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Critical Thinking Models: A Comprehensive Guide for Effective Decision Making

Critical thinking models are valuable frameworks that help individuals develop and enhance their critical thinking skills . These models provide a structured approach to problem-solving and decision-making by encouraging the evaluation of information and arguments in a logical, systematic manner. By understanding and applying these models, one can learn to make well-reasoned judgments and decisions.

Various critical thinking models exist, each catering to different contexts and scenarios. These models offer a step-by-step method to analyze situations, scrutinize assumptions and biases, and consider alternative perspectives. Ultimately, the goal of critical thinking models is to enhance an individual’s ability to think critically, ultimately improving their reasoning and decision-making skills in both personal and professional settings.

Key Takeaways

• Critical thinking models provide structured approaches for enhancing decision-making abilities
• These models help individuals analyze situations, scrutinize assumptions, and consider alternative perspectives
• The application of critical thinking models can significantly improve one’s reasoning and judgment skills.

Fundamentals of Critical Thinking

Definition and Importance

Critical thinking is the intellectual process of logically, objectively, and systematically evaluating information to form reasoned judgments, utilizing reasoning , logic , and evidence . It involves:

• Identifying and questioning assumptions,
• Applying consistent principles and criteria,
• Analyzing and synthesizing information,
• Drawing conclusions based on evidence.

The importance of critical thinking lies in its ability to help individuals make informed decisions, solve complex problems, and differentiate between true and false beliefs .

Core Cognitive Skills

Several core cognitive skills underpin critical thinking:

• Analysis : Breaking down complex information into smaller components to identify patterns or inconsistencies.
• Evaluation : Assessing the credibility and relevance of sources, arguments, and evidence.
• Inference : Drawing conclusions by connecting the dots between analyzed information.
• Synthesis : Incorporating analyzed information into a broader understanding and constructing one’s argument.
• Logic and reasoning : Applying principles of logic to determine the validity of arguments and weigh evidence.

These skills enable individuals to consistently apply intellectual standards in their thought process, which ultimately results in sound judgments and informed decisions.

Influence of Cognitive Biases

A key aspect of critical thinking is recognizing and mitigating the impact of cognitive biases on our thought processes. Cognitive biases are cognitive shortcuts or heuristics that can lead to flawed reasoning and distort our understanding of a situation. Examples of cognitive biases include confirmation bias, anchoring bias, and availability heuristic.

To counter the influence of cognitive biases, critical thinkers must be aware of their own assumptions and strive to apply consistent and objective evaluation criteria in their thinking process. The practice of actively recognizing and addressing cognitive biases promotes an unbiased and rational approach to problem-solving and decision-making.

The Critical Thinking Process

Stages of Critical Thinking

The critical thinking process starts with gathering and evaluating data . This stage involves identifying relevant information and ensuring it is credible and reliable. Next, an individual engages in analysis by examining the data closely to understand its context and interpret its meaning. This step can involve breaking down complex ideas into simpler components for better understanding.

The next stage focuses on determining the quality of the arguments, concepts, and theories present in the analyzed data. Critical thinkers question the credibility and logic behind the information while also considering their own biases and assumptions. They apply consistent standards when evaluating sources, which helps them identify any weaknesses in the arguments.

Values play a significant role in the critical thinking process. Critical thinkers assess the significance of moral, ethical, or cultural values shaping the issue, argument, or decision at hand. They determine whether these values align with the evidence and logic they have analyzed.

After thorough analysis and evaluation, critical thinkers draw conclusions based on the evidence and reasoning gathered. This step includes synthesizing the information and presenting a clear, concise argument or decision. It also involves explaining the reasoning behind the conclusion to ensure it is well-founded.

Application in Decision Making

In decision making, critical thinking is a vital skill that allows individuals to make informed choices. It enables them to:

• Analyze options and their potential consequences
• Evaluate the credibility of sources and the quality of information
• Identify biases, assumptions, and values that may influence the decision
• Construct a reasoned, well-justified conclusion

By using critical thinking in decision making, individuals can make more sound, objective choices. The process helps them to avoid pitfalls like jumping to conclusions, being influenced by biases, or basing decisions on unreliable data. The result is more thoughtful, carefully-considered decisions leading to higher quality outcomes.

Critical Thinking Models

Critical thinking models are frameworks that help individuals develop better problem-solving and decision-making abilities. They provide strategies for analyzing, evaluating, and synthesizing information to reach well-founded conclusions. This section will discuss four notable models: The RED Model, Bloom’s Taxonomy, Paul-Elder Model, and The Halpern Critical Thinking Assessment.

The RED Model

The RED Model stands for Recognize Assumptions, Evaluate Arguments, and Draw Conclusions. It emphasizes the importance of questioning assumptions, weighing evidence, and reaching logical conclusions.

• Recognize Assumptions: Identify and challenge assumptions that underlie statements, beliefs, or arguments.
• Evaluate Arguments: Assess the validity and reliability of evidence to support or refute claims.
• Draw Conclusions: Make well-reasoned decisions based on available information and sound reasoning.

The RED Model helps individuals become more effective problem solvers and decision-makers by guiding them through the critical thinking process ^(source) .

Bloom’s Taxonomy

Bloom’s Taxonomy is a hierarchical model that classifies cognitive skills into six levels of complexity. These levels are remembering, understanding, applying, analyzing, evaluating, and creating. By progressing through these levels, individuals can develop higher-order thinking skills.

• Remembering: Recall information or facts.
• Understanding: Comprehend the meaning of ideas, facts, or problems.
• Applying: Use knowledge in different situations.
• Analyzing: Break down complex topics or problems into sub-parts.
• Evaluating: Assess the quality, relevance, or credibility of information, ideas, or solutions.
• Creating: Combine elements to form a new whole, generate new ideas, or solve complex issues.

Paul-Elder Model

The Paul-Elder Model introduces the concept of “elements of thought,” focusing on a structured approach to critical thinking. This model promotes intellectual standards, such as clarity, accuracy, and relevance. It consists of three stages:

• Critical Thinking: Employ the intellectual standards to problem-solving and decision-making processes.
• Elements of Thought: Consider purpose, question at issue, information, interpretation and inference, concepts, assumptions, implications, and point of view.
• Intellectual Traits: Develop intellectual traits, such as intellectual humility, intellectual empathy, and intellectual perseverance.

This model fosters a deeper understanding and appreciation of critical thinking ^(source) .

The Halpern Critical Thinking Assessment

The Halpern Critical Thinking Assessment is a standardized test developed by Diane Halpern to assess critical thinking skills. The evaluation uses a variety of tasks to measure abilities in core skill areas, such as verbal reasoning, argument analysis, and decision making. Pearson, a leading publisher of educational assessments, offers this test as a means to assess individuals’ critical thinking skills ^(source) .

These four critical thinking models can be used as frameworks to improve and enhance cognitive abilities. By learning and practicing these models, individuals can become better equipped to analyze complex information, evaluate options, and make well-informed decisions.

Evaluating Information and Arguments

In this section, we will discuss the importance of evaluating information and arguments in the process of critical thinking, focusing on evidence assessment, logic and fallacies, and argument analysis.

Evidence Assessment

Evaluating the relevance, accuracy, and credibility of information is a vital aspect of critical thinking. In the process of evidence assessment, a thinker should consider the following factors:

• Source reliability : Research and understand the expertise and credibility of the source to ensure that biased or inaccurate information is not being considered.
• Currency : Check the date of the information to make sure it is still relevant and accurate in the present context.
• Objectivity : Analyze the information for potential bias and always cross-reference it with other credible sources.

When practicing critical thinking skills, it is essential to be aware of your own biases and make efforts to minimize their influence on your decision-making process.

Logic and Fallacies

Logic is crucial for deconstructing and analyzing complex arguments, while identifying and avoiding logical fallacies helps maintain accurate and valid conclusions. Some common fallacies to watch out for in critical thinking include:

• Ad Hominem : Attacking the person making the argument instead of addressing the argument itself.
• Strawman : Misrepresenting an opponent’s argument to make it easier to refute.
• False Dilemma : Presenting only two options when there may be multiple viable alternatives.
• Appeal to Authority : Assuming a claim is true simply because an authority figure supports it.

Being aware of these fallacies enables a thinker to effectively evaluate the strength of an argument and make sound judgments accordingly.

Argument Analysis

Analyzing an argument is the process of evaluating its structure, premises, and conclusion while determining its validity and soundness. To analyze an argument, follow these steps:

• Identify the premises and conclusion : Determine the main point is being argued, how it is related and substance of the argument.
• Evaluate the validity : Assess whether the conclusion logically follows from the premises and if the argument’s structure is sound.
• Test the soundness : Evaluate the truth and relevance of the premises. This may require verifying the accuracy of facts and evidence, as well as assessing the reliability of sources.
• Consider counter-arguments : Identify opposing viewpoints and counter-arguments, and evaluate their credibility to gauge the overall strength of the original argument.

By effectively evaluating information and arguments, critical thinkers develop a solid foundation for making well-informed decisions and solving problems.

Enhancing Critical Thinking

Strategies for improvement.

To enhance critical thinking, individuals can practice different strategies, including asking thought-provoking questions, analyzing ideas and observations, and being open to different perspectives. One effective technique is the Critical Thinking Roadmap , which breaks critical thinking down into four measurable phases: execute, synthesize, recommend, and communicate. It’s important to use deliberate practice in these areas to develop a strong foundation for problem-solving and decision-making. In addition, cultivating a mindset of courage , fair-mindedness , and empathy will support critical thinking development.

Critical Thinking in Education

In the field of education, critical thinking is an essential component of effective learning and pedagogy. Integrating critical thinking into the curriculum encourages student autonomy, fosters innovation, and improves student outcomes. Teachers can use various approaches to promote critical thinking, such as:

• Employing open-ended questions to stimulate ideas
• Incorporating group discussions or debates to facilitate communication and evaluation of viewpoints
• Assessing and providing feedback on student work to encourage reflection and improvement
• Utilizing real-world scenarios and case studies for practical application of concepts

Developing a Critical Thinking Mindset

To truly enhance critical thinking abilities, it’s important to adopt a mindset that values integrity , autonomy , and empathy . These qualities help to create a learning environment that encourages open-mindedness, which is key to critical thinking development. To foster a critical thinking mindset:

• Be curious : Remain open to new ideas and ask questions to gain a deeper understanding.
• Communicate effectively : Clearly convey thoughts and actively listen to others.
• Reflect and assess : Regularly evaluate personal beliefs and assumptions to promote growth.
• Embrace diversity of thought : Welcome different viewpoints and ideas to foster innovation.

Incorporating these approaches can lead to a more robust critical thinking skillset, allowing individuals to better navigate and solve complex problems.

Critical Thinking in Various Contexts

The workplace and beyond.

Critical thinking is a highly valued skill in the workplace, as it enables employees to analyze situations, make informed decisions, and solve problems effectively. It involves a careful thinking process directed towards a specific goal. Employers often seek individuals who possess strong critical thinking abilities, as they can add significant value to the organization.

In the workplace context, critical thinkers are able to recognize assumptions, evaluate arguments, and draw conclusions, following models such as the RED model . They can also adapt their thinking to suit various scenarios, allowing them to tackle complex and diverse problems.

Moreover, critical thinking transcends the workplace and applies to various aspects of life. It empowers an individual to make better decisions, analyze conflicting information, and engage in constructive debates.

Creative and Lateral Thinking

Critical thinking encompasses both creative and lateral thinking. Creative thinking involves generating novel ideas and solutions to problems, while lateral thinking entails looking at problems from different angles to find unique and innovative solutions.

Creative thinking allows thinkers to:

• Devise new concepts and ideas
• Challenge conventional wisdom
• Build on existing knowledge to generate innovative solutions

Lateral thinking, on the other hand, encourages thinkers to:

• Break free from traditional thought patterns
• Combine seemingly unrelated ideas to create unique solutions
• Utilize intuition and intelligence to approach problems from a different perspective

Both creative and lateral thinking are essential components of critical thinking, allowing individuals to view problems in a holistic manner and generate well-rounded solutions. These skills are highly valued by employers and can lead to significant personal and professional growth.

In conclusion, critical thinking is a multifaceted skill that comprises various thought processes, including creative and lateral thinking. By embracing these skills, individuals can excel in the workplace and in their personal lives, making better decisions and solving problems effectively.

Overcoming Challenges

Recognizing and addressing bias.

Cognitive biases and thinking biases can significantly affect the process of critical thinking . One of the key components of overcoming these challenges is to recognize and address them. It is essential to be aware of one’s own beliefs, as well as the beliefs of others, to ensure fairness and clarity throughout the decision-making process. To identify and tackle biases, one can follow these steps:

• Be self-aware : Understand personal beliefs and biases, acknowledging that they may influence the interpretation of information.
• Embrace diverse perspectives : Encourage open discussions and invite different viewpoints to challenge assumptions and foster cognitive diversity.
• Reevaluate evidence : Continuously reassess the relevance and validity of the information being considered.

By adopting these practices, individuals can minimize the impact of biases and enhance the overall quality of their critical thinking skills.

Dealing with Information Overload

In today’s world, information is abundant, and it can become increasingly difficult to demystify and make sense of the available data. Dealing with information overload is a crucial aspect of critical thinking. Here are some strategies to address this challenge:

• Prioritize information : Focus on the most relevant and reliable data, filtering out unnecessary details.
• Organize data : Use tables, charts, and lists to categorize information and identify patterns more efficiently.
• Break down complex information : Divide complex data into smaller, manageable segments to simplify interpretation and inferences.

By implementing these techniques, individuals can effectively manage information overload, enabling them to process and analyze data more effectively, leading to better decision-making.

In conclusion, overcoming challenges such as biases and information overload is essential in the pursuit of effective critical thinking. By recognizing and addressing these obstacles, individuals can develop clarity and fairness in their thought processes, leading to well-informed decisions and improved problem-solving capabilities.

Measuring Critical Thinking

Assessment tools and criteria.

There are several assessment tools designed to measure critical thinking, each focusing on different aspects such as quality, depth, breadth, and significance of thinking. One example of a widely used standardized test is the Watson-Glaser Critical Thinking Appraisal , which evaluates an individual’s ability to interpret information, draw conclusions, and make assumptions. Another test is the Cornell Critical Thinking Tests Level X and Level Z , which assess an individual’s critical thinking skills through multiple-choice questions.

Furthermore, criteria for assessing critical thinking often include precision, relevance, and the ability to gather and analyze relevant information. Some assessors utilize the Halpern Critical Thinking Assessment , which measures the application of cognitive skills such as deduction, observation, and induction in real-world scenarios.

The Role of IQ and Tests

It’s important to note that intelligence quotient (IQ) tests and critical thinking assessments are not the same. While IQ tests aim to measure an individual’s cognitive abilities and general intelligence, critical thinking tests focus specifically on one’s ability to analyze, evaluate, and form well-founded opinions. Therefore, having a high IQ does not necessarily guarantee strong critical thinking skills, as critical thinking requires additional mental processes beyond basic logical reasoning.

To build and enhance critical thinking skills, individuals should practice and develop higher-order thinking, such as critical alertness, critical reflection, and critical analysis. Using a Critical Thinking Roadmap , such as the four-phase framework that includes execution, synthesis, recommendation, and the ability to apply, individuals can continuously work to improve their critical thinking abilities.

Frequently Asked Questions

What are the main steps involved in the paul-elder critical thinking model.

The Paul-Elder Critical Thinking Model is a comprehensive framework for developing critical thinking skills. The main steps include: identifying the purpose, formulating questions, gathering information, identifying assumptions, interpreting information, and evaluating arguments. The model emphasizes clarity, accuracy, precision, relevance, depth, breadth, logic, and fairness throughout the critical thinking process. By following these steps, individuals can efficiently analyze and evaluate complex ideas and issues.

Can you list five techniques to enhance critical thinking skills?

Here are five techniques to help enhance critical thinking skills:

• Ask open-ended questions : Encourages exploration and challenges assumptions.
• Engage in active listening: Focus on understanding others’ viewpoints before responding.
• Reflect on personal biases: Identify and question any preconceived notions or judgments.
• Practice mindfulness: Develop self-awareness and stay present in the moment.
• Collaborate with others: Exchange ideas and learn from diverse perspectives.

What is the RED Model of critical thinking and how is it applied?

The RED Model of critical thinking consists of three key components: Recognize Assumptions, Evaluate Arguments, and Draw Conclusions. To apply the RED Model, begin by recognizing and questioning underlying assumptions, being aware of personal biases and stereotypes. Next, evaluate the strengths and weaknesses of different arguments, considering evidence, logical consistency, and alternative explanations. Lastly, draw well-reasoned conclusions that are based on the analysis and evaluation of the information gathered.

How do the ‘3 C’s’ of critical thinking contribute to effective problem-solving?

The ‘3 C’s’ of critical thinking – Curiosity, Creativity, and Criticism – collectively contribute to effective problem-solving. Curiosity allows individuals to explore various perspectives and ask thought-provoking questions, while Creativity helps develop innovative solutions and unique approaches to challenges. Criticism, or the ability to evaluate and analyze ideas objectively, ensures that the problem-solving process remains grounded in logic and relevance.

What characteristics distinguish critical thinking from creative thinking?

Critical thinking and creative thinking are two complementary cognitive skills. Critical thinking primarily focuses on analyzing, evaluating, and reasoning, using objectivity and logical thinking. It involves identifying problems, assessing evidence, and drawing sound conclusions. Creative thinking, on the other hand, is characterized by the generation of new ideas, concepts, and approaches to solve problems, often involving imagination, originality, and out-of-the-box thinking.

What are some recommended books to help improve problem-solving and critical thinking skills?

There are several books that can help enhance problem-solving and critical thinking skills, including:

• “Thinking, Fast and Slow” by Daniel Kahneman: This book explores the dual process theory of decision-making and reasoning.
• “The 5 Elements of Effective Thinking” by Edward B. Burger and Michael Starbird: Offers practical tips and strategies for improving critical thinking skills.
• “Critique of Pure Reason” by Immanuel Kant: A classic philosophical work that delves into the principles of reason and cognition.
• “Mindware: Tools for Smart Thinking” by Richard E. Nisbett: Presents a range of cognitive tools to enhance critical thinking and decision-making abilities.
• “The Art of Thinking Clearly” by Rolf Dobelli: Explores common cognitive biases and errors in judgment that can affect critical thinking.

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Very good book, engaging, good use of figures and diagrams. Good application to practice - I will also be adding this to an International Health Assessment reading list.

This is a fantastic update from previous versions giving good scenarios for the students to work through. It includes all the relevant theories of clinical decision making and relates this to up to date practice.

Personally I love the practical approach and as such, it should be of use to my students. It couldn't be a core text though as the module is speciality specific, but I expect students to develop critical thinking and clinical reasoning within the module and they need ideas of ways to do this. Thank you for writing this text.

An excellent book used by other staff members and students. Very helpful when teaching communication and interpersonal skills

An exceptionally well written book, that related to all Healthcare professionals not just Nursing Students - the aspects on critical thinking has been central to the course

This year I was able to use a few chapters of the book to develop the basics of nursing course for English students.

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• Paul-Elder Critical Thinking Framework

Critical thinking is that mode of thinking – about any subject, content, or problem — in which the thinker improves the quality of his or her thinking by skillfully taking charge of the structures inherent in thinking and imposing intellectual standards upon them. (Paul and Elder, 2001). The Paul-Elder framework has three components:

• The elements of thought (reasoning)
• The  intellectual standards that should be applied to the elements of reasoning
• The intellectual traits associated with a cultivated critical thinker that result from the consistent and disciplined application of the intellectual standards to the elements of thought

According to Paul and Elder (1997), there are two essential dimensions of thinking that students need to master in order to learn how to upgrade their thinking. They need to be able to identify the "parts" of their thinking, and they need to be able to assess their use of these parts of thinking.

Elements of Thought (reasoning)

The "parts" or elements of thinking are as follows:

• All reasoning has a purpose
• All reasoning is an attempt to figure something out, to settle some question, to solve some problem
• All reasoning is based on assumptions
• All reasoning is done from some point of view
• All reasoning is based on data, information and evidence
• All reasoning is expressed through, and shaped by, concepts and ideas
• All reasoning contains inferences or interpretations by which we draw conclusions and give meaning to data
• All reasoning leads somewhere or has implications and consequences

Universal Intellectual Standards

The intellectual standards that are to these elements are used to determine the quality of reasoning. Good critical thinking requires having a command of these standards. According to Paul and Elder (1997 ,2006), the ultimate goal is for the standards of reasoning to become infused in all thinking so as to become the guide to better and better reasoning. The intellectual standards include:

Intellectual Traits

Consistent application of the standards of thinking to the elements of thinking result in the development of intellectual traits of:

• Intellectual Humility
• Intellectual Courage
• Intellectual Empathy
• Intellectual Autonomy
• Intellectual Integrity
• Intellectual Perseverance
• Confidence in Reason
• Fair-mindedness

Characteristics of a Well-Cultivated Critical Thinker

Habitual utilization of the intellectual traits produce a well-cultivated critical thinker who is able to:

• Raise vital questions and problems, formulating them clearly and precisely
• Gather and assess relevant information, using abstract ideas to interpret it effectively
• Come to well-reasoned conclusions and solutions, testing them against relevant criteria and standards;
• Think open-mindedly within alternative systems of thought, recognizing and assessing, as need be, their assumptions, implications, and practical consequences; and
• Communicate effectively with others in figuring out solutions to complex problems

Paul, R. and Elder, L. (2010). The Miniature Guide to Critical Thinking Concepts and Tools. Dillon Beach: Foundation for Critical Thinking Press.

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Multilevel Modeling of Individual and Group Level Influences on Critical Thinking and Clinical Decision-Making Skills among Registered Nurses: A Study Protocol

Nur hidayah zainal.

1 Department of Community Medicine, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia

Kamarul Imran Musa

Nur syahmina rasudin.

2 Biomedicine Programme, School of Health Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia

Zakira Mamat

3 Nursing Programme, School of Health Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia

Associated Data

Not applicable.

Critical thinking and clinical decision-making are two essential components of nursing services. The practice of nursing requires both components at every level of nurses’ daily tasks. This paper describes the protocol for an ongoing project, which aims to examine the prevalence of critical thinking and clinical decision-making among registered nurses and determine the factors that influence the skills at individual and group levels using a multilevel modeling approach. Survey data will be collected from approximately nine states, with nine general hospitals, nine district hospitals, one private hospital, and one educational hospital in Malaysia included. We aim to recruit 800 registered nurses working shifts in hospital settings. We will use questionnaires to measure the perceived nurses’ knowledge, critical thinking skills, and clinical decision-making skills. The study will have three levels as the nurses are nested within the unit and further nested within the hospitals. This study will give an insight into the nursing profession today where critical thinking and clinical decision-making skills can play a significant role in patient safety and the quality of care in nursing practice.

1. Introduction

Critical thinking (CT) and clinical decision-making (CDM) are two essential components of nursing services. The practice of nursing requires both components at every level of nurses’ daily tasks. It was depicted by Florence Nightingale in the 19th century [ 1 ], recognized by the World Health Organization (WHO), and included in the State of the World’s Nursing 2020 Report. The report emphasized the critical thinking skills in nurses that can contribute to more advanced judgment in clinical decision-making and increase the safety of care provision [ 2 , 3 ].

Background Research

The requirement to assess CT and CDM skills among nurses and measure the effects of such skills is widely debated [ 4 , 5 , 6 ]. Research in this area is active because CT and CDM skills are crucial for nurses. The skills are necessary for nurses to develop quality plans of care for patients, to effectively cope with advancing technologies, human resource limitations, the high level of acuity required in diverse healthcare settings, and most importantly, to improve the care outcomes of patients [ 7 , 8 , 9 ]. Concerning competencies related to CT and CDM skills in nursing, there are calls for researchers to study competency profiles and relevant frameworks and the factors or variables that determine both skills and the quality of nursing services [ 10 , 11 ].

Performance evaluation and measurement of skills are crucial. Therefore, many recent measurement models have been developed to study these skills. Nestel [ 12 ] used a multilevel evaluation strategy model to elicit development in trainees’ knowledge, attitudes, and skills and detected sustained changes in clinical practice. This study showed positive directional changes in technical, teaching, and communication skills. Meanwhile, Meghdad [ 13 ] used a multi-criteria decision-making model to assess the performance of nurses. It reported that human skills, identification of strengths and weaknesses, suitability of patient relationships, and partnership with colleagues earned the top score. These models have focused on the sociodemographic or individual level as the predictive factor (individual-factor level). Instead of focusing only on individual-level factors, this present study will apply a multi-level modeling framework that focuses on individual- and group-level predictive factors. Multilevel models recognize the existence of such data hierarchies by allowing for residual components at each level in the hierarchy. For example, a three-level model that allows for grouping nurses’ clinical decision-making outcomes within hospitals would include residuals at the nurse, unit, and hospital levels.

Most of the literature has focused on CT and CDM levels and factors from the individual level that influence the skills [ 14 , 15 ]. Given the evidence that both individual and organizational characteristics play significant roles in patient safety and quality of care, it is essential to not only include measures of both individual-level and group-level factors using the multilevel approach. Hence, in this paper, we describe the protocol for a multilevel modeling framework, including the review and field study phases, to assess the most significant factors at the individual and group levels that may influence CT and CDM skills among registered nurses. This study aims to assess CT and CDM skills among registered nurses in Malaysia. In the phase one of the study, we will obtain a comprehensive review of CT and CDM skills using a systematic review. For the phase two, there are four objectives, (a) to determine the prevalence of CT and CDM skills among registered nurses in Malaysia and (b) to identify the significant predictors for CT and CDM at the individual and group levels among nurses in Malaysia, (c) to assess the potential effect of the potential mediator and moderator on the skills and (d) to compare CT and CDM performances between three different hospital settings.

2. Materials and Methods

2.1. study setting and population.

This study will be conducted in six regions throughout Malaysia: northern, central, southern, the east coast, Sabah, and Sarawak. The total number of registered nurses in Malaysia is around 108,000 [ 16 ]. This study will recruit registered nurses from grades U29 and U32, working shifts in hospital settings and having a minimum diploma as the basic qualification. We will exclude nurses who work office hours and are involved in administrative work, in-service education units, infection control units, central sterile supply units, and clinics.

2.2. Sample Size Estimation

The minimum sample size was calculated using the Cochran formula with around 384 minimum samples [ 17 ]. Additional sample size using the power analysis for multilevel modeling study were determined using Simr and lme4 in R packages [ 18 ]. With for the significance level (alpha) set at 0.05, the sample size will achieve 94% power for the model (between hospitals) and 89% power for the model (within hospitals) at 95% CI. However, to ensure that the sample becomes more representative, to cover for possible missing data and to perform multiple comparisons during analysis, an additional 10% from the calculated sample size has been added. Hence, the total number of registered nurses to be recruited will be 800 (20 nurses from each unit).

2.3. Sampling Method and Subject Recruitment

The source population is registered nurses from 20 hospitals. The participants will be recruited using multistage stratified cluster random sampling [ 19 ]. First, we will obtain the list of government hospitals from the official portal of the Ministry of Health. Next, we will list and stratify the hospitals based on six regions (northern, central, southern, east coast, Sabah, and Sarawak). We will then classify each region as a cluster and select hospitals by region size for general hospitals (GH) and randomly for district hospitals (DH) by using simple random sampling. However, we will use purposive sampling for the teaching and private hospitals due to the small number of teaching and private hospitals available. There will be nine general hospitals, nine district hospitals, one teaching hospital, and one private hospital. In every hospital, we will select two departments or units: medical and emergency. Next, we will randomly select participants from the nurses’ lists. Figure 1 and Figure 2 depict the sampling method for this study.

Multistage stratified cluster random sampling for the selection of general hospitals and district hospitals.

Subject recruitment.

2.4. Data Collection Method

Each participant will be given explicit information about the study background, the purpose of the study, the risks and benefits, and the data collection process. Informed consent will then be obtained before they can enrol on the study. The recruitment e-poster and the online data collection will be distributed online using Google Forms. To protect the confidentiality, participants will not be required to sign into an account to complete the survey. Participation in this study is voluntary. Those not willing to participate will be excluded from the study. The benefit of online form is that the results can be collected easily, rapidly, and inexpensively. The form contains the study's objectives, instructions and data about the demographic profile. The online form is expected to be completed within 10–20 min. The participants’ identification information, such as their name and identity card number will not be recorded. The data collection period will be ongoing for 12 months from the date the link is distributed to each hospital. At the end of the 12 months, the link will be disabled, and no other person except the researchers will be able to access it.

2.5. Study Flow Chart

In phase 1 we will conduct a systematic review to assess CT and CDM skills among registered nurses. The review will assess the level of both skills using the international and local studies, assess the current predictive variables, and look for the study designs and instrumentation used in previous studies. In phase 2, we will perform a cross-sectional study to determine the prevalence of CT and CDM skills and to identify the predictive factors (that may influence both skills). The flowchart of the study is shown in Figure 3 .

Study flow chart.

2.6. Conceptual Framework

Generally, nurses are a hierarchical structure nested within a unit or department and further nested within hospitals; the responses obtained from each unit within the same cluster usually bear some similarity due to the influence of a common context; thus, statistical dependencies may occur [ 20 ]. Hence, this study will address this dependency by examining registered nurses’ critical thinking and clinical decision-making skills using a multilevel modeling approach. The multilevel analysis begins with the determination of randomly varying outcome parameters which includes a variation in the level of the outcome (intercepts). Next, the analysis will determine within-group relationships which are indicated by the regression coefficients (slope) across the groups [ 21 ]. This study will identify the variation of a nurse’s clinical decision-making score as randomly varying outcome parameters. In Figure 4 , the framework of multilevel modeling of critical thinking and clinical decision-making skills is shown.

Conceptual framework of multilevel modeling of critical thinking and clinical decision-making skills.

• H1: The nurses’ knowledge significantly influences their critical thinking score;
• H2: Critical thinking significantly influences the clinical decision-making score;
• H3: Critical thinking mediates the relationship between the nurses’ knowledge and clinical decision-making;
• H4: In-service training moderates the relationship between the nurses’ knowledge and critical thinking skills;
• H5: In-service training moderates the relationship between critical thinking and clinical decision-making skills;
• H6: The group level in level 3 (hospital settings and hospital size) has a significant influence on CDM;
• H7: The group level in level 2 (unit or department) has a significant influence on CDM;
• H8: The individual-level factors in level 1 (sociodemographic) have a significant influence on CDM.

2.7. Instrument

The self-administered questionnaire contains four sections: (a) demographic data, (b) nurses’ perceived knowledge, (c) critical thinking skills, and (d) clinical decision-making skills. The nurses’ perceived knowledge instrument will be used to measure the nurses’ perceived knowledge regarding CDM skills [ 22 ]. This questionnaire was developed based on the situated clinical decision-making framework by Mary Gillespie. It consists of 22 items. We have chosen this instrument because it focuses on measuring nurses’ perceived knowledge regarding their CDM skills. Next, a validation study will be conducted to provide validated and reliable instruments for local respondents. Nur Hidayah Zainal developed the critical and clinical decision-making scale (CTCDMS) based on the 4-Circle Critical Thinking Model and the conflict theory model of decision-making [ 23 ]. We chose this scale because it explicitly measures the CT and CDM of nurses in clinical practice. The critical thinking construct consists of 11 items with two factors: critical characteristic (4 items) and critical knowledge (7 items).

In contrast, the clinical decision-making construct consists of 10 items with two factors: decision abilities (5 items) and decision accuracy (5 items). There are interval scales of five units reflecting the subject's perceived quality. Scale one is for strongly disagree, while scale 5 for strongly agree. We will sum the scores and then group them into 3 categories, (a) low (11–25), (b) moderate (26–40), and (c) high (41–55).

2.8. Statistical Analysis

Data will be analyzed by using the Statistical Package in R software. The significance level ( p < 0.05) will be considered in all statistical tests. All essential R commands will be provided and clearly described to conduct and report the analyses:

The systematic review answers a defined research question by collecting and summarizing all empirical evidence that fits the pre-specified eligibility criteria. The meta-analysis uses statistical methods to summarize the results. However, it is subject to the data availability after the systematic review. This study will use tabulation and grouping techniques to extract the data and narrative synthesis. A template and specific guidelines will be used to extract key methodological detail for each paper.

A descriptive analysis of the sociodemographic characteristics of the participants will be performed using two R packages; the ‘ gtsummary ’ and ‘ epiR ’ packages. All variables will be assessed for the normality distribution. The median and interquartile range (IQR) will be reported for numerical variables with a skew distribution. Meanwhile, the frequency of observation and its percentage will be reported for categorical variables.

We will perform a three-level general linear mixed model with registered nurses nested within departments and hospitals to model the variability explained by individual-level and group-level variables taking the correlated data structure into account. In this study, the ‘ lme4 ’ package in Rstudio IDE will be used [ 24 ].

The standard procedure for analyzing causal mechanisms in applied research is called mediation analysis, where a set of linear regression models are fitted and then the estimates of “mediation effects” are computed from the fitted models [ 25 ]. In this study, the R package ‘ mediation ’ will be used to analyze mediation effects and ‘ processR ’ for moderation.

Multiple comparisons will be applied to compare CT and CDM among registered nurses between government, private, and educational hospitals. The ‘multcomp’ package in Rstudio IDE will be used in this study to analyze the comparisons across the hospital settings. The ‘ multcomp ’ package formulates simultaneous inference procedures in situations that were previously hard to deal with [ 26 ].

3. Expected Results

The primary outcomes of this study include the prevalence of critical thinking and clinical decision-making skills among registered nurses in Malaysia. This study will also document the level of CT and CDM skills of the study participants and understand the factors that influence CT and CDM skills. Specifically, this study will (a) determine the predictive factors on various individual and group levels, (b) quantify the contribution of critical thinking to clinical decision-making formation, and (c) estimate whether the in-service training affects the direction of the relationship between nurses’ knowledge, critical thinking skills, and clinical decision-making skills.

4. Discussion

Critical thinking and clinical decision-making skills are at the core of nursing services, yet both are poorly understood. Research shows that individual and organizational characteristics play a significant role in patient safety and the quality of care in nursing practice, but the relative contributions of these characteristics remain unclear [ 27 ]. Limited studies also focus on the relationship between group-level factor and CT and CDM skills. To our knowledge, this is the first study to assess CT and CDM using multilevel modeling. By including individual- and group-level factors in the model, the most significant factors that may have a greater influence on CT and CDM skills can be assessed. The results of this study will provide additional information to policymakers to further improve the quality of nursing services and their improvement.

Previous studies have shown that currently available instruments are not sensitive to measuring skills in nursing practice [ 28 , 29 ]. Therefore, one of the products of this study is a validated instrument to measure the critical thinking and clinical decision-making scale in Malay language. In addition, this study will also translate and validate the nurses’ knowledge instrument to the Malay version. This instrument can assess the score of the nurses’ perceived knowledge of CDM. During validation process, we will be using structural equation modelling (SEM) because SEM is a powerful tool and it provides more accurate confirmatory factor analysis results.

There are several limitations that we have identified. First, this study will be conducted only selected hospitals (based on the regions), which may result in limited generalizability. However, multistage stratified cluster random sampling and adequate sample size will minimize this limitation. Secondly, using a self-reported, online survey may lead to response bias (reduce the accuracy of the data collection). In addition, the respondents, due to social desirability, may answer the items in ways to reflect well on themselves. To minimize the effect of social desirability, the instruments used in this study include complex tasks and negative statements. The tasks and statements will reduce the acquiescent bias and increase the confidence and honesty of the participants in answering the questionnaire.

5. Conclusions

This manuscript describes a protocol for conducting research to model critical thinking and clinical decision-making skills among registered nurses. The protocol describes two main components of the research project that is (a) the systematic review and (b) the multilevel modeling. The systematic review will provide information on the levels, predictive variables, and instrumentation used in previous studies and the multilevel modeling framework will generate new findings about the nurse’s critical thinking and clinical decision-making skills. The protocol is useful for researchers who want to study the individual and organizational characteristics that play a significant role in patient safety and quality of care among nurses.

Acknowledgments

We received financial support for the APC payment from the Probability of Cardiovascular Disease and Assessing the Predictive Effect of Job Stress on CVD Risk: A Study Among Healthcare Providers Using the Framingham and Globorisk Scores Research Universiti Grant (RUI Number: 1001/PPSP/8012359), Universiti Sains Malaysia.

Funding Statement

This survey did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The survey was self-supported at the country/group team level.

Author Contributions

All authors are listed as a group of collaborators. In addition, the authors’ contributions have been recorded. Conceptualization, K.I.M. and N.H.Z.; methodology, K.I.M., N.H.Z., N.S.R. and Z.M.; software, K.I.M., N.H.Z. and N.S.R.; validation, K.I.M., N.H.Z. and N.S.R.; formal analysis, K.I.M., N.H.Z. and N.S.R.; investigation, resources, and data curation, N.H.Z.; writing—original draft preparation, N.H.Z.; writing—review and editing, visualization, and supervision, K.I.M., Z.M. and N.S.R.; project administration, N.H.Z. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The study was conducted following the Declaration of Helsinki and approved by the Medical Research and Ethics Committee (MREC), Ministry of Health Malaysia (protocol code: NMRR ID-22-00708-UAX (IIR) and date approval: 30 June 2022). Additional approval was also obtained from the Human Research Ethics Committee of Universiti Sains Malaysia (protocol code: USM/JEPeM/22030176 and date approval: 15 August 2022) and KPJ Clinical and Research Ethics Review Committee (protocol code: kpj_007/2022 and date approval: 26 September 2022).

Informed Consent Statement

Informed consent will be obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

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The Four-Circle Model

View this edition in our enhanced digital edition format with supporting visual insight and information.

Thanks to this week’s contributor and FFI Fellow, Dean Fowler, for providing an overview of his Four-Circle Model. In the article, Dean explains how his model builds upon the Three-Circle Model and can be utilized by advisors to help understand and map the role of individuals in the system and their relationship to their family.

Over the past forty years, two themes have been critical for shaping consulting with family businesses: first, a systemic approach, and second – in more recent years – the inclusion of the next generation in transition planning. In this article, I discuss my Four-Circle Model for consulting with family enterprises that is both systemic and honors the next generation as individuated adults. My purpose is not to critique the more well-known Three-Circle Model, but rather to offer a proposed enhancement to the systemic approach for understanding families in business and families of wealth.

Prof. John Davis is a pioneer in the field of family business. The main purpose for developing his original Three-Circle Model was to identify the distinct roles held in the family business and how those roles shape individual perspectives . For more than 40 years, numerous consultants and researchers have used the systemic approach described by the Davis-Taguri model to explore a broad range of other topics as well.

The celebration of the 40 th anniversary of the Three-Circle Model was explored in depth in two issues of the FFI Practitioner (see the sidebar for the two interviews with John Davis).

On the one hand, models, theories, and paradigms are powerful tools to focus our attention when studying a given discipline. On the other hand, models may also limit the questions we ask, the topics we explore, and our understanding of critical issues. 1 My Four-Circle Model focuses attention on the role of individual adults in relationship to their own family of origin and broadens the systemic approach to working with and studying business families.

In the 1980s, when FFI was first holding national conferences, I presented my Four-Circle Model for studying families in business at several workshops. After discussing my model and research ideas with the Psycho-Dynamic Family Business group (PDFB) in 1993, I was encouraged to complete research to determine how the Four-Circle Model could be used to identify the most critical competencies that business families had to master for success. That research was published in the proceedings at the 1999 FFI conference.

The Four-Circle Model is different from the Three-Circle Model in four significant ways:

• The addition of the “individual circle” is critical, because in a family-owned business, advisors are often dealing with a family of adults, and healthy adults have typically individuated themselves from their family of origin. Healthy adult families are intentional. In my judgment, intergenerational family therapies, such as those developed by Murray Bowen 2 and James Framo, 3 are well suited to examine the systemic relationships between adults and their families of origin.
• The model focuses attention on competencies, particularly the competencies that must be mastered at each of the four intersection areas illustrated in the diagram.
• Individuals and/or individual beneficiaries, not families, own family businesses.
• Individuals such as board members and advisors who are not family members fit into the model in Sector 8.

Based on my research, twelve statistically reliable “factors” were identified that represent the competencies that must be mastered by individuals and their families for success:

Competencies of Intersection 1: Between adult individuals and their family of origin

• Maturity – Individuals must separate both emotionally and financially from their family of origin and develop a strong sense of their own self-esteem.
• Purpose – Adults must determine their own purpose by developing and pursuing passions either inside or outside the family business.
• Communication – Families must listen for understanding as well as to be understood and develop strong communication skills.

Competencies of Intersection 2: Between the family and the business

• Roles – Clear guidelines should be established concerning appropriate boundaries between the business and the family, so that roles can be differentiated.
• Business Competency – Business competency deals with developing a broad-based knowledge of the business.
• Compensation – Families must determine how to balance family fairness with the best business practices, based on national and regional compensation plans.

Competencies of Intersection 3: Between the business and ownership

• Strategy – For long-term success across generations, the owners and the business must develop a clear and comprehensive strategy with a mission, vision, and goals for growth.
• Structure – The organizational structure of the business must support the strategy. This requires having the right people in the right roles.
• Leadership – Professionalization of the business may be necessary, perhaps by having qualified family members coupled with a capable non-family executive leadership team.

Competencies of Intersection 4: Between ownership and adult individuals

• Succession – Based on the strategy and structure of the business, the transition of management from one generation to the next is critical. This succession may include next-gen family leaders, or a non-family president/CEO.
• Governance – Either an advisory board or a fiduciary board of directors should be in place for the long-term success of the business.
• Estate Planning – Estate, financial, and tax planning should support rather than drive the other competencies. The ownership transition plan should capture the voice, vision, and values of both the current and next generation shareholders.

The Four-Circle Model and the related twelve competencies from my research have shaped my consulting practice for decades. With an emphasis on adult individuals, and the individuation process, my primary client is the next generation–individuals, siblings, and/or cousins.

The senior generation gives legal permission to their advisors including the attorneys, accountants, insurance, and financial planning professionals to work directly with the successor generation. The next generation of adults then would design the optimal structure for the transition of the business and ownership, so that the business and the family will be setup to thrive in the future. In addition to planning with a team of advisors, the next generation also works on mastering the twelve competencies for future success and the implementation of the recommended structures and policies for the intergenerational transition. The process often takes several years, working interactively through a family or owners council, through which the next generation makes their recommendations to the senior generation, who controls the voting shares for their approval.

Based on my research using the Four-Circle Model, I developed an online assessment process with a questionnaire and report that benchmark how family members, non-family executives, and advisors–from the perspective of different sub-groups (roles ala Davis) –assess how the family is mastering these twelve competencies. 4

1 In his seminal work The Structure of Scientific Revolutions (1970) , Thomas Kuhn demonstrated that scientific theories are in fact “paradigms.” From the perspective of the sociology of knowledge, Kuhn argued that scientific communities share a common set of theories and ideas that are excellent tools to explore problems. However, in the history of science, there is a paradigm shift through which new theories emerge – for example from Newtonian physics to Einstein’s theory of relativity. Kuhn’s position contrasts with classical rationalism put forth by Karl Popper.

2 For key principles regarding Bowen read The Eight Concepts of Bowen Theory First Edition by  Dr. Roberta M Gilbert  or see the website https://www.thebowencenter.org/

3 Family-Of-Origin Therapy: An Intergenerational Approach by  James L. Framo

4 This online assessment and questionnaire can be found at ( https://www.deanfowler.com )

About the Contributor

Dean R. Fowler, PhD, FFI Fellow has advised business families for 38 years as well as facilitating Forums for Family Business TM – peer advisory boards – that specialize in personal and professional development through diversified experiences and accountability, while focusing on successful intergenerational transitions. He is the author of several books, including Love, Power and Money: Family Business between Generations . He can be reached at [email protected] .

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• Research Guides

QEP - Thinking and Beyond

Diane halpern’s four-part model.

• What is Critical Thinking?
• William Perry Model
• The Delphi Report Model
• Visible Thinking Model
• Susan Wolcott’s Steps for Better Thinking
• Foundation for Critical Thinking Framework
• Information Literacy
• AVID: High Engagement Practice
• QEP Assessment
• Faculty Showcase
• Online Resources
• Further Reading

Halpern extensively describes the model in Thought and Knowledge: An Introduction to Critical Thinking , a text popular for use in stand-alone critical thinking courses at colleges and currently in its fifth edition.  Halpern embeds the four parts of the model within the definition she provides for critical thinking. Halpern defines critical thinking as “the use of those cognitive skills or strategies that increase the probability of a desirable outcome” and further labels critical thinking as “purposeful, reasoned…goal-directed” and “involved in solving problems, formulating inferences, calculating likelihoods, and making decisions” (8). The definition also stipulates that the thinker must be using appropriate skills for a particular “context” and “type of thinking task” (8). The four-part model then aligns with these definition components and elaborates upon them.

The model’s first part is the overt teaching and learning of specific critical thinking skills and is also delineated in the book’s appendix (Halpern 563-92).

The model’s part two, that “develop[ing] the disposition” of a critical thinker relates to essential “attitudes” such as the “willingness to plan…flexibility…persistence… [and] admit[ting] errors,” as well as “chang[ing] your mind when the evidence changes.” Halpern indicates these attitudes undergird all thinking that raises the chances of attaining goals and solving problems (18-25).

Halpern’s part three centers on student transfer of the critical skills. Along with teaching students specific critical thinking skills, instructors also need to teach students to identify circumstances that require those skills and which skills are necessary in a particular circumstance (Halpern 25-6). To transfer skills, Halpern argues that students must move past “the domain-specific surface characteristics” to identify the “structural aspects of the problem or argument” that “trigger the recall of the thinking skill” (25).

Finally, the fourth part requires students to use metacognition to track the effectiveness of their thinking (Halpern 27). Decisions, goals, and problem solving feature significantly in Halpern’s definition and model. Both the definition and model account for uncertainty in the decision-making process because the result of critical thinking skills need not be “a desirable outcome” but instead a higher chance of such an outcome (8).

Works Cited

Halpern, diane f.  thought and knowledge: an introduction to critical thinking.  5th edition, psychology press, 2014..

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