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Clinical decision-making skills are fundamental to safe and effective nursing practice. While prior studies have identified individual-level factors, they have often overlooked the hierarchical structure of nursing practice. This study aimed to investigate the complex determinants of clinical decision-making skills among Malaysian nurses at the individual, hospital-department, and regional levels using multilevel analysis. A quantitative, cross-sectional study. Hospital departments across six diverse regions in Malaysia. A total of 796 registered nurses (response rate = 99.5%) from 40 hospital departments participated in the final analysis. A three-level mixed-effects regression model was used to analyse the nested data collected from a target sample of 800 nurses. The sample was predominantly female (96%), with an average of 12.8 years of clinical experience. At the individual level, clinical decision-making scores were significantly predicted by higher critical thinking scores (b=0.788, 95% CI 0.700, 0.876, p < 0.001), more years of experience (b=0.073, 95% CI 0.027, 0.119, p < 0.01), and holding post-basic qualifications (b=0.710, 95% CI 0.109, 1.311, p < 0.05). A significant interaction revealed that the positive effect of critical thinking was attenuated for nurses with post-basic qualifications. At the hospital-department level, nurses in teaching (b=4.259, 95% CI 2.42, 6.10, p < 0.001), private (b=2.418, 95% CI 0.543, 4.293, p < 0.05), and general hospitals (b=1.648, 95% CI 0.848, 2.448, p < 0.001) had significantly higher scores than those in district hospitals. Importantly, at the regional level, the random effects model indicated that the strength of the association between critical thinking and clinical decision-making varied significantly across different regions. Clinical decision-making skills are shaped by a complex interplay of individual attributes and contextual factors. This research provides a foundation for developing targeted, multifaceted strategies in nursing education and policy to enhance professional competency and improve patient outcomes.
Zainal et al. (Mon,) studied this question.