fourth academic year of education from the University of Ordu in Turkey reported empathy scores higher than the first year students (11).
Similarly, studies with medical students showed that the score of students’ empathy decreased during the third year of education (12, 22, 24, 25). The results of our research showed that empathy of the third year nursing students, is more than the second year students. However, the results of a study with pharmacology students in Malaysia revealed that third and fourth year students, reported lower empathy in comparison with the first and second year students (26). But, the empathy of third year students of pharmacology in the UK was significantly higher than that of the first year students (23). Two other studies in India and in the Us showed that with increasing academic education years, students' empathy reduced (27, 28). In two other studies with medical students at Medical University of US and Shiraz-Iran, it was concluded that with increasing academic education year, the empathy of medical students decreased (12, 13).(29), discussed about the following factors which may reduce medical students’ empathy; lack of appropriate role models, negative attitudes toward clinical competencies, long-term presence in the clinical setting, threatening or risky educational environments, heavy educational responsibilities or clinical duties, and negative reactions of patients to students’ empathy. In Rosen et al. study (2006), these factors were raised; different aspects of stressful practices such as long hours of clinical work and sleep deprivation, dependence on technology for diagnosis, short-term hospitalization of the patients, and limited interactions between students and patients (30). But, the focus on the demographic characteristics of nursing students and their empathy scores in our study showed that the empathy of students aged 20 years and older, single and female, is higher than that of students under the age of 20 years, male and married. Australian research results in undergraduate paramedic/nursing students indicated that students aged 30-36 years old and 31-35 years earned a higher score than their younger classmates (31). One of the reasons for higher empathy in older students can be linked with more experience in life, which in turn increases their empathy (18). Also, the acquisition of experiences such as love, loss, regret, entanglement, pain and loneliness leads to more attention to the effects of these experiences throughout the life on others (31). In a study conducted with another scale of empathy, “Empathic Tendency Scale”, to measure the empathy of nursing students, the authors concluded that the empathy of nursing students younger than 20 years was lower than those aged 21-30 years (11). While (32),found that increasing the age of Brazilian nurses had no effect on the level of their empathy.
A review of gender-focused empathy research has also shown that women are generally more empathetic than men (18, 22, 27, 33-35). Findings of a research in Chicago showed that the average empathy of female pharmacology students was significantly higher than that of male students (36). Another study showed that the empathy of Bangladeshi female medical students was higher than that of male students (37). Although, the number of male nursing students was not sufficient in the current study, the results are consistent with previous studies. It can be argued that female students, due to the inherent nature of the desire to care for individuals and interest in this area, are likely to be less influenced by the factors that lead to diminished empathy. Furthermore, the high level of empathy among female students may also be due to their better management of confronting with life stressors, compared to men (38) This gender difference in the empathy between men and women can also be due to sexual bio-evolutionary characteristics, interpersonal care styles, socialization, and gender role expectations (39). The results of a study show that women have a better understanding of emotional support that is important in developing interpersonal communication with the patient (12). In the present study, the empathy of single nursing students was higher than the married ones, but in a similar study with oncology nurses in Iran, the marital nurses' empathy was higher (40). However, in another study on oncology nurses in Turkey, marital status did not show a correlation with nurses' empathy (41). It seems that the low number of married students in our study influenced on this result.