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Introduction
According to studies in healthcare, empathy is a special psychological resource, due to its effects on patients and medical personnel, through the establishment of personal relationships and improved patient communication [1]. Empathy is a notion that was brought to medicine in the 1980s and is now observed as an essential skill for medical personnel [2]. After conducting a systematic review, in nurses who show empathy [3], the patients’ levels of anxiety and discomfort are reduced; additionally, the ability of nurses to empathize helps them to understand the requirements that patients perceive. For these reasons, the significance of developing an empathetic relationship with patients and fundamental communication skills remains emphasized to nursing students in undergraduate programs [4]. Empathy is a type of social feeling that is frequently influenced by the surrounding environment, since the family is the primary setting for socialization in childhood, parental rearing has an certainly significant and long-lasting impact on how a child develops both their personality and their capacity for thought [2]. The term parental rearing styles was initially created by Schaefer in the 19th century. He suggested four parental styles as follows: Authoritarian (affective coldness/high control), authoritative (high warmth/low control), overprotective (high warmth/high control), and neglecting (affective coldness/low control) [5]. Parenting style can be considered a collection of attitudes, objectives, and child-rearing practices that form the emotional climate of the parent-child connection and remain constant across a variety of life situations [6]. Much research has shown that a person’s family of origin might have an impact on the level of empathy in an adult, a significant element influencing adult empathy is the poor parenting of preadolescents [7]. According to certain research, parenting styles may have a varied impact on emotional and cognitive empathy, which categorize empathy additionally, these results demonstrate that probably parenting styles are more associated with affective empathy, that strong prosocial conduct was associated with active empathy in children, and that these children had more supportive parents [8]. 
Only a few investigations have been conducted on how parental education and empathetic behavior affect the teaching hospital nurses in Iraq. Therefore, this study assesses nurses’ level of empathy and its relationship to parenting practices.

Materials and Methods 

Study design
In this study, the researchers used a descriptive-correlation design because of its suitability with the study goals to investigate the relationship between parental styles and empathy among nurses working at teaching hospitals in Kerbala City, Iraq. The study period was from September 26, 2022, to June 14, 2023. 

Study setting
The data were collected from academic nurses who worked in four teaching hospitals in Kerbala City, Iraq (Kerbala Teaching Hospital for Children and Obstetrics, Al-Imam Al–Hussian Medical City, Al-Imamul, Hassan Al-Mujtaba Hospital, and Gynecology Teaching Hospital). The target population was 335 academic nurses working in four teaching hospitals in Kerbala City, Iraq. 

Sample size and methods
A purposive (non-probability) sample of 180 nurses was selected according to specific inclusion criteria. The inclusion criteria comprised academic nurses with bachelor’s degrees in nursing, working in various departments of the four main hospitals, providing direct nursing care to patients, and working in the morning and night shifts.
The sample size was estimated according to the Soper sample calculator [9]. The predicted effect size was 0.5, the desired statistical power level was 0.8, and the probability value was set at 0.05. The minimum sample size was 128 academic nurses, considering the possibility of incomplete or non-responses from the participants. The researchers selected a sample of 180 academic nurses to get more representation of the sample population and get more accurate results. 

Study instruments
The researchers used an instrument consisting of three parts: Demographic information data, the parental authority questionnaire, and the Jefferson scale of empathy physician/health professions (HP–version).

Demographic data
The socio-demographic sheet included questions on nurses’ age, gender, marital status, work shift, job desire, monthly income, hospital, and years of experience. 

Parental authority questionnaire
A short version of the parental authority questionnaire was used [10]. The short version of this scale was used in the current study based on a prior study [11]. It includes 30 items, namely 15 items for the father and 15 items for the mother covering three dimensions of parental styles. The authoritative style which was investigated by 5 items [1, 3, 6, 9, 12]. The permissive style was assessed with 5 items [4, 8, 11, 13, 14], and the authoritarian style was examined with 5 items [2, 5, 7, 10, 15]. The scale has two identical images, one of which measures the mother’s treatment style, and the other measures the father’s treatment style from the sons’ point of view. The response was scored based on a Likert scale as follows: Strongly disagree, disagree, neutral, agree, strongly agree.

Jefferson scale of empathy physician/health professions
The Jefferson scale of empathy physician/health professions was developed by Bakrey. in 2019 [11], and the researchers examined the data worth, scale assumptions, and reliability through the international quality of life assessment. The scale was translated into Arabic and was applied in this study. The Jefferson scale of empathy physician/health professions is a 20-item tool that is precisely developed to estimate empathy in the context of health careers education and patient care for administration to health careers students and general practitioners. Items are responded based on a 7-point Likert scale (from 1=strongly disagree to 7=strongly agree), in which, 10 items are immediately scored and favorably written. The remaining 10 items are negatively expressed (reverse scored) [14]. The range of possible scores is from 20 to 140. Higher mean scores indicate a greater level of self-reported empathy. The Arabic translation of the questionnaire was done in light of a previously published Arabic study [11].

Validity of the questionnaire
To make the instrument more valid, it was presented to a panel of experts [16, 17] (they had more than 10 years of practice) in the different fields related to the study title. Changes and modifications were made based on the experts’ suggestions and recommendations to best fit to nursing sample. Item 6 of the Jefferson scale of empathy was modified since people are diverse, it is hard for the researcher to see matters from the patients’ viewpoints because people are different.

Pilot study
A pilot study was done before data collection to determine the study instrument’s reliability. It was applied to [18] academic nurses working in the four main hospitals. They complete the forms before conducting a full-scale study. The average time taken to complete the form was 15-20 min which was considered acceptable. The pilot study was conducted from December 21st, 2022, to 25th December 2022. the sample of the pilot study was excluded from the original study. 

Reliability of the instrument
The Cronbach α coefficients were used to test the reliability of the current study instrument. The result of the test showed acceptable and demonstrated construct validity. The Cronbach α was 0.70 for the Jefferson scale of empathy and 0.70 for the parental authority questionnaire. In addition, the statistical analyses included an intraclass correlation coefficient to evaluate the study’s methodology, and the intraclass correlation coefficient value was sufficiently dependable (0.77).

Data collection
The self-administer scheme was utilized by asking the applicants to fill in the format of the inquiry form and fulfill the requests. Then the researchers explained the purpose of the study in a simple way to the nurse. An agreement of participation was obtained from the academic nurse before the interview. 

Data analysis
The data were analyzed and interpreted via the SPSS software, version 22. The quantitative features were represented by numbers and percentages. To assess the correlations between the study variables, the Spearmen Correlation Coefficient was used. The P=0.05 was considered statistically significant.

Results
The age group of 26-30 years was abundant (50.0%) among the nurses followed by the age group of ≤25 years (37.8%). Meanwhile, 52.8% of the participants were female and 52.2% of the nurses were married. The majority of the nurses had morning work shifts. A total of 89.4% of the nurses had a good job desire, with a sufficient monthly income in most of them (64.4%) (Table 1).



Table 2 demonstrates the parenting style (father and mother). The average total means indicate that nursing staff face a moderate level of authority (father and mother), besides a lower level of both permissive and authoritarian parenting styles. 



A total of 60% of nursing staff have a low level of empathy, and the average total means also specify a low level of empathy among the nursing staff (mean=59.2) (Table 3).



There was a highly significant correlation between the father’s and mother’s parenting style and the nurse’s empathy (Table 4).



Table 5 shows no significant relationship between nurses’ empathy and their age, gender, marital status, work shifts, monthly income, and years of experience at P>0.05, except for their job desire, the results show a significant relationship with the empathy of the nurses at P<0.05.



Discussion 
The average number of nurses face a moderate level of authoritative style (father and mother). There was a low level of both permissive and authoritarian parenting styles. This finding is consistent with another study [11] that found both parents’ authoritative parenting techniques to be of a moderately high standard. Concerning the assessment of empathy, the study indicated that nurses have a low degree of empathy, which was in life with another researcher who found that the lower the level of empathy, the higher the academic year of the student [13]. As well, another research investigation demonstrated that, except for nursing students, paramedic students had statistically worse results for empathy [14]. 
The outcomes of the present survey, on the other hand, differ from the results of a study by Williams et al. that observed the empathy levels in nursing, undergraduate emergency health, and midwifery students and found that midwifery students had higher empathy levels than emergency health and nursing students [15]. Additionally, a study testing occupational therapy students’ empathy at a Spanish institution revealed that these students demonstrated a high level of empathy [16].
The discrepancy in results may be explained by the various study tools, study samples, or population. Several authors discussed barriers to nurses acting empathically, including time constraints, shift work, difficult interactions with patients, carers, and coworkers, workload, deadline pressures, and competitiveness [17]. 
Regarding correlation between the parenting styles and empathy, the current study indicates a highly significant relationship between the father’s and mother’s parenting styles (authoritative, permissive, and authoritarian dimensions) and empathy. The present study findings are in line with the study conducted by other researchers [19] that demonstrated authoritative parenting was favorably correlated with empathy, which was in line with our expectations; nevertheless, no significant correlations between empathy with permissive, authoritarian, or neglectful parenting were discovered. In addition, a study conducted by [20] revealed authoritative parenting practices are positively associated with empathy, according to the relationship between nurses’ empathy and their demographic data. 
Our results found no significant association between nurses’ empathy and their age, gender, marital status, work shifts, monthly income, and years of experience, except for their job desire, the study results indicate a significant relationship with the nurses’ empathy. The present study findings are in line with another study [18] which concluded that there are no relationship was found between the levels of empathy and age, marital status, total period of employment in nursing, and shift work. Also, another study [21] shows no found in the association between marital status and job experience. 
In addition, the results of a study [22] showed a non-significant difference in nurse empathy was found for age, gender, and marital status. In the same line, a previous study [23] showed no significant relationship between age, gender, marital status, type of shift work, work experience, and empathy. There is a study [24] whose results demonstrated a significant correlation between empathy and household monthly income; this finding is in contrast with our present study. In addition, a study [25] reported that empathy scores were significantly associated with household income. 
Regarding job desire, the current study demonstrated a significant relationship with nurse empathy. Empathy was significantly and negatively correlated with job satisfaction in other studies [1]. These outcomes are in line with our study. 
The study acclaims parents in general and mothers especially use the authoritative style, which has a positive effect on increasing empathy [26, 27] and is a style that is considered to be more beneficial and most optimal parenting style, also recommends preparing awareness programs through various media for parents about instructed in the best positive style that must be followed and negative style that must be avoided in rearing children and importance of parental styles because of its impact on their lives and jobs in the future.

Conclusions 
The parenting style of both fathers and mothers is associated with empathy among nurses and job desire may be an important factor that is related to nurses’ empathy. Further, well-designed larger studies are recommended about parenting styles and their relation to empathy among nurses. 

Ethical Considerations

Compliance with ethical guidelines
The College of Nursing/University of Karbala has independently examined the study protocol and granted official clearance for the study to be carried out (Code: IRB: CN-2022-0043-MN). After receiving the study’s title and questionnaire, the College of Nursing’s Ethics Committee evaluated the study’s instruments (questionnaire) and approved the conduct of the study. The Declaration of Helsinki was followed throughout the entire study protocol.

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

Authors' contributions.
Investigation, data collection, data collection and writing the original draft: Zahraa Mahdi Abd Ali; Conceptualization: Safi Dakhil; Final approval: All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors express their appreciation for the hospital’s administrative and nursing staff, parents, and participating nurses for their kind support.




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