Holistic Empathy Development in Palestinian Nursing Students: A Cognitive-Emotional Analysis with Implications for Oncology Care

Abstract

Aim/Objective

To holistically assess cognitive and emotional empathy development among nursing students in a resource-limited Middle Eastern setting, examine the cultural validity of Western empathy thresholds, and identify implications for holistic oncology nursing education.

Background

Empathy is essential for whole-person, healing-centered care, especially in oncology, yet its measurement remains dominated by Western tools with limited evidence from non-Western contexts.

Desig

A descriptive cross-sectional study at three Palestinian universities.

Methods

A stratified sample of 320 nursing students completed the Jefferson Scale of Empathy (JSE). Data were analyzed using descriptive statistics, non-parametric tests, Spearman correlations, and multiple regression.

Results

Students demonstrated moderate total empathy (M = 98.21, SD = 16.54) with a marked cognitive-emotional gap. Cognitive empathy (Perspective-Taking) increased significantly from first (M = 52.10) to fourth year (M = 66.35), whereas emotional empathy (Compassionate Care) remained stable and low (M≈23). Perspective-Taking was the strongest predictor of total empathy. Exposure to integrated palliative care content was associated with higher empathy scores.

Conclusions

Cognitive empathy developed with education, while emotional empathy did not, revealing an imbalance in holistic empathy development. Western classification thresholds may misrepresent culturally distinct empathy patterns. Nursing education should integrate culturally grounded, spiraled empathy training within a holistic framework to nurture the whole-person empathetic capacity essential for oncology and healing-centered care.

Keywords

holistic nursing empathy development nursing education oncology nursing cultural competence

Introduction

Empathy constitutes a fundamental holistic competency for nursing practice globally, requiring harmonious integration of cognitive understanding, emotional resonance, and compassionate presence, essential for whole-person care (American Holistic Nurses Association, 2019). This integration holds particular importance in oncology and palliative care settings where nurses must balance technical expertise with bio-psycho-socio-spiritual engagement (Jeffrey, 2016; Treglia, 2020). As cancer burden escalates worldwide, preparing nurses with robust, balanced empathetic capacity becomes increasingly critical, especially in resource-limited settings facing workforce shortages and high occupational stress (Al Zoubi et al., 2020; World Health Organization, 2023). Within holistic nursing scholarship, empathy is understood not solely as a clinical technique but as an expression of relational presence—the authentic, whole-person attunement of the nurse to the patient's inner life world (Watson, 2012). This relational dimension of empathy encompasses not only cognitive understanding of another's perspective but also genuine emotional resonance and spiritual sensitivity to the patient's experience of suffering, meaning, and dignity. Holistic nursing principles, as articulated by the American Holistic Nurses Association (2019), emphasize that empathic caring must honor the full complexity of human experience across physical, emotional, social, and spiritual dimensions. From this standpoint, an empathy that is predominantly cognitive—intellectually adept but emotionally and spiritually underdeveloped—is an incomplete holistic competency, however technically proficient it may appear.

Yet empathy measurement and education in nursing remain predominantly informed by Western theoretical frameworks, validated instruments, and normative data (Hojat et al., 2001; McKenna et al., 2012). This raises fundamental questions from a holistic nursing perspective: Do Western-derived empathy thresholds account for spiritual and cultural dimensions of caring? Might patterns deemed “low” in one cultural context represent normative or even adaptive holistic expressions in another? How do empathy dimensions develop across the educational trajectory in non-Western settings? How do resource constraints and collectivist values shape holistic empathy development? These questions carry significant implications for nursing education globally, as holistic educators recognize that one-size-fits-all approaches may fail to account for cultural, contextual, and spiritual factors influencing empathy expression and development (Kavuran et al., 2024; Ozcan et al., 2012).

Empathy as a Holistic, Multidimensional Construct

Foundational scholarship distinguishes cognitive empathy (intellectual perspective-taking ability) from emotional empathy (affective capacity for shared emotional experiences) (Davis, 1983; Decety & Jackson, 2004). From a holistic nursing perspective, these dimensions represent essential, interconnected components of whole-person caring that should ideally develop in harmony. Cognitive empathy enables nurses to understand complex treatment decisions and family dynamics, while emotional empathy proves vital for grief management, existential distress addressal, and dignity fostering in terminal care (Treglia, 2020). Balanced development of both dimensions appears essential for comprehensive, person-centered oncology nursing practice.

However, emerging evidence suggests these dimensions may develop differentially across educational contexts and cultural settings (Batt-Rawden et al., 2013; Rahimi-Madiseh et al., 2010). Few studies have systematically examined how cognitive and emotional empathy develop across the nursing education trajectory, particularly through a holistic lens in non-Western contexts. Understanding these developmental patterns becomes particularly important in regions where nursing education occurs under challenging conditions that may influence holistic empathy development and expression (Giacaman et al., 2011).

Cultural and Spiritual Context in Holistic Empathy Expression

Cultural and spiritual factors substantially influence how empathy is conceptualized, experienced, and expressed within holistic care frameworks (Dwairy, 2006; Ozcan et al., 2012). In collectivist cultures common in the Middle East, emotional regulation, practical assistance, and spiritual support may be prioritized over overt emotional expression, particularly in professional healthcare settings (Giacaman et al., 2011). Additionally, populations experiencing chronic adversity may develop specific resilience mechanisms emphasizing “endurance” and pragmatic problem-solving over demonstrative emotional engagement (Afana et al., 2010). These patterns raise critical questions about measurement validity when applying Western-normed instruments cross-culturally, particularly regarding spiritual dimensions of caring.

The Palestinian context provides a compelling case study for examining these issues through a holistic lens. Palestinian healthcare faces substantial obstacles including limited specialized cancer center availability and resource scarcity in palliative services (World Health Organization, 2023). The population experiences chronic adversity related to prolonged political conflict and economic constraints (Giacaman et al., 2011). Palestinian culture, characterized by collectivist values, specific emotional expression norms, and community-wide trauma exposure, may substantially influence how empathy develops and manifests among nursing students (Afana et al., 2010; Dwairy, 2006). Yet no studies have systematically examined cognitive versus emotional empathy patterns among Palestinian nursing students using validated instruments across the full educational trajectory through a holistic nursing framework.

Theoretical Framework

To frame our investigation holistically, we draw upon three complementary theories. The Clinical Empathy Model (Mercer & Reynolds, 2002) conceptualizes empathy as a multi-stage process involving cognitive understanding and affective sharing. Situated Learning Theory (Lave & Wenger, 1991) posits that learning is embedded within specific activities, contexts, and cultures. Most significantly, we integrate Watson's Theory of Human Caring (2012), which positions caring as the moral ideal of nursing involving transpersonal, holistic engagement that honors mind-body-spirit unity. This holistic framework supports our examination of empathy as a multidimensional, spiritually informed capacity essential for healing relationships. Crucially, Watson's framework directs us to understand empathy not merely as an interpersonal skill but as a form of relational presence—a mode of being fully present with patients that honors their whole personhood across physical, emotional, social, and spiritual dimensions. Within this lens, empathy encompasses the nurse's authentic attunement to the patient's inner life world, a quality that transcends cognitive understanding alone and requires the cultivation of both emotional resonance and compassionate presence. This conceptualization meaningfully informs our interpretation of findings: a cognitive-emotional empathy imbalance is not merely a statistical disparity but a signal that nursing education may be cultivating intellectual competence while underdeveloping the relational presence central to Watson's vision of holistic, healing-centered caring. The theoretical convergence of these three frameworks thus enables a richer, more holistically grounded analysis of empathy development than any single theory would permit.

Based on these frameworks, we formally hypothesized that: (1) a cognitive-emotional empathy disparity exists, with this disparity's magnitude varying significantly across academic years; (2) cognitive empathy would increase across academic years while emotional empathy would remain stable; (3) palliative care content integrated within clinical courses would be associated with higher empathy scores compared to standalone courses; and (4) overall empathy patterns would differ from established Western norms, raising questions about cross-cultural measurement validity within holistic care contexts.

Study Aims and Holistic Relevance

This study addresses critical knowledge gaps through three aims: first, holistically assessing cognitive and emotional empathy development across all four academic years among nursing students in a Middle Eastern resource-limited setting; second, examining whether demographic and educational factors influence empathy dimensions; third, exploring cultural measurement validity questions and implications for holistic nursing education globally.

While conducted in Palestine, findings carry potential relevance for holistic nursing education worldwide. They contribute to evidence questioning universal applicability of Western-normed instruments (Ozcan et al., 2012), provide insights into empathy development in resource-limited settings, examine pedagogical approaches with potential applicability across cultural contexts, address oncology nursing preparation as global cancer burden rises, and offer unique insights into how empathy dimensions develop differentially across the educational trajectory—informing holistic curriculum design and intervention timing.

Methods

Design and Setting

A descriptive cross-sectional design was implemented at three Palestinian universities in the West Bank offering Bachelor of Science in Nursing (BSN) programs. Following ethical approval (May 2025) and copyright permission for the Jefferson Scale of Empathy (June 2025), data collection spanned June 15 through July 16, 2025.

Participants and Sampling

Target population encompassed all first-through-fourth-year undergraduate nursing students enrolled at the three institutions (total N = 1,461). A stratified sampling approach was employed to ensure balanced representation across all four academic years. Within each academic year stratum, convenience sampling was used to recruit participants until the target of 80 students per year was achieved. Final sample comprised 320 participants with equal distribution across years. Several methodological transparency points warrant explicit acknowledgment. First, although stratification ensured proportional academic year representation, convenience sampling within each stratum means that participating students may systematically differ from non-participants in ways that could influence empathy scores—for example, students who are more academically engaged, more accessible on campus, or more interested in empathy-related research may have been more likely to participate. This potential volunteer bias may inflate empathy estimates relative to the true population. Second, the overall achieved sample (n = 320) represents approximately 21.9% of the eligible population (N = 1,461), which, while adequate for the planned analyses given the stratified design, means that the majority of eligible students were not enrolled. Third, the quota-based design, while efficient, does not allow for the calculation of a traditional response rate in the same manner as a random probability sample; the reported 100% return rate applies specifically to questionnaires that were distributed rather than to the proportion of eligible students who participated. These design characteristics should be considered when interpreting the generalizability of findings to all Palestinian nursing students.

This balanced sampling strategy enables robust statistical comparisons of empathy development across the educational trajectory. Inclusion criteria specified actively enrolled nursing student status plus informed consent provision. Students on academic suspension or leave of absence were excluded.

Measurement Instruments

Demographic and Academic Data: Variables included age, gender, academic year, university, and oncology/palliative care course exposure. Integrated palliative care content exposure was determined through student self-report via a single yes/no question: “Have you encountered dedicated palliative care content within other courses?”

Jefferson Scale of Empathy - Health Profession Student Version (JSE): The official Arabic version of the JSE was used. This 20-item Likert-scale instrument (1 = Strongly Disagree, 7 = Strongly Agree) measures overall clinical empathy plus three subscales: Perspective-Taking (cognitive empathy), Compassionate Care (emotional empathy), and Walking in Patient's Shoes (imaginative empathy). Total scores range 20–140. For preliminary international comparison, scores were categorized using original JSE validation study tertiles (Hojat et al., 2001): Low (≤85), Moderate (86–105), High (≥106).

Critical Measurement Validity Consideration

JSE cut-offs employed derived primarily from Western population validation studies. No Palestinian-specific JSE normative data existed at study time. This represents a substantial measurement validity limitation. Western-derived cut-off utilization decisions were made for enabling preliminary international literature comparison, but any “low” emotional empathy score interpretation must be considered preliminary and potentially reflective of cultural measurement non-equivalence. Specifically, the JSE was originally developed and validated with North American medical students and healthcare professionals (Hojat et al., 2001), raising important questions about its cross-cultural measurement equivalence in Palestinian and broader Middle Eastern contexts. Cross-cultural validity encompasses several psychometric dimensions, including conceptual equivalence (whether empathy is understood similarly across cultures), item equivalence (whether specific JSE items carry equivalent meaning in Arabic-speaking collectivist societies), scalar equivalence (whether the numeric scale points function identically), and normative equivalence (whether Western-derived tertile thresholds represent appropriate benchmarks for non-Western populations). The absence of established measurement invariance testing between Western and Palestinian samples means that direct score comparisons and threshold-based classifications should be interpreted with particular caution. Emotional expression norms, professional socialization patterns, and cultural scripts for caring differ substantially between the populations on which the JSE was normed and the Palestinian population studied here. What registers as “low” Compassionate Care on a Western-normed scale may reflect culturally adaptive, context-appropriate expressions of holistic caring rather than a genuine deficit in empathetic capacity. Readers should therefore interpret all threshold-based classifications in this study as preliminary and heuristic, intended to facilitate broad international comparison rather than to render definitive judgments about the empathetic capacity of Palestinian nursing students.

Data Collection Procedures

Following administrative coordination and in strict accordance with the copyright permission from Thomas Jefferson University for exactly 320 administrations of the JSE-HPS version, we distributed 320 paper questionnaires to participants at three universities. All 320 questionnaires were returned complete, yielding a 100% response rate with no missing data. Researchers remained present for answering procedural questions. Targeted recruitment was conducted within each year level until the quota of 80 students per year was achieved.

Ethical Considerations

Investigation was conducted according to Declaration of Helsinki principles. Ethical approval was obtained from Nablus University Institutional Review Board for Vocational and Technical Education (Approval Ref: Nrs. May 2025/5). Written informed consent was secured from all participants. Participation was voluntary and anonymous, with withdrawal rights at any time without consequences.

Data Analysis

Data were analyzed using SPSS version 21. Descriptive statistics characterized the sample and empathy scores by academic year. The Shapiro-Wilk test indicated significant departures from normality for all empathy scores (p < .05); therefore, non-parametric tests were selected as the more conservative analytical approach. No missing data were present in the final dataset, as all questionnaires were checked for completeness during collection. For two-group comparisons, Mann-Whitney U tests were employed; for comparisons across the four academic years, Kruskal-Wallis tests were used, with post-hoc Dunn's test and Bonferroni correction applied to identify specific inter-year differences. Effect sizes were calculated for non-parametric tests (r = Z/√N for Mann-Whitney; η² for Kruskal-Wallis). Relationships between JSE subscales and total scores were assessed using Spearman correlation (ρ). Multiple linear regression was used to identify predictors of total JSE scores; multicollinearity was assessed with Variance Inflation Factor (VIF), with a threshold of < 5.0 indicating no substantial collinearity. Internal consistency of the JSE and its subscales was evaluated using Cronbach's α. For preliminary cross-cultural comparison, continuous empathy scores were categorized using the original JSE validation tertiles (Low ≤85, Moderate 86–105, High ≥106), though we explicitly acknowledge potential cultural measurement non-equivalence. The threshold for statistical significance was set at p < 0.05.

All quantitative variables, including empathy scores and demographic data, were analyzed as continuous variables. No categorization was performed for analysis purposes, except for the preliminary cross-cultural comparison using established tertiles as described above. No sensitivity analyses were conducted, as the primary analyses were considered robust given the complete dataset and consistent measurement approach. A participant flow diagram was not included, as the sampling design was straightforward: all 320 distributed questionnaires were returned complete, yielding a 100% response rate with no exclusions or loss to follow-up. All analyses reported are unadjusted. No confounder-adjusted analyses were performed, as preliminary exploration revealed no substantial associations between potential confounders (demographic variables) and empathy outcomes. Results are presented as unadjusted means, medians, and effect sizes with 95% confidence intervals. No additional subgroup or interaction analyses beyond those reported were conducted. The analyses presented represent the complete set of statistical tests performed on the dataset.

Results

Reliability and Participant Characteristics

The Jefferson Scale of Empathy demonstrated acceptable internal consistency: JSE Total (Cronbach's α = 0.730), Perspective-Taking (α = 0.764), and Compassionate Care (α = 0.692). The Walking in Patient's Shoes subscale exhibited marginal reliability (α = 0.598).

The study included 320 participants with a balanced distribution across all four academic years (80 students per year, 25% each). The sample was predominantly female (74.7%) and aged 19–26 years (87.5%). Most participants (64.4%) had completed a dedicated oncology/palliative care course, and exposure to integrated palliative care content was reported by 59.7% of students (Table 1). All participants provided complete data for all variables; no missing data required imputation.

Table 1.

Participant Characteristics (n = 320).

Characteristic	Category	n	%
Gender	Male	81	25.3
	Female	239	74.7
Age Group	19–26 years	280	87.5
	27–34 years	26	8.1
	35–42 years	10	3.1
	43–50 years	4	1.3
Academic Year	First Year	80	25.0
	Second Year	80	25.0
	Third Year	80	25.0
	Fourth Year	80	25.0
University	A	158	49.4
	B	80	25.0
	C	82	25.6
Had Oncology Course	Yes	206	64.4
	No	114	35.6
Had Integrated Palliative Content	Yes	191	59.7
	No	129	40.3

Empathy Patterns and Cross-Cultural Comparison

The overall empathy level was moderate when classified using Western thresholds (JSE Total: M = 98.21, SD = 16.54, 95% CI [96.39, 100.03]). However, subscale analysis revealed a marked cognitive-emotional disparity. Students reported elevated cognitive empathy (Perspective-Taking: M = 58.92, SD = 11.35, 95% CI [57.67, 60.17]), classified as “High,” while their emotional empathy scores (Compassionate Care: M = 23.45, SD = 8.72, 95% CI [22.48, 24.42]) were substantially lower and classified as “Low” relative to Western norms (see Table 2).

Table 2.

Empathy Patterns with Cross-Cultural Comparison (n = 320).

Scale	Mean (SD)	95% CI	Range	α	Classification Per Western Thresholds
JSE Total	98.21 (16.54)	[96.39, 100.03]	20–140	0.730	Moderate
Perspective-Taking	58.92 (11.35)	[57.67, 60.17]	10–70	0.764	High
Compassionate Care	23.45 (8.72)	[22.48, 24.42]	8–56	0.692	Low
Walking in Patient's Shoes	7.85 (2.56)	[7.57, 8.13]	2–14	0.598	Moderate

Western classification based on Hojat et al. (2001); cultural validity questioned in Discussion.

Empathy Development Across Academic Years: A Critical Finding

Kruskal-Wallis tests revealed highly significant differences in empathy scores across the four academic years, with distinct developmental trajectories for cognitive versus emotional empathy dimensions, as detailed in Table 3. The post-hoc analysis for total empathy indicates that the significant overall difference is primarily driven by the substantial gap in scores between students in the earlier years (first and second) versus those in the later years (third and fourth), rather than by consecutive year-to-year changes.

Table 3.

Empathy Development Across Academic Years (n = 320).

Academic Year	Perspective-Taking Mean (SD) [95% CI]	Compassionate Care Mean (SD) [95% CI]
First Year	52.10 (9.85) [49.94, 54.26]	23.15 (8.40) [21.31, 24.99]
Second Year	56.25 (10.50) [53.95, 58.55]	23.40 (8.65) [21.49, 25.31]
Third Year	61.05 (11.20) [58.58, 63.52]	23.30 (8.95) [21.32, 25.28]
Fourth Year	66.35 (8.92) [64.39, 68.31]	23.95 (8.65) [22.04, 25.86]
Statistical Test	H(3) = 45.82, p < 0.001, η² = 0.141	H(3) = 2.14, p = 0.544, η² = 0.003

Note: JSE Total scores were First Year: 85.25 (15.20) [81.91, 88.59]; Second Year: 92.65 (16.10) [89.10, 96.20]; Third Year: 102.35 (16.85) [98.61, 106.09]; Fourth Year: 112.65 (17.40) [108.82, 116.48]; H(3) = 28.45, p < 0.001, η² = 0.086.

As illustrated in Figure 1, Perspective-Taking scores demonstrated substantial growth across the educational trajectory, increasing by 14.25 points from first to fourth year (27% improvement). In stark contrast, Compassionate Care scores showed minimal change, increasing by only 0.80 points over the same period. This divergent pattern resulted in a widening cognitive-emotional gap, which expanded from 29.0 points in the first year to 42.4 points by the fourth year.

Figure 1.

Developmental of Cognitive Empathy (Perspective-Taking) Versus Emotional Empathy (Compassionate Care) Across Four Academic Years of Nursing Education.

Associations with Demographic and Educational Factors

No statistically significant associations were found between empathy scores and gender or age (all p > 0.05). University affiliation showed significant but small-effect associations. The completion of a dedicated oncology/palliative care course showed no significant association with empathy scores. In contrast, students who reported encountering palliative care content within other clinical courses scored significantly higher in both Perspective-Taking (U = 8,942, p < 0.001, r = 0.45, large effect) and Compassionate Care (U = 8,401, p < 0.001, r = 0.48, large effect), as detailed in Table 4.

Table 4.

Compassionate Care Scores by Academic Year and Integrated Palliative Care Exposure.

Academic Year	Integrated Exposure (n = 191) M (SD) [95% CI]	No Integrated Exposure (n = 129) M (SD) [95% CI]
First Year	22.85 (8.35) [21.66, 24.04]	21.97 (8.45) [20.50, 23.44]
Second Year	23.25 (8.60) [22.02, 24.48]	21.89 (8.70) [20.38, 23.40]
Third Year	23.65 (8.90) [22.38, 24.92]	21.45 (8.95) [19.89, 23.01]
Fourth Year	24.12 (8.60) [22.89, 25.35]	21.42 (8.70) [19.91, 22.93]

Correlational and Regression Analysis

Spearman correlation analysis revealed strong positive relationships between all JSE subscales and the total score. The strongest correlation was between Perspective-Taking and the total JSE score (ρ = 0.94, p < 0.001). Multiple linear regression was used to predict the total JSE score from the three subscales. The model was statistically significant, F(3, 316) = 1142.8, p < 0.001, and explained 91.5% of the variance in total empathy (R² = 0.915). Perspective-Taking was the strongest predictor (β = 0.82, p < 0.001), followed by Compassionate Care (β = 0.16, p < 0.001) and Walking in Patient's Shoes (β = 0.05, p = 0.002). An important interpretive clarification is warranted here: because the JSE total score is arithmetically derived by summing its subscale scores, the very high R² (0.915) and the strong subscale-to-total correlations are in part a mathematical artifact of this compositional relationship rather than an independent empirical discovery. The regression should therefore be understood as a decomposition analysis that quantifies each subscale's relative weight within the composite, rather than as a conventional predictive model. The substantively meaningful finding is the relative dominance of Perspective-Taking (β = 0.82) over Compassionate Care (β = 0.16), which reflects the markedly higher item count and score range of the Perspective-Taking subscale (10 items, range 10–70) relative to Compassionate Care (8 items, range 8–56). This structural imbalance in the instrument itself partially explains why cognitive empathy emerges as the stronger driver of total scores and should be acknowledged as a limitation when interpreting the regression findings.

Discussion

This investigation's primary finding is a pronounced cognitive-emotional empathy imbalance among nursing students in a Middle Eastern resource-limited setting, with a critical developmental pattern: cognitive empathy increases systematically across the four-year educational trajectory while emotional empathy demonstrates remarkable stability. From a holistic nursing perspective, this imbalance reveals fragmentation in how nursing education cultivates the whole person, raising questions about spiritual dimensions of caring and implications for healing-centered practice. Interpreted through Watson's Theory of Human Caring, this imbalance represents more than a pedagogical gap—it signals a fundamental tension between the intellectualized model of empathy that formal nursing curricula tend to reinforce and the transpersonal, relationally present mode of caring that Watson identifies as the moral foundation of holistic nursing. Watson posits that genuine caring requires the nurse to enter into the patient's subjective life world with authentic emotional presence, not merely to understand it intellectually. The divergent developmental trajectories observed in this study suggest that Palestinian nursing education, as perhaps nursing education more broadly, is succeeding at the cognitive but not the transpersonal dimension of this vision. This contributes uniquely to holistic nursing scholarship by providing empirical evidence that the cognitive-emotional empathy gap is not merely a measurement artifact but a developmental pattern that widens across the educational journey, with implications for how holistic curricula worldwide should be sequenced and evaluated.

A Holistic Interpretation of Empathy Imbalance and Developmental Trajectory

The most striking finding is the divergent developmental trajectories of empathy dimensions. Perspective-Taking scores increased by 27% from first to fourth year, demonstrating that nursing education effectively cultivates cognitive empathy. In stark contrast, Compassionate Care scores showed negligible change across the four years, remaining consistently in the “low” range by Western standards.

From a holistic nursing perspective, this pattern suggests that while cognitive skills are systematically developed, emotional and possibly spiritual dimensions of empathy are not similarly nurtured. The widening cognitive-emotional gap across academic years reflects curriculum design choices that prioritize intellectual understanding over emotional and spiritual engagement. This imbalance contradicts holistic nursing principles that emphasize harmonious development of all dimensions of human caring (American Holistic Nurses Association, 2019).

The regression analysis, which identified Perspective-Taking as the overwhelmingly dominant driver of total empathy scores (β = 0.82), further confirms that students’ self-concept of empathy is rooted primarily in intellectual understanding rather than balanced emotional-spiritual engagement. This finding suggests clear intervention points for educational reform aligned with holistic nursing values. It is important to note, however, that this regression finding should be interpreted with methodological caution: because the JSE total score is computed by summing its subscales, the high explanatory variance (R² = 0.915) and the dominance of Perspective-Taking partly reflect the compositional structure of the instrument and the greater item count and score range of the Perspective-Taking subscale (10 items, range 10–70) relative to Compassionate Care (8 items, range 8–56). The educational inference that cognitive empathy dominates students’ overall empathy profile is nonetheless valid and substantively meaningful, but the regression coefficient magnitudes are influenced by instrument design as well as true differences in empathetic development.

Cultural Measurement Validity Through a Holistic Lens

Before interpreting “low” emotional empathy scores as deficits, the cultural and spiritual validity of measurement tools must be scrutinized through a holistic lens. The classification stems from cut-offs derived from Western populations, which may not account for culturally distinct expressions of holistic caring.

In Palestinian culture, as in many collectivist societies, professional strength and resilience are often demonstrated through emotional restraint, practical problem-solving, and spiritual fortitude rather than overt emotional display (Dwairy, 2006; Giacaman et al., 2011). What Western instruments code as “low emotional empathy” may reflect culturally normative emotional regulation or different spiritual expressions of caring, a pattern increasingly noted in cross-cultural health research (Soleimani & Yarahmadi, 2023).

The collective experience of chronic adversity has fostered specific resilience mechanisms within Palestinian society (Afana et al., 2010; Giacaman et al., 2011). Cultural narratives emphasizing “endurance” and tangible support may manifest as strong cognitive, problem-solving orientation alongside measured emotional expression—protective coping strategies potentially misinterpreted by existing scales.

The stable emotional empathy scores across all four years, despite increasing clinical exposure to suffering, may represent an adaptive form of “compassionate detachment” among students anticipating careers in high-stress environments (Figley, 2002; Klimecki & Singer, 2012). This phenomenon is well-documented among oncology professionals worldwide who develop emotional regulation strategies to prevent burnout (Labrague et al., 2019). However, from a holistic perspective, the crucial question remains whether this represents healthy professional boundary-setting or problematic emotional disengagement that limits healing potential.

Situated Learning and Integrated Curricula: A Holistic Pedagogical Approach

One of the most promising findings is the strong association between palliative care content integrated into clinical courses and significantly higher empathy scores, with large effect sizes for both cognitive and emotional dimensions. This aligns strongly with Situated Learning Theory (Lave & Wenger, 1991) and holistic nursing pedagogy, which posit that caring competencies are most effectively acquired within relevant, authentic contexts.

When empathy and palliative care concepts are woven into clinical courses, they become immediately relevant to holistic practice. Students can directly perceive how understanding a patient's perspective is critical to managing symptoms or providing spiritual support. In contrast, standalone courses risk presenting empathy as an abstract value disconnected from clinical practice. Recent pedagogical studies support this integrated approach, showing that contextually embedded ethics and communication training lead to more durable skill development (Horta Reis da Silva, 2025).

The stability of emotional empathy across years suggests that current educational approaches, including standalone courses, are insufficient for holistic development. Integrated content that repeatedly reinforces emotional and spiritual skills throughout the curriculum may be necessary to sustain and develop compassionate care capacities alongside technical competencies.

Implications for Holistic Oncology Nursing Preparation

The identified empathy imbalance and its developmental pattern hold profound significance for preparing nurses for oncology through a holistic lens, a specialty that demands balanced, whole-person empathetic capacity.

The necessity of holistic balance is clear: cognitive empathy enables nurses to navigate complex treatment decisions, while emotional and spiritual empathy are vital for managing grief, alleviating existential distress, and preserving dignity at the end of life (Treglia, 2020). A nurse might understand a patient's fear of death cognitively but requires emotional-spiritual empathy to be compassionately present with that fear. In the Palestinian oncology and palliative care context specifically, this gap carries heightened urgency. Palestine faces severe shortages of specialized oncology and palliative care services, meaning that general ward nurses frequently encounter patients experiencing advanced cancer, end-of-life distress, and grief without the support of specialist teams (World Health Organization, 2023). In this environment, the capacity for genuine emotional-spiritual presence is not a supplementary quality but a clinical necessity. Graduating nurses who possess strong cognitive empathy but underdeveloped emotional empathy may be intellectually prepared to understand patient needs but relationally under-equipped to provide the compassionate, whole-person presence that patients and families value most in end-of-life care. Educational programs preparing nurses for Palestinian and similar resource-constrained oncology contexts must therefore give explicit, sustained attention to cultivating emotional resilience, compassionate presence, and spiritual sensitivity as core clinical competencies alongside technical knowledge. Furthermore, the finding that integrated palliative care content—rather than standalone courses—is associated with stronger empathy across both dimensions offers a concrete, actionable lever for educational reform that extends beyond the Palestinian context to holistic nursing education internationally.

The developmental trajectory revealed in this study suggests that graduating nurses may be progressively better equipped for the intellectual demands of oncology care but no better prepared for its profound emotional-spiritual challenges than they were upon entering nursing school. This pattern is particularly concerning given evidence that emotional empathy, not cognitive empathy, predicts compassionate behaviors and patient satisfaction in palliative care contexts.

The observed pattern of “compassionate detachment” may represent a double-edged sword for holistic oncology nursing. While emotional stability could protect against burnout, it may simultaneously limit the depth of therapeutic presence that patients value most during end-of-life care. This tension between self-protection and patient-centered compassion requires explicit acknowledgment and skillful navigation in holistic oncology education. Holistic oncology nursing education must therefore help students to distinguish between adaptive professional boundary-setting—which preserves the nurse's capacity for sustained caring by preventing empathic overwhelm—and maladaptive emotional disengagement, which diminishes the quality of relational presence and ultimately impoverishes the patient's experience of care. Curricula grounded in Watson's caritas framework can provide students with the conceptual vocabulary and reflective tools to navigate this distinction consciously, developing what Klimecki and Singer (2012) describe as compassion—a concern-based motivation to alleviate suffering—rather than empathic distress, which is emotionally overwhelming and unsustainable. This nuance is particularly important in Palestinian oncology and palliative care contexts, where nurses routinely encounter collective as well as individual suffering, and where culturally-grounded resilience strategies may be essential for sustaining compassionate practice over a career.

Holistic Educational Recommendations: An Integrated Framework

To transform the identified cognitive-emotional-spiritual empathy gap into balanced whole-person competency, nursing education must adopt deliberate, sustained, and integrated interventions. Emotional-spiritual empathy does not develop incidentally through clinical exposure; it requires intentional pedagogical cultivation woven throughout the educational journey. Our recommendations form a cohesive framework, synthesized in Table 5, that aligns specific educational deficits with holistic nursing principles and actionable strategies.

Table 5.

A Holistic Framework for Transforming Empathy Education.

Deficit Identified	Holistic Principle Applied	Recommended Educational Strategy
Cognitive-Emotional Gap	Mind-Body-Spirit Integration	Implement a spiraled curriculum that intentionally integrates cognitive, emotional, and spiritual empathy dimensions across all academic years within clinical contexts.
Emotional Empathy Stability	Self-Care & Resilience	Embed mindfulness training and structured reflective practice throughout the curriculum to develop self-awareness, emotional regulation, and personal resilience.
High Stress at Clinical Transition	Support for the Whole Person	Provide targeted emotional-spiritual resilience training and enhanced mentorship during critical transitions, particularly at the onset of intensive clinical rotations in the second year.
Cultural Measurement Bias	Cultural Humility & Relevance	Develop and validate culturally-grounded assessment tools and pedagogies that respect local norms while strengthening holistic empathetic capacity.
Risk of Compassion Fatigue	Sustainable Compassion	Implement explicit, parallel training in compassion resilience alongside clinical skill development across all four years to prevent burnout and sustain caring capacity.

First and foremost, a spiraled holistic curriculum must replace fragmented empathy training. This involves systematically integrating empathy education across all academic years, intentionally weaving together cognitive perspective-taking, emotional resonance, and spiritual presence within authentic clinical learning contexts. Such curricular redesign ensures that empathy is not a standalone topic but a thread running through every clinical decision and patient interaction.

Parallel to this, mindfulness and reflective practice must be embedded as foundational pedagogical tools. These practices cultivate the essential self-awareness and emotional regulation skills that underpin sustainable empathy. By creating regular opportunities for students to reflect on their emotional responses and spiritual insights in clinical settings, educators can foster the inner stability necessary for compassionate engagement.

Particular attention must be paid to critical transition points, especially the shift to intensive clinical rotations in the second year. Targeted emotional-spiritual resilience training during these periods can provide students with adaptive coping tools, preventing the maladaptive emotional distancing observed in our study and promoting healthy professional boundary-setting.

Furthermore, pedagogical approaches must be designed with cultural-spiritual integration at their core. This means moving beyond Western-centric models to develop teaching methods that respect local norms of emotional expression and spiritual care, while still deliberately strengthening students’ capacity for holistic empathetic connection. This approach honors cultural context while expanding empathetic repertoire.

Finally, to safeguard the well-being of future nurses, explicit compassion resilience training should run parallel to clinical skill development across the entire program. This proactive training in self-care, meaning-making, and peer support is essential to prevent burnout and sustain the empathetic engagement required for true healing-centered practice, particularly in demanding fields like oncology.

Study Limitations and Future Holistic Research Directions

This study has several limitations that inform future holistic research directions. Although the stratified sample enabled robust developmental analysis, convenience sampling within strata may introduce selection bias. The reliance on Western-derived JSE thresholds raises significant cultural-spiritual validity concerns, as “low” scores may reflect measurement non-equivalence rather than true empathetic deficits. Furthermore, the measurement of integrated palliative care exposure relies on student self-report via a single yes/no question, lacking objective validation through curriculum analysis. The cross-sectional design precludes causal inference about educational impact, and the marginal reliability of the Walking in Patient's Shoes subscale limits conclusions about imaginative empathy. Regarding response patterns, non-response analysis was not possible because no demographic data were available for non-participants; therefore, we cannot determine whether students who declined participation differed systematically from those who enrolled, and the potential direction or magnitude of any non-response bias remains unknown. To advance holistic understanding, future research should prioritize: longitudinal studies to establish causal relationships in empathy development; cultural validation of empathy measures through mixed-methods approaches that combine quantitative scales with qualitative inquiry; dedicated investigation of the spiritual dimensions of empathy in nursing education, which remain underexplored; intervention trials testing the efficacy of integrated, holistic curricula; and global comparative studies to distinguish universal developmental patterns from culturally-specific expressions of caring. Additional limitations merit explicit acknowledgment in the spirit of full methodological transparency. The unadjusted nature of all analyses means that potential confounding by unmeasured variables—including prior healthcare exposure, family background in nursing, or personal experience of bereavement—cannot be ruled out. Social desirability bias is a recognized concern with self-report empathy measures; students may have responded in ways they believed were professionally expected. The three sampled universities, while geographically distributed across the West Bank, may not represent the full diversity of Palestinian nursing programs, and the exclusion of Gaza-based institutions is a notable gap given the distinct adversity context there. No qualitative data were collected to illuminate students’ lived experience of empathy development, leaving important questions about subjective meaning unanswered. Future holistic research should additionally explore the role of spirituality and religious coping as distinct dimensions of empathetic caring in Muslim-majority nursing populations, where these factors are likely to be particularly salient influences on how care relationships are understood and enacted.

Conclusion

This study identified a marked cognitive-emotional empathy imbalance among nursing students in a Middle Eastern resource-limited setting, with cognitive empathy increasing systematically while emotional empathy demonstrated remarkable stability across all academic years. This core finding raises critical questions with holistic implications: Do Western empathy norms account for spiritual dimensions of caring? Might patterns deemed “low” in one context represent culturally adaptive holistic expressions? Why does nursing education successfully cultivate cognitive empathy while underdeveloping emotional-spiritual dimensions?

We propose that the observed pattern reflects: (1) culturally distinct holistic expressions of empathy potentially misclassified by Western-normed instruments, (2) adaptive coping mechanisms in high-stress contexts where emotional-spiritual regulation is prioritized, and (3) gaps in educational emphasis where curricula systematically develop cognitive skills while neglecting emotional-spiritual capacity building.

The strong association between integrated palliative care content and higher empathy scores offers a promising, theory-grounded avenue for holistic educational innovation. For global nursing education, these findings underscore the urgent need to move beyond one-size-fits-all approaches in both measurement and pedagogy. Preparing a compassionate, effective, and resilient nursing workforce, especially for oncology care, requires culturally-sensitive, contextually-appropriate holistic strategies for developing this essential clinical competency.

Future research must build upon these insights through cultural validation studies, longitudinal investigations, and intervention trials testing whether integrated, spiraled holistic education can promote balanced cognitive-emotional-spiritual development. Only through such rigorous investigation can we translate these findings into evidence-based educational practice that prepares nurses capable of delivering intellectually competent, emotionally resonant, and spiritually attuned care across diverse global contexts. The contribution of this study to holistic nursing scholarship is threefold. First, it provides empirical evidence from a non-Western, resource-limited context that the cognitive-emotional empathy imbalance is not a static measurement artifact but a developmental pattern that widens progressively across the nursing education trajectory—a finding with direct implications for when and how holistic nursing curricula should intervene. Second, it advances theoretical understanding by situating this imbalance within Watson's Theory of Human Caring, demonstrating that the gap between cognitive empathy development and emotional-spiritual empathy stagnation reflects a broader tension between intellectualized and relational-presence models of nursing that holistic educators must actively address. Third, it raises a methodological challenge for holistic nursing research globally: the dominant measurement tools available for assessing empathy were developed in and normed on Western populations, and their cross-cultural validity in non-Western settings remains insufficiently examined. Holistic nursing scholarship must prioritize the development of culturally-grounded, spiritually-inclusive assessment tools if it is to accurately capture the full range of empathetic caring across diverse global nursing populations.

Implications for Holistic Nursing & Health Policy

The findings of this study necessitate a series of policy reforms aligned with holistic nursing principles to cultivate a resilient and compassionate workforce. First, educational policy must formally mandate empathy as a core holistic competency, ensuring curricula deliberately cultivate emotional-spiritual skills through spiraled design and reflective practice. Second, to ensure workforce sustainability, particularly in high-stress fields like oncology, mandatory compassion resilience training and structured reflective practice must be embedded from foundational education into ongoing professional development. Third, health systems bear responsibility to prioritize palliative care competencies for all nurses and to establish hiring and promotion standards that explicitly value balanced, holistic empathy. Fourth, at the level of international standards, nursing accreditation and educational bodies must support the development and validation of culturally-sensitive assessment tools, moving beyond Western norms that may misrepresent empathetic capacity in diverse global contexts. Finally, immediate, actionable steps include conducting comprehensive curriculum audits, systematically integrating reflective practice into all clinical courses, and implementing peer support mechanisms to actively foster the development of holistic emotional-spiritual skills.

Supplemental Material

sj-doc-1-jhn-10.1177_08980101261447439 - Supplemental material for Holistic Empathy Development in Palestinian Nursing Students: A Cognitive-Emotional Analysis with Implications for Oncology Care

Supplemental material, sj-doc-1-jhn-10.1177_08980101261447439 for Holistic Empathy Development in Palestinian Nursing Students: A Cognitive-Emotional Analysis with Implications for Oncology Care by Jameela Taleb, Ibrahim Aqtam, Mustafa Shouli, Yara Salahat, Saja Ismail, Raya Mohammad and Dania Haloub in Journal of Holistic Nursing

Footnotes

Acknowledgments

The authors wish to express their sincere gratitude to the nursing students who generously participated in this study. We also extend our appreciation to the participating universities for facilitating data collection. We thank Nablus University for Vocational and Technical Education for supporting this research and Thomas Jefferson University for granting permission to use the Jefferson Scale of Empathy.

ORCID iDs

Ibrahim Aqtam

Mustafa Shouli

Ethical Considerations

This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was granted by the Institutional Review Board of Nablus University for Vocational and Technical Education (Approval Ref: Nrs. May 2025/5).

Consent to Participate

Written informed consent was obtained from all individual participants included in the study.

Consent for Publication

Not applicable. This manuscript does not contain any individual person's data in any form.

Author Contributions Statement

TALEB, Jameela: Conceptualization, Methodology, Data Curation, Writing – Original Draft, Project Administration.

AQTAM, Ibrahim: Conceptualization, Methodology, Formal Analysis, Supervision, Writing – Review & Editing, Corresponding Author.

SHOULI, Mustafa: Methodology, Data Curation, Validation, Writing – Review & Editing.

SALAHAT, Yara: Investigation, Data Curation, Writing – Review & Editing.

ISMAIL, Saja: Investigation, Data Curation, Writing – Review & Editing.

MOHAMMAD, Raya: Investigation, Data Curation, Writing – Review & Editing.

HALOUB, Dania: Investigation, Data Curation, Writing – Review & Editing.

All authors have reviewed and approved the final version of the manuscript.

Funding Statement

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets generated and analyzed during the current study are not publicly available to protect participant confidentiality but are available from the corresponding author upon reasonable request, subject to ethical and data protection approvals.

Supplemental Material

Supplemental material for this article is available online.

Jameela Taleb, RN, MSN, is a nursing educator at Ibn Sina College for Health Professions, Nablus University for Vocational and Technical Education, Palestine. Her area of research is holistic nursing education, empathy development in nursing students, and oncology nursing care in resource-limited settings.

Ibrahim Aqtam, RN, PhD, is a nursing educator and researcher at Ibn Sina College for Health Professions, Nablus University for Vocational and Technical Education, Palestine. His area of research is nursing education, empathy development, cross-cultural validation of healthcare instruments, and holistic approaches to patient care in Middle Eastern contexts.

Mustafa Shouli, MSN, PhD, is a nursing educator at Ibn Sina College for Health Professions, Nablus University for Vocational and Technical Education, Palestine. His area of research is nursing education, clinical competency development, and palliative care training in undergraduate nursing programs.

Yara Salahat, RN, is a nursing graduate and research assistant at Ibn Sina College for Health Professions, Nablus University for Vocational and Technical Education, Palestine. Her area of research is empathy in nursing practice, patient-centered care, and emotional intelligence development among nursing students.

Saja Ismail, RN, is a nursing graduate and research assistant at Ibn Sina College for Health Professions, Nablus University for Vocational and Technical Education, Palestine. Her area of research is compassionate care, nursing student well-being, and the development of emotional empathy in clinical training environments.

Raya Mohammad, RN, is a nursing graduate and research assistant at Ibn Sina College for Health Professions, Nablus University for Vocational and Technical Education, Palestine. Her area of research is holistic patient care, cultural influences on empathy expression, and nursing education in collectivist societies.

Dania Haloub, RN, is a nursing graduate and research assistant at Ibn Sina College for Health Professions, Nablus University for Vocational and Technical Education, Palestine. Her area of research is emotional resilience in nursing students, compassionate care delivery, and the integration of palliative care principles into undergraduate nursing curricula.

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