Perceptions and Motivations of Japanese Medical Students Regarding Course Evaluations: A Cultural Perspective

Introduction

Course evaluations by students are crucial for enhancing teaching quality,¹ providing valuable feedback on the quality of teaching from a student perspective.² However, the data obtained through course evaluation surveys are underutilized when systematically measuring educational outcomes. Instead, this data is commonly used by individual faculty members to reflect on whether their teaching fulfilled student’s expectations.³ Additionally, some students use course evaluations as an opportunity to express criticism toward faculty members they personally dislike.¹ Furthermore, the shift to online course evaluations, accelerated by the recent pandemic, has encountered challenges, particularly in achieving response rates as high as those using traditional paper-based methods.⁴ Given these circumstances, it is understandable that students have been raising doubts about how useful and meaningful course evaluations are.

Previous studies identified several factors affecting course evaluation data including students’ negative attitudes toward classes,^5,6 their cultural values,⁷ gender (both faculty member⁸ and student⁹), year of study,⁹ and the medium used for data collection (ie, online vs paper-based format).^10,11 Of those factors, understanding the relationships between students’ cultural values and course evaluation results is pivotal to improving education in a globalized society. For example, in evaluating an English language course in Dutch higher education, Arnold et al⁷ revealed the cultural differences of the results between Dutch and international students. In their study, students from Asian countries which scored higher in power distance with faculty members such as China and South Korea, tended to be reluctant to provide negative feedback, even in anonymous evaluations due to their profound respect for their teachers. In other words, the evaluation results by these Asian students were more positive as compared with those of their Dutch counterparts, regardless of the faculty members’ actual performance. However, to date, previous studies investigating cultural dimensions of course evaluation by students have not often included Japanese students in Asian student groups. Thus, Japanese students’ perceptions of learning and attitudes toward course evaluation have not been fully examined from a cultural viewpoint. When investigations yield data specific to Japanese students’ evaluation practices, it could highlight the diversity of behavioral patterns in course evaluations among students within Asian countries. Such findings could illuminate the benefits of country-specific studies to uncover the uniqueness of each different Asian educational context.

In Japan, medical education research has explored how course evaluations affect teaching quality¹² and faculty members’ perceptions¹³ but has not delved into what drives student participation in these course evaluations. Understanding the cultural nuances of Japanese medical students’ views and motivations regarding course evaluations can lead to more effective course evaluation processes. This, in turn, could enhance program assessments and ultimately improve medical care quality.

Therefore, this study aims to explore, through a cultural lens, how Japanese medical students perceive course evaluations and what is the motivation to participate in these evaluations.

Theoretical Framework

This study adopted Hofstede’s model of six cultural dimensions as the theoretical framework.¹⁴ This model has been developed based on survey results from over 120,000 employees of an international company across 50 countries and three regions. These dimensions of national cultural values include motivation towards achievement and success, indulgence, power distance, individualism, uncertainty avoidance, and long-term orientation. Each country is scored from 1 to 100 for each cultural dimension. The scores for each country vary widely among continents and even among neighboring countries, reflecting the unique characteristics of a country, as detailed in Table 1. For example, Japan’s high uncertainty avoidance score of 92 reflects a strong cultural emphasis on risk mitigation, shaped by its history of natural disasters such as earthquakes and tsunamis. This mindset fosters hesitation toward adopting new technologies or initiating major changes, with significant time and effort often dedicated to addressing potential risks before proceeding.¹⁵ In contrast, China, with a much lower uncertainty avoidance score of 30, demonstrates greater adaptability and a strong entrepreneurial spirit, favoring flexibility over risk aversion.¹⁶ These cultural differences, despite geographical proximity, illustrate how values shape distinct learning and decision-making behaviors. Hofstede’s model provides a valuable lens to analyze and compare these variations. Additionally, Hofstede’s model has not only been utilized as a framework in social science and cross-cultural studies but also in healthcare and medical education research to analyze data collected. Three such studies include the following: a study exploring the relationship between national differences in antibiotic use and cultural values,¹⁷ a study predicting national differences in medical communication,¹⁸ and a study investigating the influence of national culture on physician-scientist mentoring relationships.¹⁹ Hofstede’s model offers a valuable theoretical framework for analyzing and interpreting the perceptions and motivations of Japanese medical students towards course evaluations from a cultural standpoint. Specifically, the results of the students’ perceptions and motivations will be theoretically reinterpreted through the lens of Hofstede’s model.

Table 1 Hofstede’s Model of Six Cultural Dimensions and Associated Scores in Japan

Methods

The method of conducting course evaluations at this school is described below. This study was conducted at a typical medical school in Japan that offers a standard six-year undergraduate program. Course evaluations at this school are systematically conducted for selected courses from November to January every year. The curriculum features a series of lectures, each given by a different faculty member in various specialized fields. The curriculum consists of liberal arts and general education (first-year), basic medicine (second-year), clinical and social medicine (third to fourth years), and clinical clerkship and preparation for national licensing examinations (fifth to sixth years). The evaluation targeted the initial lecture delivered by a professor or associate professor post-November. All students taking the applicable classes received advance notification of the course evaluation schedule via Email. The evaluation form was created using Google Forms and the link was sent via Email for students to submit their evaluation of the lecture targeted for evaluation. Students were instructed to respond within two days; however, participation and submission were optional. The feedback was shared exclusively with the faculty members involved and not shared with students. The response rate was approximately 15% and students have little interest in participating in course evaluations.

Data Collection

This study targeted third- and fourth-year students as its primary group because their curriculum includes more lecture-based classes, offering them more opportunities to participate in course evaluations. In this study, 23 medical students (Student A - Student W), comprising 12 third-year and 11 fourth-year students, provided their consent to participate after hearing explanations of the study’s objectives, data collection procedures and ethical considerations. Their written consent was provided directly to the first author, indicating their understanding that their anonymized responses, including direct quotes translated into English, would be published.

Four Focus Groups²⁰ comprising 5–7 students each were created. In order to create an environment conducive to open discussion, groups consisted of students from the same year only. Discussion themes for the focus groups were developed based on Hofstede’s model, focusing on their experiences, perceptions and emotions regarding course evaluations. The details of these topics are shown in Box 1. Specifically, the first author asked the students to discuss their experiences with course evaluations. These sessions lasted between 40 to 70 minutes and were audio-recorded. The recorded data were transcribed and translated by the authors.

Box 1 Discussion Topics

Note that the student comments throughout this paper were originally communicated orally in Japanese. They were translated, edited and revised for clarity and to remove inappropriate expressions.

Data Analysis

The study used a reflexive thematic analysis²¹ (TA) approach to analyze the discussion during the Focus Group. Braun and Clarke²¹ suggested that TA is highly theoretically flexible, allowing researchers to use a range of theoretical frameworks, and offers a structured technique for identifying patterns in qualitative data. As such, using TA, this study analyzed the data of focus groups inductively for coding and theme development. Subsequently, Hofstede’s model was applied to reinterpret the identified themes.

Specifically, Braun and Clarke²¹ outlined six analytical steps for coding and theme development within TA. During this first phase, all the researchers systematically reviewed the transcribed data to better understand its content. The second phase involved coding, where the text data was broken into small units according to student beliefs, actions, or ideas. In this phase, the first and second authors individually performed initial coding for the data from the first focus group. The third phase involved generating the initial theme from the coded texts. In this phase, all the members compared the results of individual initial coding in the second phase and identified significant broader meaning patterns (ie, theme). Replicating this process, the first author coded the transcribed data from the remaining three Focus Groups. The fourth phase involved reviewing themes, whereby all the researchers iteratively reviewed the initial themes developed in the previous phases to ensure that the interpretation was congruent with the presented data. The researchers defined the final themes in the fifth phase, which involved determining the focus and establishing the story behind each theme. The themes identified in this study were discussed and agreed upon among the co-authors before being finalized. They were informed by the Hofstede model. Theoretical saturation was achieved on the basis of the authors’ agreement after analyzing the data of the four groups.

Ethical Considerations

This study was approved by the Institutional Review Board of Gifu University School of Medicine (No.2021–A199) and the Institutional Review Board of Nihon University School of Medicine (No.2021–16).

Results

This study identified three main themes, and 11 sub-themes related to Japanese medical students’ perceptions and motivations regarding course evaluations, as detailed in Table 2.

Table 2 Characteristics of Japanese Medical Students’ Perceptions and Motivations Regarding Course Evaluations

Theme 1: Emotions Associated with the Courses Students are Evaluating

The emotions experienced by students during the classes and their relationship with faculty members positively or negatively influenced their decision to participate in course evaluations.

Gratitude Toward Faculty Members for Their Efforts in Providing Valuable Classes

Students’ participation in course evaluations was driven by their positive feelings for the course, and a desire to express gratitude towards faculty members. Some students hoped to motivate faculty members by acknowledging the value of their classes.

I want to say the class was good, not just to be encouraging, but because teachers invest time to teach us, and I appreciate that. (Student K)

I think that evaluations are generally harsh and can be disheartening to read. So, I believe it boosts teacher motivation to know some of us found their class beneficial, which is why I am providing this feedback. (Student M)

Anger and Class Dissatisfaction

Personal negative feelings such as anger and dissatisfaction drove students to criticize classes in course evaluations. The reasons students felt negatively included the following: excessively teacher-centered teaching, insufficiently prepared lectures, and overly challenging assessments. Their comments were not necessarily made with constructive intentions to enhance future education.

Desire to make complaints can sometimes drive motivation to submit evaluations. I know it’s a bad word, but I thought ‘<Expletive>!’, as I was filling in my course evaluation. (Student O)

I’m quite self-centered. If I have complaints with a class, I reflect that in my evaluation. I don’t think I’m going to try to evaluate a course for my juniors or peers. (Student W)

Indifference Towards Unremarkable Classes

Motivation to participate in course evaluations was diminished for classes perceived as unremarkable by students. This was because they believed that course evaluations should only be completed when they experienced strong feelings, such as gratitude or anger, during the class. Because they often expected something in return for participating in course evaluations, they tended to withhold their thoughts regarding an “unremarkable” class.

Nothing good, nothing bad, nothing to say. (Student M)

I can’t think of a message. (Student O)

I may not be phrasing this well, […] but while I like seeing good teachers recognized and bad teachers identified, I question the value of rating average teachers as just that—average. […] I don’t see how it changes anything. (Student J)

Anxiety About the Potential Presumptuousness of Critically Evaluating Faculty Members

Some students were hesitant to critique faculty members, feeling it was presumptuous due to the respect owed to educators and their own position as learners. This discomfort was compounded for students who were struggling academically, leading them to feel presumptuous about providing negative feedback. Consequently, these students often refrained from expressing their true opinions.

I may have a strong feeling of being presumptuous. […] Whenever I give a positive rating, I consistently opt for the highest score, such as a 10, over a 9 or an 8. This approach stems from the respect I hold for the teacher. (Student T)

I find it presumptuous to critique given my poor grades. It makes me feel apologetic. (Student U)

When I begin an evaluation, my initial intent is to share my honest opinion. However, as I proceed, […] I hesitate to express negative feedback and end up revising my comments to be more positive, feeling apologetic for the criticism. (Student W)

Fear of Retaliation from Faculty Members

Students were either reluctant to express their opinions honestly or simply did not participate in course evaluations because of the intimidating attitudes of faculty members and fear of retaliation.

The presence of intimidating teachers makes me hesitant to submit a course evaluation. (Student Q)

I write my comments in a manner that would be ok for the professor to read. (Student U)

Theme 2: Insufficient Understanding of the Significance of Course Evaluations

Students demonstrated a limited understanding of the importance and necessity of course evaluations. A key contributing factor was their lack of experience receiving feedback regarding evaluation results, leaving them unaware of how the evaluations were utilized. This insufficient understanding was associated with a diminished sense of responsibility toward participating in evaluations. Consequently, students were motivated to engage in evaluation activities only when it benefited them or if told to do so.

Doubts About the Use of Course Evaluation Results

Students who doubted the impact and overall influence of course evaluations were less motivated to participate. Many students were uncertain if their submitted data was being accurately recorded and shared with faculty members due to a lack of experience in receiving results regarding course evaluations. This skepticism made numerous students view the evaluations as mere formalities. Consequently, a substantial number of students believed that participating in course evaluations was futile, seeing them as pointless and not worth the effort involved in engaging in a meaningless process.

Sometimes I think it’s just a formality because I don’t get feedback. (Student C)

I think the information is getting through, but whether it’s being reflected, I’m not sure. (Student Q)

Diminished Sense of Responsibility as an Evaluator

During course evaluations, because there is minimal to no recognition among students about the value of their feedback, many believed that even if they did not participate, either the more serious or high-achieving students would cover for them, or only those with strong opinions needed to contribute. This mindset led to a general neglect of participation in course evaluations. In addition, the anonymous format further discouraged involvement, as students felt their absence would not be noticed, leaving them more inclined to let others take the lead.

Well...I often think it’s fine if I’m the only one who doesn’t participate, so I tend to believe there’s no need for me to submit a course evaluation. (Student B)

Sometimes, I don’t submit because I figure if it’s anonymous, no one will notice. Other times, I just find it too much of a hassle, so I just skip it altogether. (Student E)

Expected Impact of Course Evaluations

For faculty members teaching few lessons, students were less inclined to submit an evaluation because they doubted that their feedback could lead to significant changes to the course as a whole. Additionally, many students felt that in situations with few classes, it was better to endure any shortcomings rather than suggest improvements. However, students were more likely to engage in evaluations of lessons with content relevant to other courses, hoping their feedback would influence those other courses. Furthermore, students showed greater motivation to participate in evaluations of faculty members with numerous class sessions, especially when they anticipated their feedback could lead to improved courses they would take in the future.

In med school, I feel that classes are merely to be endured. (Student H)

When a course is finished, it has nothing to do with me anymore. I think. (Student F)

I submit course evaluations with the hope that other teachers will emulate this teacher’s qualities. (Student T)

I submit course evaluations partly for the sake of the younger students, but also with the hope for improvement if I have a plan to take that teacher’s class in the future. (Student L)

Faculty Members’ Attitudes Toward Improving Classes

Students showed greater motivation to engage in course evaluations when faculty members explicitly requested their participation. Conversely, when faculty members adhered rigidly to their own teaching policies and philosophies, showing little openness to student feedback, students were less inclined to participate in course evaluations.

If a teacher is genuinely interested in student feedback and makes it clear they value our input, I’m more likely to provide it; especially if teachers ask me politely. (Student C)

I feel that a teacher who is so set in his/her ways is not going to be able to do anything we say. So then, I feel it’s pointless to even bother to submit a course evaluation. (Student T)

Theme 3: Course Evaluation Logistics Impacting Student Motivation

Course evaluation logistics impacted student motivation, particularly in practical aspects such as scheduling and designing online evaluation forms, as well as methods for sharing student responses with classmates.

Survey Practicality

Students were more inclined to participate in course evaluations when the form was sent at the end of a class session, highlighting the convenience of completing it immediately without setting aside additional time. A preference was noted for multiple-choice formats over free written responses, as they were seen as easier and more straightforward to complete. Conversely, students reported being less likely to engage with course evaluations when these are distributed outside of class hours. This reluctance stems from the inconvenience of allocating time for evaluations, delays in checking Emails, or prioritizing other tasks over completing evaluations. Additionally, form complexity involving multiple steps such as logging in or filling out free-text fields, further deterred participation. Consequently, there was a clear preference for simpler and more user-friendly evaluation formats. Those would more likely result in greater participation.

If the evaluation form offered multiple-choice options, I might be more likely to participate, rather than if it required free written descriptions. (Student A)

I might plan to complete the evaluation during free moments, thinking, ‘Oh, logging in is a hassle, I’ll do it later at home.’ But then, I get home, don’t do it, go to bed, and eventually realize I’m not going to do it at all. (Student N)

Methods for Sharing Student Responses with Classmates

The availability of information (number of respondents, response rate, and summarized results) boosts student participation. This motivation is partly due to a desire to align with their peers, feeling a sense of obligation to participate if others are doing so, and a curiosity to compare their opinions with those of their classmates. Additionally, students finding it a hassle to participate in course evaluations, may be more motivated to submit if the class response rate is low. Those students changed their mind because of a concern that faculty members may not adequately understand student opinions, so they feel a need to express themselves.

I’m pretty much wanting responses from friends, or from people in the same class as me. I want to see the results right away because I want to know the opinions of people who agree with me or have a different opinion. (Student W)

Besides the content of the evaluation, I would like to know how many students submitted. It’d make me think, ‘Oh, 80 responses went to this teacher, so the message is getting through. (Student H)

(But if it were only 10 responses), I’d feel like, ‘That’s not good. (Student K)

It would make me think, ‘I really need to say something about this. (Student H)

Discussion

This study is the first analysis of Japanese medical students’ perceptions and motivations towards course evaluations. This study revealed that Japanese medical students exhibit distinct emotional responses toward course evaluations, lack an understanding of the importance of course evaluations, and demonstrate a preference for specific implementation methods. Here, we reinterpret the findings through Hofstede’s model of six cultural dimensions, providing a theoretical perspective on course evaluations. Additionally, we propose educational recommendations for future improvements.

First, Japan is characterized by a very high score in Hofstede’s cultural dimension of decisiveness (masculinity).¹⁵ Such countries tend to manifest perfectionism¹⁴ which was reflected in our Japanese medical students’ views on course evaluations. The students in this study prioritized identifying areas for improvement over highlighting strengths, seeing evaluations primarily as a tool for critique. This view has driven them to participate more actively in the course evaluations, particularly when they identify courses that require significant improvement. This approach, deeply rooted in the Confucian value of error avoidance and maintaining face, underscores the cultural emphasis on correctness and the stigma of making mistakes in educational settings.²² Similar findings by Frambach et al show how shame culture fosters perfectionism in Confucian societies.²³ Another related concept is hansei (ie, reflection), which is looking back on things. In Japanese culture, reflection is habitually practiced from childhood as a fundamental skill for social and personal growth.²⁴ Reflection is the act of looking back, particularly emphasizing the negative aspects of what not to do, and Japanese people tend to prefer learning from their mistakes and improving upon them.²⁵ This study shows that the perfectionist mindset and reflective practice may have led to the attitude, which is to highlight unsatisfactory aspects and to demand improvements from faculty members.

In countries such as Japan, Hofstede’s restraint dimension score was shown to be relatively high.¹⁵ Students in that previous study believed they could not change reality on their own, therefore, they tended to accept education as is, which led to decreased motivation to implement changes.¹⁴ This phenomenon was evident in many medical students in this study, who showed little interest in evaluating courses they considered average, as expressed by Student M: “Nothing good, nothing bad, nothing to say”. They perceived such evaluations as lacking value. Guo et al²⁶ note that societies with higher indulgence levels engage more in volunteering, contrasting with the restrained approach of Japanese students, who are less inclined to participate in evaluations. This study shows that their attitude of accepting the status quo, whether positive or negative, acts as a barrier to engaging in evaluative feedback, indicating a cultural disinclination towards actions perceived as potentially futile or unnecessary.

In accordance with Hofstede’s model, large power distance cultures such as in Japan,¹⁵ have education that is teacher-centered, with a strong emphasis on respecting teachers and avoiding public opposition or criticism.¹⁴ The students in this study hesitated to express their honest opinions, fearing repercussions and seeing it as disrespectful to judge faculty members, which is consistent with the characteristics of countries with large power distance. Confucianism, influential in many Asian countries, positions teachers as the primary sources of knowledge, responsible for students learning.²⁷ This sentiment was reflected by the medical students in this study who preferred to follow the teacher’s lead rather than imposing their own views on them. Additionally, the cultural emphasis on avoiding shame and saving face, particularly for elders, encourages a “Moderation” approach that avoids direct criticism and conflict.²⁸ This cultural backdrop suggests that for some students included in this study, the challenge of critiquing faculty members is substantial for students, particularly when coupled with the perception that course evaluations are meant to highlight negatives. This led students to think that negative feedback is disrespectful and inappropriate. In contrast, when faculty members explicitly invited evaluations, students felt safer contributing. Even then, they hesitate to express their true feelings and have a “Moderation” attitude, aiming to maintain politeness and respect towards the other party, as reflected by Student W: “I hesitate to express negative feedback and end up revising my comments to be more positive, feeling apologetic for the criticism”.

Hofstede’s model asserts that in general, the bonds between individuals are loose in an individualistic society. Conversely, in collectivist societies, people belong to in-groups that look after each other in exchange for loyalty.¹⁴ According to the latest Hofstede scores of individualism vs collectivism, Japanese are considered to have a tendency towards individualism, but at the same time, they are also described as having a strong sense of loyalty to their organization and being able to behave in a collectivist manner depending on the situation.¹⁵ In fact, Japanese educational philosophy emphasizes prioritizing group harmony.²⁹ This creates peer pressure, leading students to avoid expressing dissenting opinions that might disrupt cohesion. This study shows that the students often hesitate to voice their views independently, instead gauging the consensus before contributing. While course evaluations aim to capture individual feedback, students’ responses are strongly influenced by collective attitudes, illustrating the complex interaction between individual input and group norms in Japanese education.

A high uncertainty avoidance score on Hofstede’s model reflects a focus on minimizing risk.¹⁴ In such countries, including Japan,¹⁵ decisions are cautious and thorough, a mindset mirrored in medical students in this study. The rapid social changes brought by digitalization heightens the perception of uncertainty and risk as noted by Kubota.³⁰ Consequently, there is a noticeable shift towards decision-making that emphasizes efficiency, cost-effectiveness, and rationality. Students in this study expressed apprehension towards engaging in activities with unclear outcomes and students are reluctant to invest time in evaluations unless they believe their feedback will lead to course improvements or if faculty members show commitment to change. The study also highlights that the method and timing of course evaluations influence student participation, with efficiency and cost-effectiveness playing critical roles. This study shows that students preferred evaluations conducted during class or through simplified forms, as they found out-of-class evaluations inefficient and a poor use of time.

This study found no theme associated with Hofstede’s dimension of long-term orientation,¹⁴ even though Japanese people tend to be particularly long-term oriented,¹⁵ the fact that many students chose not to participate in course evaluations because of the hassle that prevailed can be seen as rather short-term oriented. In this regard, it has been noted that there is a negative correlation between long-term orientation and social behaviors such as helping strangers and making donations, and this characteristic may be related.²⁶

To implement course evaluations effectively in Japan, the process should align with students’ emotions, follow a simple procedure, and emphasize its significance. Establishing a feedback system that shows students the outcomes of their evaluations could enhance participation. Also, improving class quality may also involve offering instructional opportunities to enhance the value of participation in evaluations to students who play a crucial role as evaluators. Moreover, recognizing the reverence students hold for faculty members, it is crucial for faculty members to be aware of their evaluated role and make efforts to remain accessible to students. Facilitating community among faculty members through Faculty Development (FD) initiatives can be a powerful strategy.³¹ Such communities promote reflective practices on teaching, increase faculty members’ engagement in medical education and foster a more open stance towards student interaction. Additionally, simplifying the process—by reducing login steps, shortening questions, and minimizing open-ended responses—combined with integrating evaluations into class time, could make it more practical for both students and faculty members.

This study has several limitations. Firstly, it focused only on third- and fourth-year students at one institution, indicating a need for future research incorporating participants from varied backgrounds across multiple institutions. Secondly, the group discussion format might have led some students to conform to the prevailing opinions, potentially hindering the expression of their genuine views. Lastly, because we were not able to interview the participants as deeply about their personal experiences as we could have with individual interviews, we need to consider incorporating individual interview data in the analysis that makes use of more concrete examples.

Conclusion

This study has illuminated three themes specifically related to Japanese culture as informed by Hofstede’s model which shape medical students’ perceptions and motivations regarding course evaluations: Theme 1) student emotional reactions; Theme 2) inadequate understanding of the significance of course evaluations; Theme 3) logistical implementation. The findings highlight that grasping these cultural nuances could possibly offer valuable insights for the successful execution of course evaluations across various cultural settings within medical schools. Additionally, the research opens avenues for applying these insights to post-graduate education, FD, and evaluations of other programs involving learner participation.