Number of Citations: 0

Submitted: 11 March 2022
Accepted: 10 June 2022
Published online: 4 October, TAPS 2022, 7(4), 73-75
https://doi.org/10.29060/TAPS.2022-7-4/CS2783

Kiyotaka Yasui, Maham Stanyon, Yoko Moroi, Shuntaro Aoki, Megumi Yasuda, Koji Otani & Yayoi Shikama

Centre for Medical Education and Career Development, Fukushima Medical University, Fukushima, Japan

I. INTRODUCTION

Educational strategies that are effective in one culture may not elicit the expected response when transferred across cultures. For instance, discussion-based learning methods such as problem-based learning, which were developed in Western contexts to foster self-directed lifelong learning (Franbach et al., 2019), are not easy for Asian students to adapt to. The quietness of Asian students, noted in multi-national contexts, is not always due to linguistic or cultural literacy barriers (Remedios et al., 2008) and requires contextual deconstruction to enable effective solution generation. In a Japanese context, we have observed how quietness manifests through insufficient question generation and a lack of spontaneous opinion expression in class. Such attitudes may be interpreted by western standards as lacking initiative and critical thinking (Tavakol & Dennick, 2010) but are in line with Japanese social norms and traditional views of learning. Because effective learning through discussion requires cognitive conflict to facilitate conceptual transformation (De Grave et al., 1996), it is necessary to ease the psychological burden experienced by our students when deviating from inherited cultural habits so that they can comfortably express opinions to embrace such conflicts. In this case study we share how we created a supportive environment to enable Japanese medical students to embrace this behavioural change.

Through our understanding of Japanese cultural norms, we hypothesised that student quietness could be attributed to the following: 1) belief that their question is insignificant and a desire not to impose on the time of others; 2) reluctance to express different opinions which might cause conflict; and 3) risk aversion to making incorrect statements. Reasons 1) and 2) reflect Japanese social norms requiring people to always act with consideration for others, while 3) is related to a Confucian-affected traditional view of learning that values humility for one’s imperfection as a driving force to self-cultivation which potentially reinforces embarrassment when giving incorrect statements. We aimed to address the above points by introducing environmental changes to boost student confidence in the significance of their questions and minimise the psychological burden of expressing their opinions during a class on ethical dilemmas.

II. METHODS

The class was undertaken by 256 first-year medical students at Fukushima Medical University in 2018 and 2019, as shown in Figure 1.

Figure 1. Flow diagram explaining the class: The closed circles represent the presenting group members and their interaction with the rest of the class (open circles) during the discussion and plenary session

A. Building Student Confidence

To minimise the risk aversion and associated anxiety of voicing incorrect opinions, we tasked students to reflect on ethical dilemmas with no clear answer, that they encountered during a 3-day placement in local nursing homes which was presented in groups of 5-6 to the rest of the class. Through removing the expectation of a right answer from the start, we created an atmosphere where students felt comfortable in generating multiple questions rather than being focused on reaching a single ‘correct’ answer.

B. A Conducive Environment for Cognitive Conflict

To break down the barriers of students seeking conformity and agreement during their presentations, we refocused the objective of the session onto the reasoning process of how they considered their ethical dilemma. This reframing supported students to embrace conflicting perspectives without worrying about achieving a consensus.

C. Nurturing a Diversity of Opinions

To facilitate the voicing of minority opinions, we harnessed a positive psychological trait in Japanese culture where pleasure is felt in acting as a collective. Therefore, when opinions were presented to the class, the entire group embraced ownership of the discussion, allowing the individuals who raised the points to remain anonymous. This reduced the potential for personal conflict and allowed diverse opinions to be aired without a loss of face.

At the end of the class, students were asked to evaluate the class using a 4-point Likert scale (good, fairly good, not so good, not good) and to write a reflection on the experience in one to two lines.

III. RESULTS

Out of the 245 students who submitted ratings, 89.9% evaluated the course as “good” or “fairly good”. About half mentioned their surprise at the diversity of opinions and their satisfaction with hearing them, acknowledging that hearing the different perspectives deepened their thoughts, broadened their perspectives, and created new ideas. Satisfaction with being able to express one’s thoughts was stated by a small number of students. Some of the students who chose “not so good” or “not good” pointed out that discussion was tough and required getting used to.

IV. DISCUSSION

When adopting a teaching method developed in a different culture, it should be delivered in the context of one’s own culture to optimise student learning. Once given a supportive environment, Japanese students, previously more content to listen than to actively contribute to discussions, exchanged their ideas and positively encountered cognitive conflict, rather than suffer from low confidence and an aversion to personal conflict. This demonstrates their potential to assimilate different perspectives and advance their thinking, akin to undergoing conceptual transformation. Through this work, we show that the standardisation of teaching methods does not equate to the globalisation of education, but how teaching must be adapted with clear implementation strategies and outcome definition, grounded in the culture to which the learners belong.

V. CONCLUSION

Generalising our adaptations outside of a Japanese context is limited, because of the cultural diversity within Asian countries that brings different challenges to discussion-based learning methods. However, vast numbers of students migrate across cultures in higher education and healthcare training. For universities and clinical training institutions with international students, understanding the barriers and supporting ‘quiet’ students to learn effectively through discussion alongside inherited cultural norms is a priority. This study aids in this understanding by providing an example from a Japanese medical undergraduate context.

Notes on Contributors

Kiyotaka Yasui designed and conducted the course, analysed the student reflections and wrote the manuscript.

Maham Stanyon analysed student reflctions and wrote the manuscript.

Yoko Mori conducted the course facilitation and supported the contextualisation of the results and discussion.

Shuntaro Aoki conducted the course facilitation and supported the contextualisation of the results and discussion.

Megumi Yasuda conducted the course facilitation and supported the contextualisation of the results and discussion.

Koji Otani conducted the course facilitation and supported the contextualisation of the results and discussion.

Yayoi Shikama planned and conducted the course as a course supervisor, analysed the student course ratings and reflections, and wrote the manuscript.

Acknowledgement

The authors would like to thank Dr. Rintaro Imafuku (Gifu University, Gifu, Japan) for constructive advice given during the medical education and research mentoring program sponsored by the Japan Society of Medical Education and Oliver Stanyon for editing a draft of this manuscript.

Funding

This study did not receive any funding.

Declaration of Interest

The authors have no conflict of interest to declare.

References

De Grave, W. S., Boshuizen, H. P. A., & Schmidt, H. G. (1996). Problem based learning: Cognitive and metacognitive processes during problem analysis. Instructional Science, 24, 321-341. http://doi.org/10.1007/BF00118111

Franbach, J. M., Talaat, W., Wasenitz, S., & Martimianakis, M. A. (2019). The case for plural PBL: An analysis dominant and marginalized perspectives in the globalization of problem-based learning. Advances in Health Sciences Education, 24, 931-942. http://doi.org/10.1007/s10459-019-09930-4

Remedios, L., Clarke, D., & Hawthorne, L. (2008). The silent participant in small group collaborative learning contexts. Active Learning in Higher Education 9(3), 201-216. http://doi.org/10.1177/1469787408095846

Tavakol, M., & Dennick, R. (2010). Are Asian international medical students just rote learners? Advances in Health Sciences Education, 15, 369-377. http://doi.org/10.1007/s10459-009-9203-1

*Kiotaka Yasui
1 Hikarigaoka,
Fukushima 960-1295,
Japan
Email: taka-y@fmu.ac.jp