Philosophers and scientists alike insist that wonder is the central virtue and engine of all education.^1-3 Wonder is defined as “a feeling of radical appreciation for a triggering event, typically accompanied by a behavior of pausing to reflect and a motivation to reorient one’s self-understanding and sense of the world.”⁴ Although curiosity seems to be related to wonder, they differ in the following ways. Curiosity is a goal-oriented interest in answering a specific question and is superficial, whereas wonder is broader, more deeply emotional, and comes from within.^4,5 Accordingly, wonder is at the origin of learning,² and experience of wonder is irreplaceable and should be protected and promoted in academic settings.

Thus, the concept of wonder has been the subject of philosophical and social scientific inquiry and has been overlooked in the health professions education.⁶ However, in 2012, Evans indicated the importance of fostering capacity for wonder (CfW) among healthcare professionals and trainees.⁷ In 2018, Geller and colleagues posited that the adverse pressures inherent in the learning environment of medical education (i.e., the pervasive competitive atmosphere) can impede the growth of essential personal virtues for healthcare professionals, which encompass respect, compassion, altruism, recognizing ambiguity/uncertainty, and acknowledging mistakes.⁸ They asserted that fostering CfW is crucial to counteract those detrimental influences.⁸ Since 2020, research has been conducted on the CfW in the field of medical education, particularly in the U.S.^9,10 Wonder is a personal resource, a source of renewal for the physician that fuels the diagnostic imagination, and a timely and valuable reminder of the embodied agency of both patient and physician, with a diminution of one’s self and an orientation towards humility.^7,11 The CfW can therefore promote ethical leadership and lifelong learning and help maintain important qualities such as tolerance of ambiguity and the fostering of empathy and humility.^7-9,12 In light of these, development of the capacity for wonder among physicians and medical trainees is of high priority.

Effective education in cultivating CfW first necessitates a tool for measuring it. A measure for assessing CfW was not available until the CfW Scale (CfWS) was developed by Geller and colleagues in 2020.⁴  The scale was validated among undergraduate students at a research university in the U.S., and then examined among medical students.⁹ Currently, in the U.S., the CfWS is widely used to assess the CfW of medical students. For example, Tackett and colleagues implemented an arts-based elective for medical students and evaluated its educational effectiveness by using the CfWS.¹⁰ Zheng and colleagues described the usefulness of the scale in the quantitative evaluation of arts and humanities activities.⁶

In contrast, in medical education in Japan, few educational interventions have been implemented to foster the CfW and develop its assessment. The primary reason is that no scale has been developed in Japan to measure the CfW. Given the potential of wonder to promote humanistic care and lifelong learning, its development is essential, and thus, the development of a scale for measuring it is urgent. However, it is unclear whether the CfWS can be directly applied in the Japanese medical education context because the CfW indeed vary across cultures and can be influenced by educational systems and societal norms. Cultural background would play an important role in shaping CfW, and tools for measuring CfW should be developed with respect to cultural context.

Accordingly, the aim of this study was to translate and culturally adapt the CfWS for use in Japan and to examine its psychometric properties.

The number of eligible participants was 2170, of whom 399 answered the questionnaire. After exclusion of 15 participants with missing data, 384 (17.7%) were included in the analysis. Table 1 summarizes the characteristics of the participants. The majority were male 238 (62.0%). Regarding academic year, the most common group were 4th-year students 127 (33.1%), followed by 1st-year students 90 (23.4%).  Table 2 shows the participants’ responses to each item of the questionnaire.

In this study, we developed the J-CfWS and examined its psychometric properties. Our translation into Japanese was performed by experienced translators in the field of health professions education, in accordance with an international guideline.¹⁶ To our knowledge, the J-CfWS is the first scale for measuring CfW in Japan.

In this study, as with the English version,⁴ our analysis supported the good structural validity, convergent validity, and internal consistency reliability of our Japanese version. In addition, the strength of the study is the robustness of its translation process. We translated the original scale with reference to a cross-cultural instrument adaptation guideline in the following steps: forward translation, synthesis, back-translation, expert review, and pilot testing.¹⁶ This rigorous translation process strengthened the validity of the scale.

Factor analysis revealed that the J-CfWS had a different factor-structure to the original English version: the former had a three-factor structure, while the latter had two factors. Similarly, previous cross-cultural validation studies in the field of Japanese medical education have also identified a factor structure that differs from the original English version, as a result of factor analysis. In their study of the development of the Japanese version of the interprofessional facilitation scale, Haruta and colleagues did not identify the factor of “contextualizing interprofessional education,” which had been identified in the recent Canadian study.^30,31 Rather, the authors did extract a factor of “respect for each professional.”³⁰ They concluded that this divergence was likely caused by characteristics of the Japanese culture, as based on relationalism.³⁰ Factor analysis extracted four factors in the development of the Japanese translation of the Patient Care Ownership Scale, while the original English version had three factors.^22,32 The research team suggested that the discrepancy might be related to a unique cultural feature of Japan, namely, a historical code of personal conduct (“Bushido”).^22,33 In our study, the precise mechanism behind the differences in factor structure between the Japanese and English versions remains unclear. Nevertheless, given that CfW is expected to be influenced by culture,⁴ participant responses to the questionnaire may have been affected by cultural differences between the U.S. and Japan. The U.S. culture frequently encourages individualism and assertiveness, potentially encouraging more open expression of wonder. In collectivist cultures, there may be a greater emphasis on maintaining harmony and conformity, which can influence the manner in which individuals express wonder.

Japan takes a middle position on the dimension of individualism/collectivism.34 The discrepancy in individualism/collectivism between the U.S. and Japan may have influenced the responses of the participants to the questionnaire. Further studies are needed to clarify the mechanism of this difference. Our developed measure will contribute to various settings and enhance the quality of health professions education. For example, it can be useful as a scale for assessing the educational interventions of curricula that aim to nurture CfW among medical trainees. Zheng and colleagues indicated that learning activities in arts and humanities subjects could nurture physicians’ CfW.⁶ In particular, visual thinking strategies could be readily and effectively integrated into medical education for cultivating CfW.⁶ It will also be useful as a research tool to examine the association between CfW and other concepts (e.g., academic performance and empathy) in the field of medical education. Medical learners with greater CfW may foster a heightened sensitivity to nuance, an attitude that admires deep contemplation and radical appreciation, and deeper pursuit for meaning.⁶ This can ultimately contribute to enhanced patient care, scientific discovery, and lifelong learning.⁷ Thus, the CfWS has the potential to be used in a range of medical education settings and research contexts, with the possibility of enhancing the quality of medical education and patient care.

Potential limitations of this study should also be noted. First, the number of institutions in which the validation survey was performed was relatively small. Further studies which recruited larger numbers of institutions would strengthen the robustness of the J-CfWS. Second, the response rate was relatively small, which may raise questions about representativeness. The voluntary nature of the study, which was recruited via mailing lists or electronic bulletin board system, and the use of an online survey format,³⁵ may have contributed to the lower response rate. Efforts were made to optimize the response rate, including the use of reminder emails and remuneration.

Figure 1. Factor structure of the Japanese version of the Capacity for Wonder Scale (confirmatory factor analysis). Ellipses are latent variables (factors). Rectangles are observed variables (items). Values on single-headed arrows are standardized factor loadings. Values on double-headed arrows are correlation coefficients.

Third, although our study used split-half validation approach, EFA and CFA were conducted on the same dataset, which might introduce bias. However, this is an acceptable method, commonly used in previous exploratory studies.^15,21,36 Future research should use independent samples for EFA and CFA to validate the findings further. Fourth, we should acknowledge that the three-factor structure identified in this study may not be final. The three factors were named based on discussions among researchers, rather than from literature or theory. Finally, psychometric properties other than structural validity, convergent validity, and internal consistency reliability were not examined. Future studies should test the three-factor model across different samples to confirm its stability and examine other psychometric properties (e.g., test-retest reliability and discriminant validity), which would also strengthen the developed scale.

We translated and adapted the CfWS into Japanese and examined its psychometric properties. The scale will be useful in evaluating the impact of the curricula aimed at cultivating CfW among medical trainees (e.g., arts and humanities courses). It can benefit medical education researchers who aim to uncover the relationship between CfW and other concepts. Thus, the results of this study and the measure developed will provide helpful information to faculty members and researchers aiming to improve the medical education system by enhancing CfW among medical students.