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

Abstract

Age discrimination in nursing may result in judgmental care and compromise the quality of care offered to older adults. While geriatric–gerontological education can address ageism among nursing students, cross-cultural perspectives on aging remain understudied. This study describes the characteristics of nursing students in the USA and Japan and explores their perspectives on aging after completing a life review assignment, both personally and professionally. A mixed-methods study using quantitative surveys and an exploratory–descriptive qualitative design was conducted at two nursing schools (one each in the USA and Japan). Students participated voluntarily with strict anonymity and confidentiality. There were significant differences between American and Japanese nursing students in both demographics and perceived impact of the life review assignment. The American students were predominantly older and had more experience in caregiving for older adults, whereas the Japanese students were younger and lacked such experience. The qualitative analysis revealed an increased awareness of patient-centered care for older adults as a major professional theme across both groups. The life review assignment proved effective in providing meaningful experiential learning opportunities for future nurses across different cultural contexts. This method appears promising in addressing ageism through personalized engagement with older adults.

1. Introduction

The global demographic shift toward an aging population presents unprecedented challenges for healthcare systems worldwide, particularly in nursing care delivery. As life expectancy increases, the prevalence of chronic physical and mental health conditions among older adults expands [1]. This demographic transformation is especially pronounced in high-income nations. In the United States (USA), the population aged ≥65 (older adult population) has grown approximately five times quicker than the total population over the past century, comprising more than 17% of the U.S. population in 2022 [2,3]. Japan exemplifies this aging trend, with older adults accounting for 29.1% of its total population in 2022, the highest proportion in the world [4]. Global aging poses many social challenges. The demand for long-term care (LTC) for older adults aged >80 years is a pressing reality. Complex care demands in both acute and long-term settings require specialized geriatric–gerontological (geri–gero) nursing knowledge to ensure both quality of care and quality of life for older adults [5,6,7].

A critical challenge in addressing the care needs of this aging population is the continued presence of age discrimination, or ageism, in the nursing profession. Ageism manifests as negative perceptions about older adults’ physical, psychological, social, and spiritual aspects. The changes associated with chronic diseases and illnesses that result in increased disability among older adults are one of today’s major issues influencing new nurses’ career choices and potentially compromising care quality. Working in a long-term care facility as a registered nurse is not an appealing career choice to current nursing students, highlighting the urgent need to address ageism in nursing [8,9]. New nursing graduates often prefer to start their careers in acute care settings or specialized units perceived as more prestigious, such as emergency departments or intensive care units. Yet, the reality is that one in three patients in these specialized units is likely to be an older adult with multiple worsening chronic conditions [10].

To address this challenge, nursing education must evolve to effectively combat ageism among future professional nurses. Embedded in life review assignments, reflective learning has emerged as a promising pedagogical approach in nursing courses with geri–gero content to enhance students’ worldviews and understanding of aging-related changes. Reflective learning enables nursing students to critically examine their experiences, analyze their responses, and modify their understanding of aging-related issues [11,12]. Through engaging with older adults’ stories and lived experiences, nursing students can develop their own philosophy of aging and envision its application in their future nursing practice [13].

Research indicates that multiple factors, including knowledge, personal experiences, beliefs, and values, shape nursing students’ attitudes toward older adults [13,14,15]. Students with geri–gero knowledge or experience caring for older adults generally report more positive attitudes and a greater willingness to work with this population [14,16,17]. Besides knowledge and experience, cultural differences appear to significantly influence nursing students’ perspectives. Studies have revealed varying attitudes toward aging among nursing students from different ethnic backgrounds, with some research indicating more negative attitudes among Asian students compared to their Western counterparts [18,19]. These findings present an interesting paradox, considering that many Asian students originate from Confucian heritage societies with traditional respect for older people.

The younger generation’s anxiety about aging, such as fear of death and lower expectations for aging, hinder the mitigation of ageism [20]. Knowledge of aging and interaction with older adults may reduce ageism [21]. Age discrimination among healthcare professionals tends to decrease as they become older, obtain more knowledge about aging, and gain higher expectations regarding aging [22]. Nursing students’ negative feelings toward older adults can potentially result in judgmental care, with a negative impact on the quality of their care [23,24]. Students need to address these feelings and biases toward older adults before entering the workforce [25].

Various tools are available to evaluate attitudes, myths, and facts about older adults. Some examples are Kogan’s Attitudes toward Older Persons [26], Facts on Aging Quiz [27], Fraboni Scale of Ageism [28], and Ageing Semantic Differential [29]. However, developing meaningful teaching materials remains critical to preparing future nurses [30]. This study employs a life review assignment (the English version is called LR-SF pertaining to San Francisco and the Japanese version LR-JP) as an educational intervention to impart practical knowledge about aging through reflective learning, comparing perspectives between nursing students in the USA and Japan. The specific aims are to (1) compare the demographic characteristics and eldercare experiences of nursing students in the USA and Japan, (2) explore students’ perspectives on aging, and (3) examine the correlations between the students’ demographics and perspectives after completing the life review assignment, both personally and as future nurses.

2. Background

2.1. Overview of Nursing Education in the USA vs. Japan

Nursing is the largest healthcare profession in the USA, with about 89% of the 5.2 million registered nurses (RNs) currently employed in healthcare [31]. Findings from the Gallup Poll 2023 indicated that, for 22 consecutive years, nursing has remained the most trusted profession with the highest ethical standard among all professions in the USA [32]. RNs collaborate independently with other healthcare professionals, such as physicians of various specialties [33].

To become an RN in the USA, a person must graduate from an accredited nursing program and successfully pass the National Council Licensure Examination (NCLEX-RN), a license to practice nursing. There are several pathways to obtaining a prelicensure nursing education. Most RNs enter the workforce with a baccalaureate degree or an associate degree. While the National League for Nursing’s (NLN) recommended goal was for 80% of nurses to be educated to the Bachelor of Science in Nursing (BSN) degree level by 2020, only about 72% of practicing RNs have a BSN or higher degree as their highest level of nursing education [34].Recommended as an entry-level degree requirement for professional nursing, the BSN program provides the basis for leadership and graduate education in nursing. Before applying to the BSN program, students must complete all prerequisite nursing courses. The BSN program prepares students to sit for the national licensing examination to become registered nurses (RNs).

Several pathways lead to the BSN at San Francisco State University, California, the participating school for this study. The most common is a four-semester BSN program for first-degree applicants. Another pathway is the master’s entry to the nursing program (ELM) for applicants with bachelor’s degrees in other disciplines. The ELM is a six-semester program where students complete all the prelicensure nursing coursework in the first four semesters in addition to one master’s-level course each semester. The last two semesters of the ELM program focus on graduate courses toward a master’s degree in nursing. In recent years, another pathway has facilitated students concurrently enrolled in an associate degree of nursing (ADN) program to obtain a BSN within one year of their ADN graduation. The program is aptly called ADN to BSN. This pathway fulfills the requirement of the American Association of Colleges of Nursing for all practicing RNs to have a BSN upon entry into professional nursing or to obtain a BSN within three to five years of graduating from an ADN program.

Nursing education was first introduced as a university degree program in Japan in 1952. Since then, 275 universities have offered nursing programs. In 2021, there were 192 universities offering master’s degrees in nursing and 106 offering doctoral degrees [35]. The number of nurses per 1000 population is 12.1, one of the highest nursing ratios in the world [36]. In the recent National Nursing Examination, 40% of successful candidates (approximately 58,000) were university graduates [37]. Nursing was officially registered as a science in 1985 by the 7th Subcommittee of the 14th Science Council of Japan (Medicine, Dentistry, and Pharmacy). Although this establishment of nursing as a science occurred later than in Western countries, Japan has since developed comparable standards for nursing education and training [38].

The curriculum for nursing university education in Japan consists of a four-year enrolment period (124 credits), where students can apply to nursing programs right after high school completion. The foundation of the curriculum is the “core nursing practical abilities in the bachelor’s program and goals to achieve at graduation” commissioned by the Ministry of Education, Culture, Sports, Science, and Technology to the Japan Association of Nursing Programs in Universities, which lists six groups of abilities necessary for nursing practice [39], p. 6. Each university is expected to adopt the learning objectives specified in these ability groups and use them to organize their curricula, including the setting of course subjects and content, teaching methods, course order, etc.

The University of Tokyo Health Science in Japan participated in this study. Similar to other universities offering nursing degrees in Japan, the university’s curriculum aims to provide knowledge in various fields, from liberal arts and science to core nursing courses. Thus, students enroll in general education courses (e.g., philosophy, language (English), information literacy, and other social studies) concurrently with nursing courses. For example, in the first two years of nursing school, students take courses such as anatomy and physiology, pathology, infectious immunology, pharmacology, psychology, and public health to acquire basic medical knowledge.

The main difference in nursing education between the participating universities in the USA and Japan lies in the timelines of four semesters and four years, respectively. As such, nursing students at San Francisco State take their nursing didactic/theory courses concurrently with their clinical training, while nursing students at the University of Tokyo Health Science mostly attend classes in the first two years and undergo practical training from the third year onward.

Table 1. Comparison of nursing coursework requirements.

Participated School in the USA (>132 Units)		Participated School in Japan (>124 Units)
Prerequisites		Prerequisites
■ General Education (>48 units) ■ Nursing Prerequisites (28 units)		■ General Education (>58 units)
SEM	Class Contents (56 units)	Year	Class Contents
1st	■ Human Development and Health Assessment Theory/Lab ■ Research and Evidence-Based Practice in Nursing ■ Health Promotion in Nursing/Practicum I	1st	■ Introduction to Nursing ■ Basic Nursing Methodology ■ Basic Nursing Seminar ■ Introduction to Community Nursing ■ Community Nursing Seminar
2nd	■ Reproductive Health Theory/Practicum ■ Psychiatric Mental Health Nursing Theory/Practicum ■ Nursing Interventions Practicum	2nd	■ Adult Nursing Geriatric Nursing ■ Pediatric Nursing Maternal Nursing ■ Psychiatric Nursing ■ Methodology courses for each nursing field ■ Seminar for each nursing field
3rd	■ Nursing Care of Children Theory/Practicum ■ Nursing Care of Adults Theory/Practicum ■ Nursing Interventions Lab II	3rd	■ Practical training in each field ■ Family Nursing ■ Medical Safety Theory ■ Nursing Ethics ■ Nursing Management ■ Team Medical Theory ■ Introduction to Public Health Nursing
4th	■ Advanced Medical Surgical and Critical Care Nursing/Capstone Practicum ■ Chronic Care and End-of-Life Care Theory ■ Community Health and Global Perspectives Theory/Practicum	4th	■ Nursing Education ■ Disaster Nursing ■ Nursing Research ■ Integrated Practical Training

USA = Nursing coursework requirement [40]. Japan = Nursing department curriculum [41].

shows the coursework requirements of the two schools for a nursing baccalaureate degree. In this study, San Francisco State University represents data from the USA and the University of Tokyo Health Science represents data from Japan.

2.2. General Nursing Students’ Characteristics

Students enter nursing school after at least two years of college, having completed all the prerequisite courses in the sciences (e.g., Human Anatomy and Physiology, Chemistry, and Microbiology) and humanities (e.g., Written and Oral Communication, Critical Thinking, and Statistics) [40]. Nursing students vary in characteristics from school to school, including age, race, and experience with older adults. For example, at San Francisco State University’s nursing school, the students range in age from their early 20s to early 40s, and the ethnic distribution is approximately 40% White, 30% Asian, and 30% other ethnicities.

Unlike in the USA, students in Japan usually enter nursing school directly after high school and have almost no experience working in healthcare or elsewhere. Within our cohort, the nursing students were similar in age (i.e., 18–20 years), and the ethnic distribution was homogenously Japanese. Their only experience with older adults, if any, came from living with grandparents.

3. Materials and Methods

3.1. Educational Tools

3.1.1. Life Review Assignment (LR-SF)

The researcher (TD) developed the life review assignment as an immersion experience for students to apply their geri–gero knowledge and active listening skills to interview an older adult living in the community. The theoretical framework for the assignment was based on Erikson’s Stages of Psychosocial Development [42] and Butler’s Reminiscence Theory [43] to assess age-related changes and support the wisdom of older adults as they reminisce about their lives. The student learning outcomes for the assignment were to practice engaging in meaningful conversation with an older adult, reflect on the interview, and develop a nursing care plan to address their respective interviewees’ bio-psycho-social or spiritual needs. The assignment provided questions for the interview and guidelines for the written report in the following five parts: (1) biographical sketch; (2) perception of health and wellness; (3) medication and nutrition; (4) family, intergenerational relationships; and ethnogerontological factors; and (5) reflection on the interview. To complete the assignment, the students were required to find an adult aged ≥65 years, obtain verbal consent for the interview, conduct and reflect on the interview, and submit a report including their philosophy of aging. The interviewee could be a family member, a friend, or a patient. For anonymity, the students were instructed to include only the initials and age of the interviewee. The English version of the life review assignment, LR-SF, has been reported elsewhere [13]. The LR-SF life review interview guide is shown in Supplementary File S1.

3.1.2. Japanese Version of Life Review (LR-JP) Assignment

The translation and cultural adaptation of the LR-SF assignment was carried out following the World Health Organization guidelines for the translation of measurements [44]. The process involved multiple stages. First, SB, a gerontologist on the LR-SF team, conducted the forward translation from English to Japanese. The initial Japanese version underwent a thorough review by two specialists from the Japanese team, MB (geriatric psychiatry) and JS (Nursing/Health Science). Both researchers then independently performed backward translation, allowing Japanese team members to assess the translation’s consistency and cultural appropriateness. To ensure both cultural relevance and fidelity to the original LR-SF, we implemented the following validation strategies:

• Multiple collaborative revision sessions between the LR-SF and LR-JP teams via Zoom meetings
• Consultation with additional nursing and gerontological faculty within our professional network to assess question validity
• Systematic examination of inter-rater reliability during the translation process
• Iterative refinement until all questions met our standards for cultural adaptation and sensitivity

The final validation step involved a comprehensive review by the Japanese Ethics Committee, which examined all questions before approving this study.

3.2. Sample and Sampling

3.2.1. USA

Eighty-eight students enrolled in the three-unit “Chronic Care and End of Life Care Theory” course at the School of Nursing in their last semester of the prelicensure program were invited to participate. The course examined chronic care and end-of-life care nursing, including discussions about caring for the older population, palliative care, cultural, legal/ethical issues, safety, evidence-based practice, case studies, and communication strategies [45]. The final sample comprised students from the three following different cohorts: Bachelor of Science in Nursing (BSN), Associate Degree to BSN (ADN-to-BSN), and Entry-Level Master of Nursing (ELM).

3.2.2. Japan

Ninety-six nursing students enrolled in a two-unit “Geriatric Nursing Methodology” course at the University of Tokyo Health Sciences in their second year of the program were invited to participate. They had completed Introduction to Geriatric Nursing (first half of the second year) and Geriatric Nursing Support Theory (first half) and then taken Seminar in Geriatric Nursing (second half of the second year) and Geriatric Nursing Methodology (second half) [38]. The life review interview was introduced as an assignment for the students to apply therapeutic communication in interviewing older adults. The first part of the course consisted of the required nursing care depending on the place of treatment (acute phase, rehabilitation phase, chronic phase, or LTC facility) and nursing care for major diseases commonly occurring in older adults (cerebrovascular disorders, musculoskeletal disorders, Parkinson’s disease, dementia, etc.).

3.3. Data Collection

3.3.1. USA

After the assignment was graded, the survey was available for four weeks on the university’s Qualtrics™ site. Qualtrics™ is an American management software offering a cloud-based survey solution for businesses and academic settings. Students were invited to participate in the study voluntarily and at their convenience, ensuring their rights and ethical considerations were respected. Data were collected during the last two weeks of the courses in the fall of 2022 and 2023.

3.3.2. Japan

The assignment was given at the beginning of December 2022 to be submitted by the end of January 2023. Data collection took place from the end of January to February 2023. The Google Forms link to access the survey was sent to each student’s university email address. The survey was anonymous and confidential. The students were informed that the completion and return of the survey indicated their implied consent for the study. The students were assured that completion or non-completion of the survey had no impact on their course grade.

3.4. Survey Questionnaires

This study explores how life review assignments impacted nursing students as individuals and future nurses. Students were assured that participation in the study had no consequence on their course grades. Methods to reduce potential bias included voluntary participation, anonymous responses, and participation after the graded life review assignment. The participants were also informed that the completion and return of the survey indicated their implied consent for the study.

After completing the LR assignments, all students were asked the following questions.

• Overall, the life review assignment has an impact on you as a person
  • 5-point Likert scale (strongly agree-strongly disagree)
  • Text entry
• Overall, the life review assignment has an impact on you as a future nurse
  • 5-point Likert scale (strongly agree-strongly disagree)
  • Text entry

3.5. Design and Statistical Analysis

This mixed-method study utilizes a quantitative and exploratory–descriptive qualitative design. Researchers from the U.S. and Japan developed a cross-sectional survey that included two open-ended questions to examine the impact of the life review assignment on students in both countries. Descriptive analysis was conducted, and correlational statistics (t-tests) were performed to compare the mean scores and identify any differences between the two groups. To explore the students’ perspectives on aging, qualitative analyses of all students’ responses to the open-ended questions were conducted. Every student comment was transcribed and categorized for thematic analysis. First, the written feedback was converted into text and then systematically assigned specific codes to uncover recurring themes or patterns in the data. This process allowed for a more thorough examination of the overall meaning and insights derived from the comments. This process continued until the U.S. authors reached a consensus on all themes (T.D. and S.B.). The Japanese authors (M.B. and J.S.) transcribed and coded the Japanese data to identify the main themes, while S.B. supervised the final coding to ensure alignment with the U.S. themes.

4. Results

Of the 88 students enrolled in the course in the USA, 44 (50.0%) participated in the survey. Of these 44 students, 32 (72.7%) interviewed their family members, followed by 7 neighbors/acquaintances (15.9%), 3 friends (6.8%), and 2 patients (4.5%). In Japan, of the 96 students on the course, 52 (54.2%) participated in the survey. Of these 52, 49 (94.2%) interviewed family members and 3 interviewed neighbors/acquaintances (5.8%).

Table 2. Characteristics of nursing students in the USA vs. Japan.

	USA n (%)	Japan n (%)
Age
Average, SD	29.8 ± 7.1	20.0 ± 0.8
Range	22–44	19–21
Median	27.5	20
Mode	22 & 23 (13.6 ea.)	20 (84.6)
≤25	19 (43.2)	52 (100)
26–30	5 (11.4)	0
31–40	16 (36.4)	0
41+	4 (9.0)	0
Gender
Male	7 (16.0)	3 (5.8)
Female	35 (79.5)	48 (92.3)
Non-binary/third	2 (4.5)	0
Decline to state	0	1 (1.9)
Years of living and/or experiences with older adults
none	11 (25.0)	31 (59.6)
<1 year	3 (6.8)	4 (7.7)
1–5 years	5 (11.3)	2 (3.8)
>5 years	16 (36.4)	15 (28.8)
Unknown	9 (20.5)	0
Years of experience in eldercare
none	2 (4.5)	39 (75.0)
<1 year	8 (18.2)	8 (15.4)
1–5 years	14 (31.8)	5 (9.6)
>5 years	11 (25.0)	0
Unknown	9 (20.5)	0

USA (n = 44); Japan (n = 52).

shows the student characteristics.

4.1. Personal and Professional Meaning of the LR Assignment

Table 3. Comparison of quantitative impacts of the assignment n (%).

	Strongly Agree	Somewhat Agree	Neutral	Somewhat Disagree	Strongly Disagree
Personal
USA	22 (50.0)	13 (29.5)	6 (13.7)	3 (6.8)	0
Japan	12 (12.5)	15 (29.4)	19 (37.3)	4 (7.8)	1 (2.0)
Professional
USA	23 (52.3)	14 (31.8)	4 (9.1)	3 (6.8)	0
Japan	13 (26.0)	19 (38.0)	11 (22.0)	6 (12.0)	1 (2.0)

USA: n = 44; Japan: personal (n = 51), professional (n = 50).

shows the results of the following two questions: whether the LR assignment had any impact on the students (1) as an individual (personal) and (2) as a future nurse (professional). The students determined this on a scale from one to five, where one is “strongly disagree” and five is “strongly agree”.

4.1.1. USA

With quantitative analysis, the personal and professional results were quite similar (n = 44). About 50 percent of the students reported that the assignment had impacted them “strongly” personally (n = 22) and professionally (n = 23), followed by about 30% of students saying “somewhat agree” for personally (n = 13) and professionally (n = 14). Three students (6.8%) reported “somewhat disagree”, and no students reported, “strongly disagree”.

4.1.2. Japan

In Japan, the personal (n = 51) and professional (n = 50) results were similar to the USA data. As a person, more than 40% of the students reported either “strongly agree” (n = 12) or “somewhat agree” (n = 15) for whether the assignment had impacted them. For professional impact, approximately 65% of the students reported either “strongly agree” (n = 13) or “somewhat agree” (n = 19). Approximately 40% (n = 19) of the students had neutral feelings about the impact of the assignment on them as a person and about 20% reported being “neutral” about its impact on them as a future nurse.

Since there were significant differences in the student characteristics between the two countries, we conducted a correlational analysis of the results. Spearman’s rank correlation coefficient was used to assess the relationship between student characteristics and the personal/professional impact of the assignment. Among the different characteristics, age positively correlated with both personal (r_s = 0.30, p = 0.003) and professional (r_s = 0.27, p = 0.009) impact. Similarly, care experiences positively correlated with the professional impact of the assignment (r_s = 0.31, p = 0.003).

Table 4. Comparison of quantitative impacts of LR assignment.

	USA	Japan
	M (SD)	M (SD)	t	p	MD	d
Personal	4.23 (0.94)	3.65 (1.00)	2.91	0.005 *	0.58	0.60
Professional	4.30 (0.90)	3.74 (1.04)	2.74	0.007 *	0.55	0.57

USA: n = 44; Japan: personal (n = 51), professional (n = 50). t = t-tests, MD = mean difference, d = Cohen’s measure of effect size. * p < 0.01.

compares the personal and professional impacts of completing the LR assignment on nursing students in the USA (n = 44) and Japan (n = 51). The mean “personal” score for the USA (M = 4.23, SD = 0.94) was higher than Japan’s (M = 3.65, SD = 1.00). An independent t-test showed a significant effect (t (93) = 2.91, p = 0.00), with a medium effect size of 0.60. For the “professional” score, the USA’s mean score (n = 44, M = 4.30, SD = 0.90) was also higher than Japan’s (n = 50, M = 3.74, SD = 1.04). Both countries’ professional mean scores were slightly higher than their personal ones. There was also a significant effect between the two countries (t (92) = 2.74, p = 0.00), with a medium effect size of 0.57.

4.2. Qualitative Comments About the Meaning of LR Assignments

Two open-ended questions were asked to explore the meaning of the LR assignment for students as (1) an individual (personal) and (2) a future nurse (professional).

4.2.1. USA

The primary outcome of this assignment was that approximately a quarter of the students (n = 10, 22.7%) gained professional awareness of patient-centered care. A student said, “This assignment has impacted me as a future nurse because I can talk to older patients. I will take care of them in the future and base my care specifically on what they want and value the most”.

A few students (n = 3, 6.8%) said that the assignment helped them realize the importance of patient education, especially medication. They commented that many older patients may need to realize the reasons for and/or indications of their medicines. Polypharmacy is a major issue among older patients, so understanding an individual’s routine and interests can improve medication adherence. A student reported, “It allowed me to see a few things in a new light: how many patients may not realize the impact or necessity of the medications they are on”.

Regarding professional perspectives, students (n = 7, 15.9%) reported gaining older adults’ viewpoints in general and how this learning may influence them as future nurses. Students realized that values differ from person to person, and respecting older adults’ preferences or wishes regarding their lives and healthcare is important.

“I believe that knowing older adults’ feelings and lifestyle backgrounds will be useful when I work as a nurse.”

“As a future nurse, it is important for me to work on getting a holistic understanding of each patient to ensure they are provided the best care possible.”

From a personal perspective, students (n = 8, 18.2%) reported that they felt more connected as they learned more about the lives of their family members interviewees. One student said, “The assignment inspired me to ask more questions and work to understand my family members on a deeper level.” Five students (11.4%) commented that the assignment was important to them as a person and that they enjoyed it. “Learning more about the family member is always so endearing”.

About 20% of the participants either left no comments or reported that the assignment made no impact on them personally and/or professionally.

4.2.2. Japan

Of the 96 students on the course, 35 (36.5%) provided personal and 30 (31.3%) provided professional comments on the assignment. Similar to the American students, the primary outcome for Japanese students was that approximately three-quarters (n = 22, 73.3%) gained professional awareness of patient-centered care. They reported that knowing older adults’ backgrounds, lifestyles, and wishes would be beneficial when working as a nurse. They said they would respect patients’ established lifestyles, listen to patients’ stories as much as possible, and support patients’ routines. Some (n = 6, 20.0%) realized the importance of the geriatric curriculum in nursing education and felt satisfied with the opportunity to engage in meaningful conversations with older adults through the LR assignment. No one reported that this assignment had “no impact” on them as a professional.

The Japanese students realized patient-centered care through communication.

“I know now that understanding older adults’ feelings and lifestyle backgrounds is useful when I work as a nurse.”

“As I learned about older adults’ lives, I began to think about their values, which differ from person to person.”

Regarding personal perspectives, more than 50% of the students (n = 18) were able to reconnect with their older family members, learning about their perspectives (n = 20, 57.1%) and the aging process (n = 10, 28.6%). Some students also reported that listening to their interviewees’ stories helped them to respect older adults (n = 7, 20.0%) and perceive them as life lessons (n = 6, 17.1%).

Please see

Table 5. Summary of the qualitative meaning of the LR assignment.

Themes	USA	Japan	USA	Japan
	n (%)	n (%)	n (%)	n (%)
	Personal		Professional
Nursing knowledge/skill/attitude
Awareness of patient-centered care	1 (2.3)	0	10 (22.7)	22 (73.3)
Awareness of non-judgmental care	1 (2.3)	0	4 (9.1)	0
Awareness of end-of-life care	2 (4.5)	0	2 (4.5)	3 (10.0)
Awareness of active listening	0	3 (8.6)	0	4 (13.3)
Development of empathy/compassion	4 (9.1)	6 (17.1)	4 (9.1)	0
Development of situational & emotional awareness	1 (2.3)	0	3 (6.8)	0
Thinking about my own aging	4 (9.1)	0	1 (2.3)	0
Learning from older adults’ perspectives	8 (18.2)	20 (57.1)	7 (15.9)	11 (36.7)
Self-reflection	4 (9.1)	2 (5.7)	2 (4.5)	0
Skills (communication/assessment) improvement	2 (4.5)	0	2 (4.5)	0
Experience having difficult conversations	1 (2.3)	0	0	0
Perceived as a life lesson	0	6 (17.1)	0	0
Want to learn more about older adults	0	2 (5.7)	0	1 (3.3)
Improved communication/assessment skill	0	0	0	3 (10.0)
Relationship improvements
Reconnection with older family/friends	8 (18.2)	18 (51.4)	4 (9.1)	5 (16.7)
Building bonds with older patients	1 (2.3)	0	3 (6.8)	0
Development of respect for older adults	0	7 (20.0)	0	3 (10.0)
Recognition that older adults are also humans	0	6 (17.1)	0	2 (6.7)
Learning the aging process	1 (2.3)	10 (28.6)	1 (2.3)	2 (6.7)
Learning the importance of patient education	1 (2.3)	0	3 (6.8)	0
Learning the importance of geriatric education	0	1 (2.9)	0	6 (20.0)
Good assignment/enjoyed	5 (11.4)	0	0	0
No impact/no comments	9 (20.5)	11 (31.4)	10 (22.7)	0

USA: n = 44; Japan: personal (n = 35), professional (n = 30).

for a summary of the qualitative analysis of themes of students’ personal and professional perspectives.

5. Discussion

Regardless of geographical location, nursing education worldwide upholds the World Health Organization’s standards for international medical education to establish nursing knowledge, skills, and attitudes [46]. This descriptive study compared how nursing students in the United States and Japan engaged with older adults through life review assignments, providing insights into preparing future healthcare professionals to meet the challenges of the aging global population. The unique demographic and healthcare characteristics of the United States and Japan make this comparison particularly valuable. Japan has the highest proportion of older adults, while the USA has a rapidly aging population facing a high chronic disease burden, both encountering similar challenges in geriatric care. This study’s insights and perspectives can improve international collaboration on gerontology courses and nursing education exchange programs.

5.1. Student Characteristics

There was a significant difference in the timing of the life review assignment between the two participating schools. Aligned with their respective curricula, the U.S. students completed the assignment in their fourth semester of the four-semester BSN program. In contrast, the Japanese students completed it in their second year of the four-year BSN program. Significant differences were also between the students’ characteristics and aging care experience. The American nursing students were older (mean age of about 30 years) with substantial experience living with or caregiving for older adults. In contrast, the Japanese students were younger (mean age of 20 years) with limited or no such experience.

The differences between the American and Japanese nursing students’ caregiving/living experience with older adults reflect broader societal changes in both countries. Considering that Japan has the highest percentage of older adults, along with the tradition of multi-generational households, one would expect Japanese students to have more eldercare exposure than U.S. students from nuclear families. However, Japan’s tradition of adult children living with and caring for aging parents has begun to fade over the last two decades [47]. In 2019, 32.3% of older adults aged ≥65 lived with their spouse, and 28.8% lived alone [48]. In the USA, 46% of older adults aged ≥60 live with their spouse, and 24% live alone [49]. These shifts in multi-generational living arrangements suggest a growing need for structured educational interventions such as life review assignments that provide meaningful interactions with older adults, particularly younger nursing students with limited personal exposure to aging-related issues.

5.2. Personal and Professional Perspectives

The students’ responses reveal how educational interventions can shape attitudes toward aging across different cultural contexts. Drawing from prior caregiving experience, the American students described an enhanced professional understanding of age-related needs. The Japanese students’ responses highlighted the following two significant themes: (1) the development of respect for older adults and (2) the recognition that older adults are also humans.

Concurring with previous studies [50,51], the quantitative results of this study showed that American students provided higher ratings for the personal and professional impacts of the assignment. The lower ratings from Japanese students were likely because most marked “neutral” responses to the quantitative questions. Research on different ethnic groups has also shown that Japanese respondents often select the “neutral” or midpoint option in surveys. Anecdotally, why Japanese people frequent the midpoint/neutral response is to avoid openly expressing their agreement/like/acceptance or otherwise of certain viewpoints. Japanese people often avoid giving definitive answers when they are not entirely confident [30,52]. This response style reflects the influence of cultural background on the respondents.

The Japanese students tended to select “neutral” responses to quantitative questions, but provided rich qualitative feedback. In general, a nurse’s identity is constructed through personal and professional experiences, including knowledge, skills, responsibilities, and environment [52,53,54,55,56]. American students demonstrated more consistency between their quantitative and qualitative comments. Those with eldercare experience, in particular, expressed enjoyment in their interactionswith older adults during the assignment and showed enthusiasm for acquiring new knowledge and skills. Japanese students with more than five years of experience living with older adults shared similar perspectives. For Japanese students with less experience, the qualitative results suggested that the assignment provided meaningful interaction and enhanced their aging-related knowledge.

Specific to the Japanese students, the themes of “development of respect for older adults “and “recognition that older adults are also humans” were intriguing. This raises the question of why these themes were not observed among the American students. Cultural factors such as emphasizing equality and independence in the USA rather than respect might explain this difference. The candid recognition that older adults are also humans suggests clinically relevant implications for nursing practice in Japan and elsewhere. Nurses need to continuously examine their own biases, whether implicit or explicit, against aging. Although it was a minority opinion held by the Japanese students, some reported that the assignment allowed them to realize the “importance of geriatric care in nursing programs” as a future nurse and the “importance of learning about the aging process” as a person.

5.3. Impact on Future Geriatric Care

The students shared personal and professional perspectives revealed several engagement patterns relevant to future geriatric care delivery. There was an experiential learning pattern such that students in both countries with prior caregiving/living experience with older adults focused on deepening their understanding of patient-centered care approaches, while those without experience reported fundamental shifts in their views of aging. Both groups demonstrated an enhanced awareness of the importance of understanding older adults’ life history and legacy in providing quality care.

There was also a pattern of cultural influences on care perspectives. The Japanese students’ emphasis on respect and human dignity reflects cultural values that could enhance patient-centered care approaches. The American students’ practical experience contributed to a more reflective understanding of the challenges in providing caregiving to older adults. Both groups showed an increased appreciation for patient-centered care principles, suggesting that life review assignments can potentially promote quality care for older adults across cultural contexts.

5.4. Limitations and Future Directions

Two main limitations characterize this study. First, the sample represented nursing students from two metropolitan areas, potentially limiting the generalizability of the results. Second, the predominant selection of family members as interviewees, especially among the Japanese students, may reflect specific cultural influences that affect the findings. Because the challenge in addressing ageism is in changing healthcare professionals’ behaviors and not just their perceptions, future research should explore how reflective learning in life review assignments could translate to the future employment of new nurses in different healthcare settings and their long-term impact on the quality of care for older adults. In addition, future studies should be conducted with a more diverse sample of nursing students from different countries and/or different cultural backgrounds to increase the study’s generalizability.

5.5. Implications for Geriatric–Gerontological Nursing Education

The study findings suggest several strategies for preparing the future nursing workforce to meet the needs of aging populations, as follows: (1) early integration of structured interactions with older adults in nursing education, (2) recognition of how cultural factors influence students’ understanding of aging, (3) adaptation of educational approaches based on students’ prior experience with caregiving for older adults, (4) emphasis on understanding older adults’ life experiences as the basis to quality care, and (5) development of teaching strategies that address changing intergenerational dynamics in aging societies.

Our findings about student learning outcomes suggest several promising directions for future theory-based educational interventions in geriatric–gerontological nursing, as follows:

• The structured nature of our life review interview guide with its five distinct sections (biographical sketch, health and wellness, medication use and nutrition, family/intergenerational relationships, and conclusions) provides a comprehensive patient-centered framework that helps students to systematically explore both the psychosocial and clinical aspects of aging. This integration of personal narrative with clinical assessment could inform similar theory-based assignments.
• Our results showing how students develop a more nuanced understanding of aging through direct interaction with community-dwelling older adults suggest that Erikson’s and Butler’s theories can be effectively translated into practical educational tools that bridge theoretical knowledge with clinical practice.
• The reflective component embedded throughout the life review assignment (particularly in parts 2, 4, and 5) demonstrates how theoretical concepts can help students examine their attitudes about aging while developing clinical assessment skills. This dual focus on personal growth and professional development could be a model for other theory-based educational interventions.

6. Conclusions

As global populations age, preparing nursing students to provide quality care for older patients becomes increasingly critical. This descriptive study highlights how cultural context and student characteristics shape learning. While the American and Japanese students showed different engagement patterns, both groups demonstrated an enhanced understanding of patient-centered care principles. The observed similarities and differences in the student responses across these two distinct cultural contexts could inform curriculum development in other countries with aging populations. The comparative analysis contributes to the development of culturally responsive geriatric nursing education worldwide, especially in countries experiencing similar demographic transitions. This study’s insights and perspectives can help to improve international collaboration in nursing education exchange programs. The ultimate outcome is to enable future nurses to provide quality care and, thus, enhance the quality of life of older adults across different cultural contexts.