Cross-Cultural Ageism: Perspectives from Nursing Students in the USA and Japan

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is a descriptive cross-sectional study exploring the perceived personal and anticipated professional impact of a single life review assignment embedded geriatric/gerontological course for nursing students in the USA and Japan.  Various characteristics of the two nursing programs involved plus some demographics of the two countries’ participants are described and some tested for significant differences based on country.  The primary findings were explained more by individual participant characteristics and program differences rather than country of origin (suggesting a lack of cultural explanation for this study).

In general, the manuscript is adequately written and logical in presentation but lacks some coherence due I suspect to one author writing the USA components and a different author writing the Japan components.  This lack of similar style and specifics is confusing to the reader and I strongly suggest the authors look over the entire document to see how this can be improved.  Specific concerns are listed below.

1.      Introduction: The literature is used well to argue for the purpose of the study: “compare nursing students’ perspectives in the USA and Japan about ageism using the lifre review assignment.  Two specific aims include: “…describe the differences in demographic characteristics” of the two samples and describe “what it means to complete the life review assignment as a person and future nurse... “

a.      Background: This section provides a good overview of nursing education, how a person becomes a Registered Nurse, program curricula, and general student characteristics in each country.   Please include the same age and ethnicity characteristics for Japan as for the USA.

b.      Comment: this section (background) would be enhanced if the authors would summarize the similarities and differences between the two participating schools since this is mentioned in the Discussion section.  If you identify these here it helps the reader understand up front potential bias issues or significant differences in the data in Table 2.  It would also help the authors to conclude that the timing within the program of this assignment may be crucial!

2.      Materials and Methods:

a.      Lines 203-204 this sentence is the study design and should begin the materials and methods section, not the sampling section.

b.      Please consider a relabeling of sections in this order or at least present in this order: Design, Intervention, Data collection procedure, Measurement tools, Sample and Sampling

c.      Life review assignment: Adequate description.

d.      Sample and sampling: This entire section appears to be missing and what is listed here (lines 206-211) should be in the tool/measurement section.  Lines 212-216 should be in the Data collection section.  Sample and sampling section should be the inclusion/exclusion criteria, potential size of the sample, actual size, basic demographics or other information that demonstrates the representativeness of the samples at least for each school, i.e., the percentage of participation.

3.      Statistical analysis: Please include the correlational analysis here as well including why you did this since this was not specifically states in your aims (and add that aim there as well).  Alternatively you could say a post-hoc analysis was performed since the primary finding about the lack of difference in the two countries as found and you decided that the since the two samples were quite difference, more analysis was conducted.  Just be up front about these decisions and reasons, otherwise it appears to be “fishing” to find something significant.

4.      Results:  paragraph descriptions are fine

a.      Table 2: What do you mean by “years of living experiences?  Please explain in the body of the text and with an asterisk in the table.  Do you mean years of knowing an older adult?

b.      Table 3 is good.

c.      Table 4: asterisk the values that are statistically significant

5.      Discussion: This section is well written and logical with a few comments

a.      There is significant difference between the timing of this assignment within the participating schools, not to mention the huge differences in the characteristics of the two countries’ samples.  Highlight this as important and worthy of study. 

b.      Also, if age bias is the major premise for doing this study, a single course, much less a single assignment is likely going to change what is essentially a cultural bias.  Going forward, the challenge is to change behaviors, not perceptions.  This would mean linking assignment to your graduated and employed students to see where they work, if they thought the assignment was beneficial, etc.

6.      Conclusion: Adequate but the last line really needs to be explained more and suggestions on how to do this more within the entire nursing curriculum.

Author Response

Please see the attachment. 

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

I found this paper highly engaging as it explores ageism among nursing students in the United States and Japan and discusses the impact of the life review assignment on students at different stages of gerontological nursing education.

I believe the paper is generally acceptable; however, I would like to suggest the following points for your consideration:

 

Abstract and Conclusion

The conclusion should provide a clear and concise answer to the research question or purpose. From this perspective, the Abstract and Conclusion lack sufficient reference to the demographic differences between nursing students in the United States and Japan.

Significant differences were observed in terms of age, gender, and experiences with living with and caring for older adults. For example, students in the United States tended to be older on average and had more experience in caregiving for older adults, whereas Japanese students generally lacked such experiences. Including this information would help align the conclusion more directly with the research purpose. If there are word count limitations for the Abstract, this can be excluded; otherwise, I recommend incorporating it.

Additionally, I suggest revising the Conclusion in the main text to provide a more explicit answer to the research question. For example: This study examined the demographic differences between nursing students in the United States and Japan and the impact of the life review assignment. It was found that U.S. students were older on average and had more experience in caregiving for older adults, while Japanese students lacked such experiences. The life review assignment provided students with a meaningful learning experience both personally and professionally, enhancing their empathy and understanding of patient-centered care. This study demonstrates that the assignment is a valuable tool for promoting reflective learning in nursing education.

 

Results and Discussion

The theme of "Develop respect for older adults," "Realized that older adults are also humans" (Table 5) which were specific to Japanese students, is intriguing. It raises the question of why this theme was not observed among U.S. students. Cultural factors, such as the emphasis on equality and independence in the United States rather than respect, might explain this difference. Delving deeper into this cultural background in the discussion would add depth to the analysis. I recommend considering this point for further elaboration.

 

Table1

Wouldn't Table 1 be easier to read if it were not center-aligned? The bullet points in the list are misaligned, making it difficult to read.

Best regards,

Author Response

Please see the attachment. 

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The study provides important insights into intercultural aging among nursing students. How might these findings inform nursing curricula in diverse cultural contexts? Can you elaborate? Specific examples of how the life review assignment could be integrated into nursing education globally would enhance the practical value of your study.

 

The sample for this study focused on nursing students in the United States and Japan. Given the cultural differences between these countries, the generalizability of the findings may be limited. Perhaps it would be better to discuss how these cultural differences might influence the findings and include a section on how future research might involve a more diverse sample of nursing students from different countries or cultural backgrounds.

The life review assignment appears to have had a significant impact on the students’ perspectives, both personal and professional. Can you provide more details on how the reflective learning process was structured, specifically how students were encouraged to reflect on their own biases and attitudes toward aging?

The authors could discuss the potential for bias in interviewee selection (e.g., family versus strangers) and how this may have affected the results, given the limited sample size.

It would be more fluid to add a section on how future studies could address the limitations of this research, such as including more diverse populations of nursing students or exploring the longitudinal impacts of the life review assignment over time.

Overall, the language is clear, but there are sections where sentences could be restructured for readability.

Author Response

Please see the attachment. 

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

First and foremost, I would like to congratulate you on addressing such a relevant and timely topic as ageism in cross-cultural contexts within nursing education. Your work provides an innovative approach by incorporating the life review assignment as a reflective learning tool and comparing its implementation in two distinct cultural settings. However, there are areas that could be strengthened to enhance the methodological rigor, depth of the results, and clarity of the discussion. Below, I detail my observations and recommendations.

Regarding the methodology, the use of a mixed-methods design is a commendable choice, as it allows for capturing different dimensions of the phenomenon under study. However, I notice a significant disparity in the demographic characteristics of the samples from the two countries, particularly in terms of age and prior experience with older adults. This disparity could introduce biases and limit comparability. I recommend considering statistical methods to control for these differences or providing a more robust justification for how these potential biases were managed in the analysis. Additionally, while the process of translating and back-translating the LR-SF instrument into the Japanese context is described, it is unclear whether the psychometric properties of the LR-JP were formally evaluated. Demonstrating that the adapted instrument maintains its validity and reliability would be essential to ensure the quality of the data collected. Furthermore, the description of the qualitative analysis is insufficient; it is not specified whether an inductive or deductive approach was used, nor how credibility and reliability were ensured. Including details about the coding process, triangulation strategies, and whether thematic saturation was achieved would strengthen this section.

In the results, the presentation is clear but could benefit from further enrichment. While the quantitative results identify significant differences between the students from both countries, the practical relevance of these differences is not sufficiently discussed. Including measures of effect size, such as Cohen’s d, would help contextualize the findings. Similarly, the qualitative categories presented are useful but somewhat broad; it would be interesting to break them down into more specific subthemes and provide representative textual quotes that better illustrate the participants’ experiences. Incorporating visual aids, such as graphs, to display differences in group responses would also make the comparisons more accessible to readers. Additionally, I note that the cultural characteristics specific to each country, which could influence the responses, are not deeply discussed. This would be crucial to contextualize the results within their respective sociocultural frameworks.

As for the discussion, I appreciate that you highlight cultural differences and connect some findings with previous studies on attitudes toward older adults. However, the connection to the theoretical framework, particularly Erikson’s and Butler’s theories, is superficial. Exploring how the results support or contradict these theories and what implications they hold for designing educational interventions would be valuable. I also believe that the practical implications of your work could be further developed. For instance, including concrete recommendations on how to integrate the life review assignment into nursing curricula in different cultural contexts and suggesting specific adaptations to maximize its impact would be beneficial. Additionally, while you mention the study’s limitations, you could delve deeper into how these affect the interpretation of the results, especially the lack of homogeneity in the samples and the cross-sectional design. Addressing these aspects would enhance the transparency and credibility of the article. Finally, expanding the discussion to include a global perspective, reflecting on how these findings might apply to other countries facing similar challenges in geriatric care, would provide additional value.

In conclusion, I consider your work to address an important topic with an innovative approach, but there are areas that could be significantly strengthened. Enhancing the methodological description, delving deeper into the analysis of the results, and further developing the practical and theoretical implications will not only improve the quality of the article but also its impact on nursing education and geriatric care. I am confident that, with these adjustments, your article will be a valuable contribution to the academic and professional literature in the field.

Additionally, your introduction sets a solid context for the aging population and the issue of ageism in elderly care, but I believe there are aspects that could be reinforced to provide greater clarity and depth. While you present relevant data on demographic trends in the United States and Japan, these statistics are not explicitly linked to the objectives of your study, which may make it less clear to readers how these figures justify the need for your research. It would be helpful to establish a more direct connection between the challenges of aging and their educational implications in nursing, particularly in terms of fostering positive attitudes toward older adults. Furthermore, I think the cross-cultural comparison between the United States and Japan could be emphasized more explicitly, highlighting how cultural and educational differences might influence attitudes toward aging and the effectiveness of the life review assignment as a pedagogical tool. A critical review of previous literature, identifying specific gaps your study addresses, and highlighting how the life review assignment differs from other educational tools such as Kogan’s Attitudes Toward Older Persons or the Fraboni Scale of Ageism would also strengthen your justification and better prepare readers to understand your findings and implications.

In relation to the limitations, I believe they could be addressed in greater detail to reinforce the transparency of your study and provide a stronger framework for future research. While you mention differences in sample characteristics, such as the age and prior experience of students, these disparities could have affected the results, and it would be important to discuss how they influenced data comparability. Additionally, the cross-sectional nature of your design limits the ability to evaluate longitudinal changes in attitudes toward aging or to determine whether the impact of the assignment is sustainable over time. Exploring this limitation in more depth would be beneficial. I also think you could highlight the possible lack of representativeness of the samples, as participants come from two specific institutions in metropolitan areas, which might limit the generalizability of the findings to other educational contexts. Regarding the tools used, while the qualitative approach adds significant value to the analysis, it would be important to acknowledge that the lack of formal validation of the adapted instrument in the Japanese context might have affected the consistency of the responses. Lastly, the tendency of Japanese students to select “neutral” responses on Likert scales reflects a cultural response style that might have influenced the interpretation of the data, which could be explored more thoroughly in future studies.

I recommend concluding this section by noting that, while these limitations do not diminish the validity of your study, they open the door to new research opportunities that could address these issues, such as longitudinal designs, more diverse samples, or methodologies that consider cultural differences in response styles. I am confident that with these adjustments, your work will be even more robust and valuable to both the academic community and nursing professionals.

Author Response

Please see the attachment. 

Author Response File: Author Response.pdf

Reviewer 5 Report

Comments and Suggestions for Authors

COMPREHENSIVE MANUSCRIPT EVALUATION REPORT

General Considerations:

The manuscript presents a cross-cultural study on ageism among nursing students in the USA and Japan, utilizing a life review assignment as a reflective learning tool. The study demonstrates relevance, sound structure, and makes a significant contribution to the field of geriatric nursing education.

General Strengths:

1. Innovative cross-cultural approach
2. Effective utilization of mixed methods (quantitative and qualitative)
3. Clear alignment between objectives, methodology, and results
4. Adequate consideration of ethical aspects
5. Significant contribution to understanding ageism in nursing education

General Weaknesses:

1. Limited discussion of study limitations
2. Absence of supplementary files that could enhance the study's value

General Improvement Suggestions:

1. Expand the discussion on study limitations
2. Consider including supplementary files with raw data or research instruments

Evaluation by Manuscript Sections:

1. Title:

Strengths:

• Concise and informative
• Reflects the content and cross-cultural nature of the study

Weaknesses:

- Lacks explicit mention of the life review tool

Improvement Suggestions:

- Consider incorporating "life review" in the title to highlight the study's unique methodology

2. Abstract:

Strengths:

• Well-structured (Background, Objective, Methods, Results, Conclusions)
• Provides a concise overview of the study

Weaknesses:

- Lack of specific details about key findings

Improvement Suggestions:

• Include specific numerical data or main qualitative themes in the results
• Briefly mention practical implications in the conclusions

3. Introduction and Theoretical Framework:

Strengths:

• Clear contextualization of ageism in nursing
• Solid theoretical foundation

Weaknesses:

- Could expand further on specific cultural differences between the USA and Japan

Improvement Suggestions:

- Include more information on differences in healthcare systems and nursing education between the USA and Japan

4. Methodology:

Strengths:

• Clear description of data collection procedures
• Adequate consideration of ethical aspects

Weaknesses:

- Lack of details on the translation and cultural adaptation process of the instrument

Improvement Suggestions:

• Provide more details on the translation and cultural adaptation process of the research instrument
• Include a more robust justification for the sample size

5. Data Analysis:

Strengths:

• Appropriate use of statistical methods
• Well-conducted thematic analysis for qualitative data

Weaknesses:

- Lack of more detailed analysis of the relationship between demographic characteristics and atitudes

Improvement Suggestions:

• Include a correlation analysis between demographic characteristics and attitudes towards ageism
• Consider including a regression analysis to identify predictors of positive/negative attitudes

6. Results:

Strengths:

• Clear and objective presentation of quantitative and qualitative data
• Effective use of tables to summarize data

Weaknesses:

- Limited number of direct participant quotations

Improvement Suggestions:

• Include more direct participant quotations to illustrate qualitative themes
• Add a graph or figure to visualize key differences between groups
• Provide a brief synthesis of main findings at the end of the section

7. Discussion:

Strengths:

• Pertinent interpretation of results
• Good contextualization with existing literature

Weaknesses:

- Limited discussion on implications for health and education policies

Improvement Suggestions:

• Expand the discussion on the implications of results for health and nursing education policies
• Include a more robust section on future research directions
• Deepen the discussion on how results may influence nursing curriculum development in different cultural contexts

8. Conclusions:

Strengths:

• Clear synthesis of main findings
• Alignment with study objectives

Weaknesses:

- Limited discussion on practical implications

Improvement Suggestions:

• Expand the discussion on how results may inform nursing education policies
• Include a brief reflection on how findings may impact clinical nursing practice with elderly patients
• Add a final paragraph synthesizing the study's main message for the field of geriatric nursing

9. Contributions and Limitations:

Strengths:

- Explicit acknowledgment of contributions and limitations

Weaknesses:

- Overly brief discussion of limitations

Improvement Suggestions:

• Expand the limitations section, addressing potential biases in sample selection, limitations of the data collection instrument, challenges in cross-cultural comparison, and possible influences of uncontrolled factors
• Discuss how each limitation may impact the interpretation of results
• Suggest strategies to address these limitations in future research
• Create a dedicated subsection for "Limitations and Future Directions"
• Balance the discussion of limitations with the study's strengths

10. References:

Strengths:

• Current and relevant references
• Balance between empirical studies and theoretical works

Weaknesses:

- Lack of some recent meta-analyses on ageism in nursing

Improvement Suggestions:

• Include more recent meta-analyses or systematic reviews on ageism in nursing
• Expand references related to specific cultural differences between the USA and Japan in the context of health and elderly care
• Add more references on the use of life review tasks as an educational tool in other contexts

11. Supplementary Files:

Strengths:

- Not applicable, as no supplementary files are mentioned

Weaknesses:

- Absence of supplementary files that could enrich the study

Improvement Suggestions:

• HIGHLY RECOMMENDED: Include a file with the complete research instrument
• Provide anonymized raw data to promote transparency and allow secondary analyses
• Include more extensive transcripts of qualitative responses in a supplementary file

This comprehensive report provides a detailed view of the manuscript's strengths, weaknesses, and areas for potential improvement. The suggestions, if implemented, could significantly strengthen the study, enhancing its methodological rigor, clarity of presentation, and potential impact in the field of geriatric nursing education. The inclusion of the complete research instrument as a supplementary file is highly recommended to increase the study's transparency and replicability.

 

Author Response

Please see the attachment. Thank you for your time and consideration. 

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

 All previous concerns have been addressed.  This reads extremely well now!

Author Response

 Comment 1: All previous concerns have been addressed.  This reads extremely well now!

Response: 

Dear Reviewer, 

Thank you so much for your generosity of time in reviewing our revised manuscript. Your thorough feedback in the first round was instrumental in helping us strengthen our paper. Your thoughtful comments and suggestions throughout this peer review process have significantly enhanced the quality and clarity of our work. We are delighted that the current version meets your expectations. 

We appreciate your dedication to ensuring the manuscript achieves its full potential. We are grateful for your guidance in bringing it to this stage.  

Reviewer 4 Report

Comments and Suggestions for Authors

Dear Authors,

I sincerely appreciate the effort and dedication you have invested in revising your manuscript. Your commitment to improving methodological clarity, depth of analysis, and integration of previous comments is evident. In particular, I value the inclusion of more detailed sections on differences between student groups, the expansion of theoretical discussion, and the incorporation of effect size measures to contextualize the results.

However, there are still some aspects that could be strengthened to ensure maximum clarity and academic rigor in your work. Below, I outline key points that I suggest revising before final acceptance:

1. Validation of the Japanese Adaptation of the LR-SF Instrument
   I understand and respect your perspective that the life review (LR) task is an educational method rather than a psychometric measurement tool. However, it would be beneficial to include a brief reflection on how the adaptation of the instrument to the Japanese context may have influenced responses. Additionally, referencing quality control strategies in qualitative data interpretation (e.g., triangulation, inter-rater reliability) would enhance the credibility of your findings.

2. Deepening Theoretical Integration
   While the discussion has been expanded, the connection with Erikson’s and Butler’s theories could be further developed. It would be valuable to explore how your results support, modify, or challenge these theoretical frameworks. This would better position your study’s contribution to geriatric nursing education.

3. Justification of the Cultural Comparison
   I appreciate the revisions in the discussion section, but it would be helpful to more clearly highlight why Japan and the U.S. were selected for comparison and what implications the findings hold for other countries facing similar challenges in geriatric nursing education. Emphasizing this would further reinforce the global relevance of the study.

4. Clarity in Results Presentation
   The presentation of quantitative data has improved, but I recommend ensuring that table values align precisely with their descriptions in the text. Additionally, including more representative textual quotes in the qualitative results would enrich the interpretation of the findings.

5. Manuscript Readability and Clarity
   Some sections still contain complex sentence structures that could be simplified to enhance readability. Removing redundancies would also improve the text’s overall flow and precision.

Overall, I consider your manuscript to have significantly improved and to be close to its final version. With these minor refinements, I believe your study will make a valuable contribution to the field of geriatric nursing education.

Author Response

Thank you for your thorough and constructive feedback on our revised manuscript. Please see the attached file. 

Author Response File: Author Response.pdf