Development and Preliminary Validation of the Planetary Empathy Scale: An International Study

Abstract

(1) Background: Planetary empathy includes deep reflection on one’s relationship with nature, curiosity about other worldviews, and an assumption of responsibility for creating a healthier and more equitable world for current and future generations. (2) Purpose: This paper presents a study that aimed to develop and conduct preliminary validation of the Planetary Empathy Scale for healthcare professionals. (3) Methods: The Planetary Empathy Scale was developed based on a concept analysis and preliminary validation was conducted in accordance with COSMIN guidelines. Data from 231 healthcare students and professionals informed item analysis. Cronbach’s alpha, known-groups comparisons, and exploratory factor analysis were used to assess reliability and validity. (4) Results: Initial psychometric testing supported a six-factor structure representing distinct yet interrelated dimensions of planetary empathy. The Scale demonstrated adequate structural validity, internal consistency, and construct validity. (5) Conclusions: The Planetary Empathy Scale proved to be a valid and reliable instrument. Participants had generally high levels of planetary empathy. Further psychometric testing with diverse cohorts is recommended.

1. Introduction

Planetary health is a “solutions-oriented, transdisciplinary field and social movement focused on analyzing and addressing the impacts of human disruptions to Earth’s natural systems on human health and all life on Earth” [1]. Climate change, pollution, deforestation and biodiversity loss are presenting escalating threats to the health of the planet [2]. Sustainable practices and policies are needed to safeguard the health of current and future generations. Yet, despite scientific and technological innovations, economic investments, legislative changes and varying levels of political resolve, the systemic transformations necessary to address these critical challenges remain inadequate [3]. One contributing factor may be the dominant framing of these challenges as passive forces acting upon humanity, while neglecting the internal human dimensions. To date, solutions have largely focused on external systemic and socio-economic reforms, including innovations in technology and infrastructure aimed at decarbonization to mitigate the effects of climate change [4]. However, these strategies alone will not limit global warming, nor will they adequately address the interconnected planetary crises facing society [5]. In this paper, we argue for a complementary approach that addresses inner transformations in addition to systemic changes, a view that is particularly important for healthcare professionals who have a critical role in environmental stewardship.

Previous studies have identified that people who are highly connected to nature are 72 times more likely to engage in pro environmental behaviours than people with low levels of nature connectedness [6]. The Intergovernmental Panel on Climate Change (IPCC) report [7] advocates for new paradigms that support human-nature connectedness and inner transformations to support virtuous cycles of change. This includes shifts in personal values and belief systems that motivate pro-environmental behaviours at both individual and collective levels. Such psychological shifts include relational capacities such as empathy, as well as individuals’ values, beliefs, worldviews and motivations with regards to the natural environment [8]. This view is supported by the Lancet Commission, who asserts that a lack of empathy is a core factor underlying the current widespread ecological and societal crises [9].

The tendency to seek connections with nature and other living things, often referred to as biophilia, has been described as a key transformative quality and deep human need [10]. It has also been suggested that positive affective responses to natural environments may have an evolutionary basis as humans have always been dependent on natural resources such as water, vegetation and shelter for survival [11]. Connectedness to and empathy for nature is associated with both psychosocial, physical and spiritual wellbeing, as well as pro-environmental attitudes and behaviours [12,13].

It should be noted that concepts such as ‘Caring for Country’ ecological responsibility and empathy for the environment are not new ideas [14]. For millennia, Indigenous peoples have recognised the interconnectedness of humans, nature, the environment and the planet as core values [15]. Nevertheless, contemporary social structures, particularly in the Global North, have often failed to acknowledge Indigenous wisdom, privileging individualism over collectivism and prioritising economic growth over ecological resilience [16]. These orientations have contributed to the environmental crisis we now face [17].

The São Paulo Declaration on Planetary Health [18], issued by the Planetary Health Alliance in 2021 and endorsed by global partners, is a global call to action to safeguard the health of humanity and the natural systems on which it depends. It outlines commitments across sectors to catalyze the “Great Transition” toward a just, sustainable, and healthy future. In the guidance for the health sector, the Declaration calls for transforming health systems to become climate-resilient, low-carbon, and nature-positive as well as integrating planetary health principles into education, clinical practice, and research. It urges healthcare professionals and institutions to reduce environmental footprints, advocate for policies that protect both human and ecological wellbeing and leverage their trusted role to communicate the health benefits of protecting the planet [18].

Empathy can be defined as a sensitivity and commitment to alleviate human suffering [19]. Environmental empathy refers to feelings of concern and a desire to ease the suffering experienced by nature, particularly in the context of environmental destruction [20]. Environmental empathy shapes how people perceive and respond to environmental issues [21]. Planetary empathy extends beyond empathy for humans or for the environment. It represents a more expansive and integrative mindset that recognises the interdependence of all life forms and the systems that sustain them [22]. Planetary empathy includes not only concern for the suffering of the environment but also people living now and into the future. This perspective encourages the adoption of practices that are ecologically sustainable and socially equitable, recognising the intricate linkages between the health of individuals, communities, and the planet. In essence, planetary empathy embraces a worldview that values interconnection, justice, and sustainability as inseparable priorities. In a recent concept analysis [22], planetary empathy was further elucidated as

“… a cyclical process that begins with deep reflection on our intrinsic interconnection with nature, and our knowledge, beliefs and values about planet Earth. It includes a reciprocal relationship with nature that values mutually beneficial ways of living. Integral to planetary empathy is a recognition of how implicit biases can affect our ways of knowing, being and doing, and the courage to be open to and curious about other worldviews. Planetary empathy includes assumption of responsibility for creating a healthier and more equitable world for current and future generations. Importantly, planetary empathy leads to a behavioural response that is both individual and collective, that catalyses transformative action to safeguard the health of the planet, now and into the future, and provides a legacy of regeneration.”

The overarching aim of the study outlined in this paper was to develop and conduct preliminary validation of the Planetary Empathy Scale (PES) that emerged from the aforementioned concept analysis, with an international sample of healthcare staff and students. This cohort was selected as nurses and other healthcare providers play a critical role in environmental stewardship and promoting planetary health through research, education, advocacy and sustainable practice [9]. Furthermore, The World Health Organization (WHO) emphasizes the important role of healthcare professionals and has called for urgent action to: (1) promote actions that both reduce carbon emissions and improve health, (2) build more climate-resilient and environmentally sustainable healthcare systems and (3) protect health from the wide range of impacts of climate change [23].

2. Materials and Methods

2.1. Methods

2.1.1. Survey Instrument Development

A structured, multi-phase instrument development process adapted from Devillis [24] and Younas and Porr [25] was used to design and test the PES. This consisted of five sequential steps. First, a comprehensive review of the literature was conducted to explore the conceptual dimensions of planetary empathy, drawing on existing scholarship in empathy and planetary health. This process was guided by a recent concept analysis [22]. Second, an initial pool of 55 items was drafted based on the concept analysis and mapped to the key concepts to be measured. Third, to enhance trustworthiness and to ensure face, construct, content validity and inter-rater reliability, an expert panel of eight academics and health practitioners with expertise in planetary health was invited to review the draft PES. The panel members were provided with instructions, the draft instrument, and a rating scale (low, medium, or high) to assess item relevance, clarity and representativeness [26].

Fourth, preliminary validation of the PES was conducted to evaluate the structural validity, internal consistency and construct validity. This included Exploratory Factor Analysis (EFA) using principal axis factoring with promax rotation to determine the underlying factor structure and reliability assessment using Cronbach’s alpha for the overall scale and subscales. Known-groups comparisons were also performed to assess construct validity by examining the scale’s ability to distinguish between groups expected to differ in planetary empathy levels. All analyses were conducted in accordance with the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) [27] to ensure methodological rigour. Finally, the items were organised into subscales and labelled to reflect the conceptual domains underpinning planetary empathy, resulting in a psychometrically sound instrument suitable for use in healthcare education and planetary health research contexts.

2.1.2. Sample and Setting

The draft PES was tested in October 2024 with an international sample of English-speaking healthcare staff and students. Sample size estimation was informed by established guidelines for psychometric scale development, which recommend recruiting between 5 and 10 participants per item for factor analysis [24,26]. Given that the preliminary version of the PES consisted of 43 items, a minimum of 215 completed responses was required to meet the lower threshold of 5 participants per item.

2.1.3. Procedures

Following ethics approval (ETH24-10074) participants were recruited via social media advertising (LinkedIn) and snowball sampling.

3. Findings

3.1. Participant and Sample Characteristics

The characteristics of the first 231 respondents to the survey are summarised in

Table 1. Participant Demographic Characteristics (n = 231 *).

Variable	Category	Frequency (n)	Percent (%)
1. Age	<20	4	1.7
	21–25	6	2.6
	26–30	11	4.8
	31–35	17	7.4
	36–40	15	6.5
	41–45	30	13.0
	46–50	34	14.7
	51–55	34	14.7
	56–60	26	11.3
	>60	53	22.9
2. Gender	Female	200	86.6
	Male	23	10.0
3. Country of Birth
Region	Country
Oceania	Australia	143	61.9
	New Zealand	3	1.3
	Subtotal	146	63.2
North America	United States	43	18.6
	Canada	4	1.7
	Subtotal	47	20.3
Europe
	United Kingdom	7	3.0
	Ireland	2	0.9
	Germany	2	0.9
	Portugal	1	0.4
	Norway	1	0.4
	Finland	1	0.4
	Subtotal	14	6.0
Asia and South-East Asia
	Singapore	4	1.7
	Pakistan	2	0.9
	Philippines	1	0.4
	Saudi Arabia	1	0.4
	India	1	0.4
	Subtotal	9	3.9
Africa
	South Africa	2	0.9
	Nigeria	1	0.4
	Cameroon	1	0.4
	Subtotal	4	1.7
Other
	Brazil	2	0.9
	Chile	1	0.4
	Subtotal	3	1.3
4. Ethnic/cultural background	Caucasian/White	188	81.4
	Middle Eastern descent	4	1.7
	Indigenous	4	1.7
	African descent	6	2.6
	Asian descent	10	4.3
	South Asian descent	4	1.7
	Multiracial/mixed heritage	4	1.7
	Prefer not to say	3	1.3
	Other	1	0.4
5. Highest level of education completed	High school	6	2.6
	Diploma or equivalent	6	2.6
	Bachelor degree	59	25.5
	Masters degree	71	30.7
	Doctorate	78	33.8
	Other (please specify)	9	3.9
6. Do you participate in any planetary health, climate change or sustainability groups?	Yes, local community group	54	14.36
	Yes, national organisation	74	19.68
	Yes, international organisation	38	10.11
	Yes, university or school group	45	11.97
	Yes, workplace initiative	62	16.49
	Yes, other	15	3.99
	No	85	22.61
	Prefer not to say	3	0.8
7. Have you undertaken any training in planetary health, climate change or sustainability?	Yes, as part of a formal education programme	27	8.44
	Yes, through workplace training	34	10.62
	Yes, via online courses or webinars	90	28.12
	Yes, through community workshops or events	47	14.69
	Other	20	6.25
	No	101	31.56
	Prefer not to say	1	0.31
8. On a scale of 1 to 5, rate your current level of interest and engagement in planetary health, climate change, and sustainability	Not at all interested	6	2.6
	Slightly interested	14	6.1
	Moderately interested	44	19.0
	Interested	71	30.7
	Very interested and engaged	94	40.7
9. Over the last 30 days, how often did you spend time enjoying nature?	Never	4	1.7
	Once a week	57	24.7
	2–3 times a week	56	24.2
	4–5 times a week	64	27.7
	Daily	48	20.8
10. What is your main health professional role?	Healthcare student	16	6.9
	Healthcare staff member	212	91.8
11. What is your current position?
Clinical Roles	Nurse	43	18.6
	Allied health	14	6.1
	Midwife	12	5.2
	Physicians and medical specialists	8	3.5
	Public health, community, and administration professionals	7	3.0
	Paramedic	3	1.3
Academic and Research Roles	Professor/academic/faculty	50	62.5
	Educator/trainer	14	17.5
	Dual role (academic and clinician)	6	7.5
	Researcher	4	5.0
Administrative and Leadership Roles	Executive director/director	7	3.0
	Manager	5	2.0
	Quality assurance/clinical governance	2	0.8
	Project officer	2	0.8
	Chief Nursing Officer	1	0.4
	Administrator	1	0.4
Volunteers and retired professionals	Retired	4	22.2
	Volunteer	3	11.1
	Total (Valid)	18	7.8
12. Years of experience in healthcare	0–5 years	21	91.
	6–10 years	31	13.4
	11–15 years	24	10.4
	15–20 years	32	13.9
	>20 years	120	51.9
13. Work setting	Educational setting	90	N/A
	Hospital	85	N/A
	Community	32	N/A
	Private Practice	25	N/A

* Note: Percentages may not total 100% due to missing data. Items were not forced-response and participants could choose to skip questions at their discretion.

. The majority of participants were born in Australia (61.9%), followed by the United States (18.6%), with a predominantly Caucasian/White background (81.4%). The age of respondents ranged widely, with the largest group aged over 60 years (22.9%), followed by 46–50 and 51–55 years (each 14.7%). Most respondents identified as female (n = 200, 86.6%) and over 90% (n = 208) of the participants had completed a bachelors degree or higher, with 33.8% (n = 78) holding a doctorate. Participation in planetary health, climate change, or sustainability groups was reported by 61.9% (n = 143), and 55.8% (n = 129) had received some form of related training. Interest in planetary health was strong, with over 71.4% of participants (n = 165) indicating they were ‘interested’ or ‘very interested and engaged’, and most reported frequent time spent in nature each week.

3.2. Content Validity

The initial 55 items of the Planetary Empathy Scale (PES) (see

Table 2. Planetary Empathy Scale.

Planetary Empathy Scale 43 Items (Mean = 4.32; SD = 0.60; α = 0.975)
	Item	Factor Loadings	Mean	SD
	Subscale 1: Refection—(Mean = 4.68; SD = 0.47; α = 1.0)
1.	I value spending time in nature	0.807	4.74	0.50
2.	I can recall times when I felt a sense of awe when I was in nature	0.803	4.77	0.50
3.	I feel a deep sense of connection with nature	0.701	4.52	0.71
4.	I believe being in nature positively affects my health and wellbeing	0.473	4.70	0.61
	Subscale 2: Reciprocity—(Mean = 4.32; SD = 0.67; α = 0.898)
5.	I sometimes feel distressed about how human actions are damaging the planet	0.782	4.40	0.79
6.	I sometimes feel concerned about the future of the planet	0.734	4.47	0.78
7.	I give a lot of thought to my impact on the environment	0.643	4.17	0.85
8.	I give a lot of thought to the consequences of human behaviours on the health of the environment	0.612	4.30	0.78
9.	I am personally committed to improving the health and well-being of the planet	0.533	4.34	0.81
	Subscale 3: Recognition—(Mean = 4.47; SD = 0.65; α = 0.954)
10.	I acknowledge that different societies and cultures provide valuable insights into caring for the planet	0.813	4.56	0.71
11.	I would like to learn more about other culture’s ecological knowledges	0.721	4.32	0.87
12.	I value the ways different cultures view the interconnections between human and environmental health	0.716	4.41	0.79
13.	When it comes to the planet, I am curious about other people’s world views	0.646	4.24	0.90
14.	I recognise that human’s attempts to dominate nature have been detrimental to the health of the planet	0.590	4.52	0.77
15.	I believe that caring for the planet will impact the health and well-being of future generations	0.446	4.68	0.65
16.	I believe we should have a sense of ‘belonging to’ nature rather than trying to dominate it	0.445	4.56	0.77
17.	I believe we each have a moral obligation to protect and preserve the planet for future generations	0.439	4.59	0.71
18.	I believe that the health of humans and the planet are deeply interconnected	0.419	4.62	0.71
19.	I consider climate change to be a social justice issue	0.413	4.42	0.88
20.	I see part of my role as being a caretaker of the planet	0.410	4.32	0.88
	Subscale 4: Responsibility—(Mean = 4.22; SD = 0.60; α = 0.899)
21.	I have the ability to help create a healthier, more equitable world for current and future generations.	0.687	4.12	0.93
22.	I believe each one of us can have a positive impact on issues such as climate change, biodiversity loss, deforestation and pollution	0.639	4.36	0.87
23.	I view humans and nature as part of an interconnected ecological family	0.605	4.54	0.75
24.	My health and wellbeing are dependent on the health of the planet	0.574	4.51	0.72
25.	I feel accountable for the impact of my personal choices on the environment	0.546	4.31	0.82
26.	I recognise the symbiotic relationships that sustain life on Earth	0.519	4.41	0.81
	Subscale 5: Response—(Mean = 3.92; SD = 0.82; α = 0.961)
27.	I speak up when I am concerned about the impact of healthcare on the environment	0.802	3.79	1.03
28.	I educate others about the importance of protecting the planet	0.790	3.80	1.10
29.	I actively advocate for policies that promote planetary health	0.776	3.67	1.11
30.	I have volunteered my time to support an environmental or climate action group/initiatives	0.775	3.47	1.32
31.	I talk to patients/consumers and colleagues about the interconnection between the health of planet and human health	0.757	3.55	1.19
32.	I feel confident discussing climate change with other people	0.678	3.72	1.02
33.	I encourage my friends and colleagues to rethink, reduce, reuse and recycle	0.631	4.00	0.10
34.	I am committed to finding a sustainable path for the environment in all aspects of my personal and professional life	0.561	4.13	0.91
35.	I believe healthcare professionals should engage in political activism to protect the planet	0.549	4.04	1.05
36.	I limit my consumption of foods that are not ethically or sustainably produced	0.548	3.63	1.10
37.	I am determined to explore more ethically sustainable approaches in my work	0.536	4.23	0.88
38.	I am determined that my environmental actions will leave a positive legacy for future generations	0.524	3.97	0.99
39.	I am committed to learning more about planetary health	0.470	4.27	0.88
40.	I recognise my duty to restore the health of the planet in any way I can	0.459	4.26	0.87
41.	I am aware of how my actions directly impact the health of the planet	0.415	4.35	0.78
	Subscale 6: Resilience—(Mean = 3.30; SD = 0.82; α = 0.261)
42.	I feel hopeful about the future of planet earth	0.847	2.87	1.12
43.	I can influence sustainable practices within my workplace or university	0.447	3.68	0.97

) were assessed for relevance and clarity using the Item-level Content Validity Index (I-CVI) [28]. Items with an I-CVI below 0.70 were removed, those scoring between 0.71 and 0.79 were revised for clarity and relevance, and items scoring above 0.80 were retained without modification. Following this expert review process, the final scale comprised 43 Likert-type items (rated from 1 = strongly disagree to 5 = strongly agree) and 14 sociodemographic questions. The Scale-level Content Validity Index (S-CVI) was above 0.90 for both relevance and clarity, indicating strong overall content validity for the PES.

3.3. Response Distribution

Visual inspection of histograms and summary statistics indicated that item responses were not normally distributed, violating the assumptions of normality. Most item means exceeded 4.5, reflecting strong clustering toward agreement on the upper end of the Likert scale. Item-level analysis confirmed deviations from normality with varying degrees of negative skewness and kurtosis. Several items were highly negatively skewed, suggesting strong consensus among respondents, while others were moderately or mildly skewed, indicating general agreement with some variability.

3.4. Structural Validity

The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was 0.955, indicating excellent suitability for factor analysis. Bartlett’s Test of Sphericity was statistically significant (Approximate Chi-Square = 8216.156, df = 903, p < 0.001), supporting the factorability of the correlation matrix. Communality estimates further reinforced the appropriateness of the data, with most variables showing communalities above 0.60. The highest communality was observed for item 10 “I acknowledge that different societies and cultures provide valuable insights into caring for the planet” (0.825), while the lowest was for item 43 “I can influence sustainable practices within my workplace or university” (0.538), suggesting all items were adequately represented in the factor structure.

Exploratory factor analysis (EFA) using principal axis factoring revealed a six components structure. Visual inspection of the scree plot showed a sharp decline in eigenvalues after the first component and a visible inflection point around the sixth component, with subsequent components contributing little to the explained variance. This supported the retention of six components. Together, these six components accounted for 71.91% of the total variance, indicating a strong underlying structure. The factor solution was conceptually aligned with the theoretical framework derived from a prior concept analysis of planetary empathy [22]. The items were organised into six subscales reflecting distinct but interrelated dimensions of planetary empathy.

The first subscale, Reflection, included items capturing a deep emotional and cognitive connection with nature. The second subscale, Reciprocity, reflected an ethical commitment to environmental stewardship and concern about the impact of human behaviour on planetary health. The third subscale, Recognition, encompassed items related to acknowledging cultural and epistemological diversity, implicit biases, and the interdependence of human and environmental health. The fourth subscale, Responsibility, included items representing moral and personal accountability for creating a more sustainable and equitable future. The fifth subscale, Response, consisted of items indicating behavioural engagement, including advocacy, education, and lifestyle choices aimed at environmental protection. The sixth subscale, Resilience, included two items: “I feel hopeful about the future of planet Earth” and “I can influence sustainable practices within my workplace or university.” Although these items loaded together, further research is needed to determine whether they constitute a unique construct or should be incorporated into an existing subscale.

3.5. Internal Consistency

The 43-item Planetary Empathy Scale (PES) demonstrated excellent internal consistency (Cronbach’s α = 0.975). Subscale reliability ranged from poor to perfect, with most subscales showing strong to excellent internal consistency (α = 0.896 to 0.958). The two-item subscale titled Resilience showed low reliability (α = 0.261), while the four-item subscale titled Reflection showed perfect reliability (α = 1.000), possibly due to item redundancy.

3.6. Construct Validity

Known-groups comparisons were conducted to assess construct validity and to evaluate whether the PES could differentiate between groups theoretically expected to vary in planetary empathy levels. Although item-level responses deviated from normality, group-level comparisons of PES scores were conducted using parametric tests, which are robust to non-normality in large samples [29]. Sensitivity analyses using non-parametric equivalents yielded consistent results.

There was no statistically significant difference in overall PES scores between male (M = 4.27, SD = 0.40) and female participants (M = 4.24, SD = 0.57), t (206) = −0.231, p = 0.817, suggesting that gender was not associated with differences in planetary empathy in this sample (see

Table 3. Known-Groups Validity Results for the Planetary Empathy Scale (PES).

Comparison	Test Statistic	p-Value	Effect Size (η2)	Significant Pairwise Differences
Gender	t (206) = −0.231	0.817	-	None
Education Level	F (5, 208) = 3.122	0.010	0.070	Doctorate > Bachelor’s (p = 0.048)
Professional Role	F (3, 177) = 3.271	0.023	—	Academic > Clinical (p = 0.021)
Healthcare Experience	F (4, 209) = 2.578	0.039	0.047	>20 years > 0–5 years (p = 0.032)
Planetary Health Engagement	F (4, 209) = 63.393	<0.001	0.548	Very interested > all other groups
Time Spent in Nature	F (4, 209) = 5.544	<0.001	0.096	Daily > Never

Note. η² = partial eta squared; significant comparisons based on Bonferroni-adjusted post hoc tests.

: Known-Groups Validity Results for the Planetary Empathy Scale). A one-way ANOVA revealed a statistically significant effect of professional role on PES scores, F (5, 208) = 3.122, p = 0.010, with a moderate effect size (η² = 0.070). Post hoc Bonferroni comparisons indicated that participants in academic or educational roles reported significantly higher planetary empathy levels than those in clinical roles (mean difference = −0.262, p = 0.021, 95% CI [−0.498, −0.025]).

Years of experience working in healthcare was also associated with significant differences in PES scores, F (4, 209) = 2.578, p = 0.039, with a small effect size (η² = 0.047). Participants with more than 20 years of experience reported significantly higher empathy levels compared to those with 0–5 years of experience (mean difference = −0.440, p = 0.032). A large effect was observed for participants’ level of interest and engagement in planetary health, climate change, and sustainability, F (4, 209) = 63.393, p < 0.001, η² = 0.548. Post hoc tests revealed that participants who identified as ‘very interested and engaged’ scored significantly higher on the PES than all other groups.

In addition, frequency of time spent enjoying nature (e.g., walking in parks, hiking, gardening, visiting nature reserves) was significantly associated with PES scores, F (4, 209) = 5.544, p < 0.001, with a small-to-moderate effect size (η² = 0.096). Post Hoc comparisons using Bonferroni adjustment indicated that individuals who ‘never’ engaged with nature had significantly lower planetary empathy scores compared to those who spent time in nature more frequently, particularly those in the ‘daily’ group. No other group differences were statistically significant. These findings provide evidence that the PES is able to differentiate between groups based on professional role and healthcare experience, supporting its construct validity.

4. Discussion

This study contributes to the emerging field of planetary health research by developing and psychometrically testing the Planetary Empathy Scale, a novel instrument designed to measure healthcare professionals’ and students’ affective and behavioural orientation toward concepts of human-environmental interconnections and protecting and preserving the health of the planet and its current and future inhabitants. The scale demonstrated strong internal consistency and a six-factor structure, providing early validation for planetary empathy as a measurable construct. These findings build on recent conceptual work that frames planetary empathy as a relational, values-driven process that underpins sustainable and socially just responses to ecological crises [22].

This study found that older, female and well-educated participants exhibited higher levels of planetary empathy. These findings are consistent with previous research suggesting that age and educational attainment are positively associated with environmental awareness and prosocial attitudes, potentially reflecting greater life experience, moral reasoning, and exposure to sustainability education [20]. Interestingly, younger participants in our sample had lower planetary empathy scores. This finding was unexpected, as previous studies have characterised young people as highly engaged in climate change activism, which may imply corresponding higher levels of planetary empathy [5,30,31]. This discrepancy may reflect nuances in how planetary empathy is defined and internalised, across life stages and socialisation contexts. It may also point to the need for more targeted planetary health education that bridges values and theoretical concepts of interconnection with practical advocacy, action, systems thinking and systems change strategies for younger cohorts.

As predicted in the background literature, time spent in nature was positively associated with higher planetary empathy scores in this study. This reinforces the role of direct, embodied nature experiences in fostering connection with the natural world [10]. These findings also support calls for integrating nature-based interventions and place-conscious pedagogies into healthcare education to strengthen relational capacities such as empathy, reflection, and reciprocity [13]. This is particularly important for clinical and academic leaders who shape the cultural and ethical fabric of health services and curricula. As theoretical perspectives frame empathy and biophilic connection as key motivators for pro-environmental behaviour, further empirical research is needed to determine whether these patterns hold consistently across different populations and settings.

Affective connection to nature has been shown to predict environmentally responsible behaviour and emotional engagement with nature and has been proposed as a foundation for transformative, values-led responses to ecological degradation [11]. Our study found that participants with higher planetary empathy scores were more likely to express interest and engagement in both personal and professional sustainability initiatives. This reinforces the earlier concept analysis [22], which proposed that individuals with heightened planetary empathy levels may be more inclined toward prosocial and transformative behaviours that mitigate environmental harms and promote intergenerational equity. For healthcare professionals, these behaviours may include sustainable clinical practices [32], advocacy for low-carbon models of care [33], and public engagement on the health impacts of climate change [34]. In this sense, the PES offers not only a measure of values and attitudes, but also a potential predictor of leadership in environmental stewardship within healthcare systems.

Importantly, these findings suggest that planetary empathy may serve as a foundation for strengthening environmentally conscious practice at individual, institutional, and systems levels. While empathy is often framed as an interpersonal trait, this study supports its relevance to broader ethical and systems-level decision making with regards to planetary health. As such, embedding planetary empathy in professional development, curricula, accreditation frameworks, and organisational and professional values statements may be a critical step toward aligning health services with the sensibilities and systems changes necessary for planetary health and human-nature well-being [35].

4.1. Strengths and Limitations

A key strength of this study is the development and initial validation of the Planetary Empathy Scale, grounded in a robust concept analysis and tested across an international cohort of healthcare staff and students. The instrument demonstrated strong internal consistency and revealed a six-factor structure that broadly reflects the theoretical dimensions of planetary empathy. Overall, the results support the use of the PES as a multidimensional instrument to assess empathy-related attitudes, beliefs, and behaviours in the context of planetary health.

However, several limitations must be acknowledged, and the study results must be interpreted with caution. The sample was self-selected and skewed toward highly educated, female-identifying participants working in academic and healthcare sectors, with a substantial proportion indicating prior engagement in planetary health initiatives. This limits the generalisability of the findings and may reflect response bias among those already orientated towards pro-environmental values. Whilst the international sample adds diversity, future studies should aim for more representative sampling across gender, education level, professional discipline and occupational setting—including populations less familiar with or engaged in planetary health discourse. There is also a distinct need to validate the PES across diverse cultural and socioeconomic groups—especially those systematically excluded from planetary health discourse yet often most affected by ecological degradation. As such, future studies to evaluate the PES with healthcare professionals who are connected to Indigenous cultures and that inherently value reciprocal relationships with nature would be valuable in extending on this work.

A small number of items showed lower loadings on their respective factors and low internal consistency of the Resilience subscale. However, these were retained to maintain conceptual integrity, as they represent distinct yet interconnected aspects of planetary empathy among healthcare professionals. Additionally, several items demonstrated negative skewness, suggesting a potential ceiling effect that may have constrained response variability. To address this, future iterations of the instrument could benefit from rewording or balancing item phrasing to capture a broader range of responses. Furthermore, additional psychometric evaluation such as confirmatory factor analysis (CFA), measurement invariance testing, and assessment of common method bias using the Harman single-factor method is recommended to further strengthen the scale’s validity and generalisability.

4.2. Recommendations for Future Research, Education and Practice

Longitudinal studies are needed to determine whether increases in planetary empathy translate into meaningful shifts in clinical practice, advocacy, healthcare policy or system-level transformation including resource allocation and systems change. Pending further validation, the PES could serve as a reflective or evaluative tool within professional development programs, both in and beyond healthcare, to support climate-conscious practice and leadership. Additionally, in educational contexts, the PES could be used as a diagnostic or evaluative tool to assess the impact of learning interventions that aim to build ecological consciousness and ethical leadership skills.

Advancements in how planetary health is measured may continue to shape perspectives and approaches in ways that influence decision-making. Enhancing planetary empathy may represent a critical domain of interpersonal development for leaders. This may then lead to beneficial effects in health and social policy making. For example, the broader literature highlights that women, particularly in policymaking roles, are more likely to make pro-environmental decisions [36], a trend that aligns with our finding that older women in this study exhibited higher levels of planetary empathy. To support organisations in becoming more climate-resilient and socially accountable, planetary empathy could be integrated into workforce policy and educational curricula. Accrediting bodies, professional standards frameworks, and continuing professional development programs should consider embedding planetary empathy as a core value in order to reach optimal climate adaptation, environmental sustainability, and health equity. Embedding planetary empathy into the cultural fabric of organisations could also catalyse system-wide transformation, positioning empathy as not only relevant to individuals, but also for the planet on which health depends.

5. Conclusions

The Planetary Empathy Scale (PES) provides a promising tool for assessing an emerging construct of increasing relevance to health education, leadership, and planetary health-related professional practice. While further psychometric testing with other cohorts and in other contexts is recommended, the PES should be deployed within real-world interventions, not only theoretical constructs. Whether embedded in curricula, used to evaluate leadership programs, or applied in climate-health, environmental health and planetary health workforce training, its value lies in catalysing reflection and action—not simply measurement—thus developing healthcare professionals with high levels of planetary empathy who are more likely to demonstrate an affiliation with nature, pro-environmental attitudes and behaviours, and a commitment to the creation of a healthier, more equitable world for all people and ecosystems. Accrediting bodies, employers, and policymakers must recognise planetary empathy as a workforce imperative. If we are serious about preparing health professionals to lead through the crises of climate change, biodiversity loss, environmental pollution, and land and water degradation, we must cultivate and measure the values that matter to mitigate climate change.