Relationship between 21st century skills and clinical decision-making in Generation Z nursing students: a cross-sectional study

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Abstract Background The complex and rapidly changing nature of modern healthcare environments requires future nurses to possess advanced competencies. While 21st-century skills are theoretically expected to enhance nursing students’ clinical reasoning, empirical research exploring this relationship remains scarce. This study aimed to determine the 21st-century skill levels of Generation Z nursing students and examine their association with clinical decision-making. Methods A cross-sectional correlational design was conducted in December 2025 at a faculty of nursing at a state university in Manisa, Turkey. Data were collected from 386 s-, third-, and fourth-year undergraduate nursing students using convenience sampling via online communication channels. Data collection tools included a sociodemographic form, the Multidimensional 21st Century Skills Scale (M21CSS), and the Nursing Decision-Making Instrument (NDMI-24). Descriptive statistics, independent samples t-tests, one-way ANOVA, Pearson correlation, and multiple linear regression analysis were performed. Results The participants’ mean total score for 21st-century skills was 154 ± 20.57, indicating a good level, with the highest scores found in information and technology literacy and the lowest in social responsibility and leadership. The mean NDMI-24 score was 69.96 ± 2.98, positioning the students within a quasi-rational decision-making model. The multiple linear regression analysis revealed that the model explained 52.4% of the total variance in clinical decision-making ( R 2 = 0.524, Adjusted R 2 =0.518, F (5,380) = 83.66, p < 0.001). Career awareness (β = 0.31, p < 0.001), critical thinking and problem-solving ( β = 0.24 , p < 0.001), entrepreneurship and innovation (β = 0.18, p < 0.001), and information and technology literacy (β = 0.11, p = 0.003) emerged as significant independent predictors predictors of NDMI-24 scores, indicating a shift toward intuitive or quasi-rational decision-making patterns. Although critical thinking showed a negative bivariate correlation with decision making, in the regression model it emerged as a significant positive predictor (β = 0.24, p < 0.001), indicating a suppressor effect when considered alongside career awareness and innovation. Conclusion Their clinical decision-making appears to align with a transitional, quasi-rational pattern. While critical thinking disposition, career awareness, and innovative skills are associated with clinical decision-making scores, these cross-sectional findings suggest that educational programs may consider exploring simulation-based training and cognitive strategies to support student decision-making in complex clinical scenarios.