Skip to main content

Factors influencing the complex problem-solving skills in reflective learning: results from partial least square structural equation modeling and fuzzy set qualitative comparative analysis



The Organization for Economic Cooperation and Development emphasizes the importance of complex problem-solving (CPS) skills in the 21st century. CPS skills have been linked to academic performance, career development, and job competency training. Reflective learning, which includes journal writing, peer reflection, selfreflection, and group discussion, has been explored to improve critical thinking and problem-solving abilities. The development of various thinking modes and abilities, such as algorithmic thinking, creativity, and empathic concern, all affect problem-solving skills. However, there is a lack of an overall theory to relate variables to each other, which means that different theories need to be integrated to focus on how CPS skills can be effectively trained and improved.


Data from 136 medical students were analyzed using partial least square structural equation modeling (PLSSEM) and fuzzy set qualitative comparative analysis (fsQCA). A hypothesized model examining the associations between the CPS skills and influence factors was constructed.


The evaluation of the structural model showed that some variables had significant influences on CPS skills, while others did not. After deleting the insignificant pathways, a structural model was built, which showed that mediating effects of empathic concern and critical thinking were observed, while personal distress only had a direct effect on CPS skills. The results of necessity showed that only cooperativity and creativity are necessary conditions for critical thinking. The fsQCA analysis provided clues for each different pathway to the result, with all consistency values being higher than 0.8, and most coverage values being between 0.240 and 0.839. The fsQCA confirmed the validity of the model and provided configurations that enhanced the CPS skills.


This study provides evidence that reflective learning based on multi-dimensional empathy theory and 21 stcentury skills theory can improve CPS skills in medical students. These results have practical implications for learning and suggest that educators should consider incorporating reflective learning strategies that focus on empathy and 21 stcentury skills to enhance CPS skills in their curricula.

Peer Review reports


When putting forward the theoretical framework of skills and competencies in the 21st century, the Organization for Economic Cooperation and Development takes complex problem-solving (CPS) skills as an important component and brings them into the evaluation system of the Program for International Student Assessment [1]. Previous research results have proved that there is a significant positive correlation between CPS skills and academic performance [2], that is, the stronger the problem-solving skill, the better the academic performance. Similarly, it is also considered to have a great influence on career selection [3], career development [4], and job competency training [5]. Therefore, the improvement of the above-mentioned comprehensive qualities, such as learning ability and post competence, and the cultivation of CPS skills, has been emphasized by a variety of teaching strategies, such as problem-based learning (PBL) [6], context-based learning (CBL) [7], situational simulation [8], and reflective learning [9].

As an important process of metacognition, reflective learning is closely related to CPS skills. Gadbury-Amyot et al. claimed that the use of reflection and writing as educational strategies to promote critical thinking and problem-solving is one of the best ways for students to express their thought processes [10]. Exploration to improve CPS skills based on reflective learning and training can be seen in medicine, computer science, mathematics, and other industries. According to Bernack, establishing problem-solving training courses could feasibly enhance the abilities of pre-service teachers [11]. Kellogg suggested that reflection and writing, as educational strategies to promote critical thinking and problem-solving skill, is one of the best ways to improve students’ expression ability and logical thinking [12]. “Reflective learning” is a common way of exploring problems and solutions in the deliberative environment, a process of learning through experience, and is a necessary learning tool in professional education [13]. Reflective learning includes journal writing, peer reflection, self-reflection, and group discussion under the guidance of teachers [14]. Illeris suggested that the result of reflective learning spans cognitive, psychodynamic, and social-societal dimensions [15]. Through its influence on students’ behavior, thoughts, and emotions, it realizes the training and improvement of students’ various abilities. It has gradually developed into a more efficient and autonomous learning model and has become an indispensable educational and learning tool for many professionals [16]. Many experts suggest that the implementation of reflective learning can improve students’ critical thinking [17], insight [18], empathic concern [19], computational thinking [20], and other skills, and this improvement of a variety of thinking modes and abilities will eventually lead to improvement of their CPS skills [21]. Our research on the factors affecting the CPS skills is based on reflective learning.

The purpose of human problem solving is to promote the understanding of human thinking through a detailed investigation of the way people solve difficult problems, such as logic or chess. Unlike computer simulations, human problem solving is influenced by psychological factors that cannot be ignored [22]. Therefore, problem solving is dynamic and needs to consider the influence of speculation, social background, and culture, while CPS skills emphasize the process of successful interaction between the problem solver and the dynamic task environment [23]. CPS skills are collections of self-regulating psychological processes necessary in the face of complex and dynamic non-routine situations across different domains [24], and comprises a combination of skills, abilities, motivation, and other psychological structures [25, 26]. The factors that impact CPS skills are complex and include cognitive and non-cognitive factors. Research shows that the development of a variety of thinking modes and abilities, such as algorithmic thinking, cooperativity, creativity, critical thinking, personal distress, fantasy, perspective-taking, and empathic concern, all affect the problem-solving skill in varying degrees [27, 28]. Among them, empathetic concern and critical thinking have been proven to affect problem-solving skill by many studies. After comprehensively exploring the emerging research on the impact of the factors on the CPS skills, we found that previous studies mainly focused on a single causality in the improvement of problem-solving skill, while there is a lack of overall theory to relate variables to each other, which means that we need to integrate different theories to advance existing research and focuson how CPS skills can be effectively trained and improved.

Theoretical background

The literature analysis of CPS skills reveals the current research status. Based on the relevant theories of skills needed in the 21st century [1], individuals use analytical, reasoning, and cooperative skills to identify and solve problems consistent with their areas of interest [29]. Kocak proposes that problem-solving skills are shaped by algorithmic thinking, creativity, cooperativity, critical thinking, digital literacy, and effective communication, and develops a model with critical thinking as a mediating factor [21]. Developing solutions for complex problems is a complicated process, and individuals require critical thinking skills [21, 30] to do so. Critical thinking often occurs at the same time as CPS skills and is one of the core objectives of general education in all subjects of higher education [29]. Critical thinking, closely related to reflective learning [17], which has been emphasized in many studies, especially in the implementation of learning strategies including reflective learning. In problem-based learning and case-based learning, instructors encourage learners to use critical reflection to engage with subject matter and to develop their own practice in closing any knowledge gaps that may exist [31]. Additionally, digital literacy involves the ability to assess the accuracy and value of online resources [32]. In this study, reflective learning was the primary learning strategy [33]; therefore, digital literacy skills were not observed in detail. Drawing on the above analysis, we developed a theoretical model that identifies algorithmic thinking, creativity, and cooperativity as antecedents, and critical thinking as an intermediary variable that influences CPS skills.

Another major area related to affecting CPS skills is empathic concern. The research suggests that students with a higher level of cognitive empathy show more positive attitudes and deal with problems more effectively [34]. In essence, empathetic concern fosters values, beliefs, attitudes, and assumptions, and affect the CPS skills from the perspective of execution [35, 36]. Some studies suggest that reflective learning improves empathy [37]. Based on Davis’s Interpersonal Reactivity Index [38], empathy was divided into four dimensions mentioned: Empathic concern, fantasy, perspective-taking, and personal distress. Nevertheless, some scholars disagree that personal distress belongs to the category of empathy. Personal distress is defined as an over-arousal caused by the lack of boundaries between oneself and others [39, 40]. Some studies show that personal distress leads to egoism and overwhelms altruistic activities mediated by empathetic concern [41]. And there is a statistically significant correlation between personal distress and empathetic concern [42]. Therefore, we still adhere to the view that the two cannot be regarded as mutually exclusive emotions, bringing personal distress into the scope of our research and exploring its role in CPS skills. Empathetic concern has been proved to associate with prosocial behavior [43]. In the relationship between empathic concern and prosocial concern, empathic concern elicits an approach orientation toward the target [44] and is used as a mediator variable in some models. For example, some studies consider empathic concern and personal distress are both mediators of perspective-taking to helping behavior [45]. Based on the above analysis, we built our theoretical model and assume that personal distress, perspective-taking, and fantasy as antecedents and empathetic concern as intermediary variables that affect the CPS skills.

Above all, the empathic concern and the critical thinking are two remarkable characteristics of the CPS skills, which can play a common role in the CPS skills [46], however, there is a lack of overall theory to connect them, which means that different theories need to be integrated to promote research. The comprehensive study of the combination of the two aspects can better understand how to improve CPS skills, which cannot be provided by any theory alone. Moreover, the results on the factors affecting the CPS skills also show some inconsistencies. For example, Batson believes that personal distress in empathy inhibits the development of problem-solving skills [41], whereas Mora disagrees [47]. A possible reasonable explanation for these contradictory results is that the previous studies on the factors influencing problem-solving skill mainly adopted traditional symmetric methods (such as regression and SEM), which did not fully capture the complexity of the factors that influence problem-solving skills, and the factors affecting the CPS skills are often based on multiple causalities rather than a single causal relationship. Simply evaluating symmetric relationships might lead to divergent results, thus masking the complexity of the problem-solving skill. Considering the complex nature of CPS skills under the condition of reflective learning, it is necessary to check the symmetric and asymmetric relationships between structures to fully understand the strategies and methods to improve CPS skills, therefore, PLS-SEM [48] and fsQCA [49] were used in our study comprehensively.

Research model and hypothesis development

Designing the PLS-SEM research model

Critical thinking in the field of cognition and empathic concern in the field of emotion are representatives of two different thinking modes affecting the CPS skills. PLS-SEM assumes that fantasy, perspective-taking, personal distress, algorithmic thinking, creativity, and cooperativity have a direct impact on the CPS skills. Empathetic concern and critical thinking play an intermediary role between these relationships and the CPS skills (Fig. 1A).

Fig. 1
figure 1

Partial least square structural equation modeling (PLS-SEM) conceptual model and fuzzy set qualitative comparative analysis (fsQCA) conceptual model: (A) The PLS-SEM conceptual model. (B) The fsQCA conceptual model

Personal distress and CPS skills

The definition of personal distress in this study pertains to the discomfort and anxiety that respondents experience when observing negative experiences of others, including fear, apprehension, and discomfort. Personal distress is an aspect of emotional empathy [38]. Some studies show that personal distress and empathy are complex and dynamic emotional experiences [50]. Personal distress, as an indicator of self-other differentiation and emotional regulation, is a kind of negative emotion. Excessive personal distress can lead to emotional regulation and interpersonal difficulties [51]. These studies advocate reducing personal distress to relieve stress [52]. The healthcare sector prioritizes a patient-centered healthcare model, which mandates that we respond to patients’ emotional distress with this principle in mind. However, in practice, health professionals tend to regard emotional health problems as “routine”; therefore, it is necessary to put patients’ emotional and identity issues in the dominant position of the marginal biomedical model used by health professionals [53]. However, empathic pain is crucial to Hoffman’s moral development framework. He believed that pain can cause significant effects that might lead to action [54]. Moitra’s research also supports the positive effect of personal distress on problem-solving skill [47]. Reflection encourages individuals to confront their own embarrassing and uncomfortable past experiences, learn from their errors, and enhance their CPS skills [55].

Fantasy and CPS skills

Fantasy acts on all aspects of reflective learning. First, to some extent, our brains process information and decisions in an irrational way, and reflection contributes to the cultivation of irrational thinking [56]. The improvement of subjects’ irrational thinking, including fantasy, can be promoted through reflective learning. Research indicates that individuals with higher fantasy and perspective-taking skills tend to have stronger social understanding [57]. Second, the development of imagination and fantasy is an important part of cultivating empathic concern [58]. This is because people understand the world through fantasy, and fantasy gives people hope that the world will become a better place [59]. For example, Melissa McInnis Brown’s research showed that children who play using fantasies are better at sharing emotions than their peers [60]. Many studies have proven the role of fantasy in problem-solving. For example, David Weibel pointed out that one can effectively use imagination in an environment, such as in artistic expression or problem-solving [61]. Fantasy is an imaginative way to find creative solutions that can help people predict the realization of creative structures [61]. From a sociological point of view, scholars usually regard fantasy as an important factor in cultivating children’s prosocial behaviour [57, 62]. Empathic concern requires a person or the whole team to have an overall and largely unconscious “feeling” in terms of emotions, body language, previous experiences, and interpersonal relationships; therefore, this requires significant support from the fantasy system [63].

Perspective-taking and CPS skills

The effectiveness of group problem solving heavily depends on group member interactions and group composition. For perspective-taking, it provides the possibility for effective communication, which mainly affects the effective presentation of information, effective understanding of that information, conflict resolution, and cooperative interaction [64, 65]. In management, perspective-taking has become an important factor in teamwork to solve problems [66]. During perspective-taking, the problem-solving process can be facilitated by promoting empathic concern, which is evident in the subjects’ cognitive dimension. For example, Falk found that perspective-taking leads to more creative solutions, and team members are more cooperative and facilitate more effective communication [64]. Bethune and Brown suggested that reflection affects the professional identity of patients by encouraging personal insights and providing different perspectives on patient interaction [67]. Reflection requires us to think about the past and sum up experiences and lessons from it. Thinking about problems from the standpoint of others can circumvent the limitations of our perspective of looking at problems only through ourselves and can promote the solution of complex problems.

Based on the points discussed above, we propose the following assumptions:


Personal distress is positively related to the CPS skills.


Fantasy is positively related to the CPS skills.


Perspective-taking is positively related to the CPS skills.

Algorithmic thinking and CPS skills

Algorithm thinking draws lessons from the algorithms of computers and artificial intelligence, which enables people to think and deal with things in parallel, process things in data, carry on data and logical reasoning to things, and finally achieve the goal of completing plans and tasks. As one of the core skills in the 21st century, algorithmic thinking abstractly and logically determines the elements used to solve problems through analysis [28]. One of the major applications of algorithmic thinking is jigsaw puzzle-based learning, which aims to make subjects think about how to build and solve problems, and improve their critical analysis and problem-solving skills [68]. Hasan Gürbüz leveraged straightforward visual and language templates to help individuals develop models and analyze information about events through games, resulting in improved problem-solving skills [69]. This mode of thinking, based on logic and steps, is very important for the development of critical thinking and computational thinking [28]. Many studies have shown that there is a positive correlation between algorithmic thinking and critical thinking [70]. In reflective learning, algorithmic thinking plays a significant role in computing, as evidenced in this study by recording a short video that necessitates organizing large amounts of data to develop suitable algorithms for analysis [71].

Creativity and CPS skills

Creativity affects our lives and is vital to the progress of society [72]. The definition of creativity highlights the integration of novel (original, unexpected) and appropriate (useful, adaptive concerning task constraint) ideas [73]. Since the 20th century, a large number of scholars in various fields have paid attention to creativity and CPS skills. Creativity is a valuable skill while designing solutions to new challenges that arise in developing societies [74]. For instance, Garrett noted that creativity plays a crucial role in problem-solving [75]. In many studies, creativity and critical thinking are interdependent, and creative tasks can improve people’s creativity [76]. In reflective learning, we utilize divergent thinking that frequently enhances our creativity.

Cooperativity and CPS skills

Many critics believe that cooperativity plays an important role in the cultivation of critical thinking [77]. Cooperativity receives considerable attention in the learning process due to its association with effective communication. For example, service-learning attaches great importance to cooperation, democratic citizenship, and moral responsibility in the learning process [78], and preschool educational institutions need to improve the experience through the collaborative exchange, to create favorable conditions for educators to re-examine educational activities, and determine the direction of new relationships through observation [79]. In reflective learning, subjects become aware of their contradictions and gain valid information, and critically assess peer opinions through active communication, which advances their ideas for program and CPS skills improvement.

Based on the points discussed above, we propose the following assumptions:


Algorithmic thinking is positively related to the CPS skills.


Creativity is positively related to the CPS skills.


Cooperativity is positively related to the CPS skills.

Mediators and CPS skills

This study assumes that empathetic concern and critical thinking act as mediators between the CPS skills and their antecedents.

In Gibbs’s theory, the emotional dimension is a very important aspect of reflective learning [80]. Madeline Kelly’s research showed that reflection has a positive effect on the improvement of cognitive empathy [81]; however, there are few studies on the effect of reflective learning on empathy. Cognitive empathy includes fantasy and perspective-taking, while the emotional empathy includes personal distress and empathic concern [82]. Research shows that the concept of emotional empathy is state empathy, with the focus on altruism [83, 84]. Emotional empathy plays an important role in patient-nurse communication [85]. Failure to deal with or understand emotions will make it difficult for nurses to think rationally and critically about issues that are important to nursing practice [86]. Therefore, we cannot ignore the influence of empathic concern on the CPS skills in reflective learning. We assumed that the ability of empathic concern can increase altruism and help to improve CPS skills. However, personal distress is usually considered to lead to egoism, which is not conducive to the formation of altruism [41]. In-depth investigation is necessary to understand its effect on CPS skills. As an important factor in prosocial behavior, the empathic concern serving as a mediator between cognitive behavior and prosocial behavior [87]. Based on the theories of O’Brien and Gülseven, we constructed a CPS skills model with empathic concern as the mediating variable [88, 89].

Effective reflection is characterized by purposeful, focused, and questioning [90]. In the process of reflection, this mode of thinking requires us to think critically and center on the results. Reflective learning, also known as critical reflection [17], emphasizes the use of critical thinking. Many critics affirm the results of critical reflection [91,92,93]. Parrish and Crookes found that among nursing graduates, reflection helped them to solve problems through thoughtful reasoning and to develop strategies for self-monitoring of their professional competence [94]. Critical thinking is typically rational thinking, and through combining theory with practice, exploring the similarities and differences between theoretical knowledge and practical experience, and considering a variety of different viewpoints and opinions, the effect of reflective learning can be enhanced. Therefore, speculative reflection is designed to help us identify our shortcomings and think about how to correct and improve them. Critical thinking is widely recognized as an important skill in mediating CPS skills [10]. Based on the research of Kocak and Tee, we also view critical thinking as an intermediary variable, playing a mediating role in algorithmic thinking, creativity, and cooperativity within CPS skills [21, 95].

Based on the points discussed above, we propose the following assumptions:


Personal distress indirectly affects the CPS skills through empathic concern.


Fantasy indirectly affects the CPS skills through empathic concern.


Perspective-taking indirectly affects the CPS skills through empathic concern.


Empathic concern is positively related to the CPS skills.


Algorithmic thinking indirectly affects the CPS skills through critical thinking.


Creativity indirectly affects the CPS skills through critical thinking.


Cooperativity indirectly affects the CPS skills through critical thinking.


Critical thinking is positively related to the CPS skills.

Designing the fsQCA configuration model

In this study, a Venn diagram is used to design the fsQCA configuration model (Fig. 1B), which was used to explore the causal model for improving CPS skills. In the diagram, arrow A represents a combination of perspective-taking, fantasy, and personal distress, and adds configurations that affect the CPS skills through, or including, empathetic concern. Arrow B represents a combination of algorithmic thinking, creativity, and cooperativity, and adds configurations that affect the CPS skills through, or including, critical thinking. Arrow C represents the combination of all the variables and represents the complex interaction of these factors to predict the resulting conditions.



Participants were 136 freshmen and medical majors from a university in southeastern China (‾Xage = 18.47, female = 82.35%, male = 17.65%). The inclusion criterion comprised students who had conducted reflective learning. The exclusion criteria comprised: (1) Students who did not make reflective videos, or (2) students suspected of plagiarizing reflective learning achievements. A total of 163 cases were included in the empirical study of reflective learning, and 136 effective samples were recovered, with an effective recovery rate of 83.44%.

Design and procedure

After receiving appropriate online training, classroom teachers implemented a reflective learning curriculum design among medical students in the autumn of 2021 (Fig. 2). Based on the Biochemistry and Molecular Biology Courses, the two rounds of teaching plan lasted a total of 14 weeks was design. In the first round of reflective learning, subjects were asked to read relevant literature, watch relevant video materials, etc., and carry out online learning. They were then asked to record learning videos on their own, and then upload the videos, followed by a double-blind mutual evaluation of learning videos between online students. In the second round of reflective learning, students adjusted their reflective learning according to the feedback from the previous round of mutual evaluation, implemented a second round of deeper material learning exploration, improved their reflective video, and summarized the main points of reflective learning. Teachers evaluated the reflective videos and learning points offline, and students learned and summarized according to the evaluation results. After the end of the entire process, we issued a competency assessment questionnaire to measure learners’ competency levels and the data was collected.

Fig. 2
figure 2

Reflective learning process


To measure the constructs under study, existing scales were used (see Table 1 for items associated with each construct and scale reliabilities).

Table 1 The Constructed Items Measurement Model

A questionnaire was developed based on the existing mature scale, and the items were slightly adjusted according to the model. The relationship between the retained items and the dimensions was not complementary. Improvement of CPS skills is described as a structure composed of six antecedent variables and two mediating variables with different ways of thinking. The Davis Interpersonal Reactivity Index (IRI) was used for personal distress, fantasy, perspective-taking, and empathic concern [38], and the Computational Thinking Scale (CTS) was used for critical thinking, algorithmic thinking, creativity, problem solving, and cooperativity [74, 96, 97]. We structured it as personal distress (three items), fantasy (three items), and perspective-taking (two items) as ante-dependent variables, and the mediating effect of empathic concern (three items) on CPS skills (three items) was directly and through empathic concern (3 items). Similarly, algorithmic thinking (3 items), creativity (three items), and cooperativity (three items) acted as ante-variables, both directly and through the mediating effect of critical thinking (three items). All items were evaluated using a Likert 5-point scale, 5 = strongly agree, 4 = agree, 3 = neither agree nor disagree, 2 = disagree, 1 = strongly disagree, and the scores of items in reverse scoring were reversed. Entries for reverse scoring are marked with * in Table 1. The questionnaire was translated into Chinese and distributed after discussion with experts.

Data analysis


We use multiple methods to analyze the data. First, PLS-SEM was carried out on the data through Smart-PLS 3.0 software to adapt the complex model analysis and explore the impact of various factors [48].

We measured the characteristics of the structure using internal consistency reliability, convergence validity, and discrimination validity. Internal consistency reliability was measured using the alpha and combinatorial reliability of Cronbach. And we checked the collinearity of the internal model and evaluated the deviation of the method using a variance inflation factor (VIF). According to the research objectives, we tested two models with different paths with significant correlations. The direct predictive effects of fantasy, personal distress, perspective-taking, creativity, cooperativity, and algorithmic thinking, as well as the mediating effects of empathic concern and critical thinking, on CPS skills were tested. A nonparametric, bias-corrected bootstrap with 5,000 subsamples and a 95% confidence interval was used. The structural model was evaluated by R² and by the significance of the estimated value of pathway relationships. The significance of pathway coefficients was evaluated using the bootstrap subsamples, and the structural model was evaluated using 5000 bootstrap subsamples [98]. R² values of 0.25, 0.50, or 0.75 are considered weak, moderate, and significant, respectively.


Although PLS-SEM can handle both external (measurement) and internal (structural) models [98], it is limited by symmetry. Therefore, we used fsQCA 3.1 software [49] to analyze asymmetry and obtain a sufficient causal combination configuration to study the complex relationship between variables more comprehensively and in detail. According to the fsQCA user guide, data calibration, truth table construction, and causal condition analysis are necessary steps in the process of data analysis [49]. In the first step, we converted the ordinary data into fuzzy sets by setting the original values from the Likert scale, which corresponded to full membership, cross-over anchors, and full non-membership based on Kallmuenzer’s analysis [99]. The second step is to construct the truth table and generate different combinations of causal conditions that are sufficient to affect the CPS skills by specifying a consistent cutoff value as the natural breakpoint in the consistency and the case number threshold as 1. The third, we analyzed the necessity of all the variables (critical thinking, creativity, algorithmic thinking, cooperativity, empathetic concern, perspective-taking, personal distress and fantasy) to the CPS skills, and the antecedent variables for mediate variables (critical thinking and empathic concern), and the necessity of mediating variables to the outcome variables. It is generally believed that a condition or combination of conditions is “necessary” or “almost always necessary” when the consistency score is higher than 0.9 [49]. Finally, we use standard analysis to obtain “intermediate solutions” (i.e., partial logical remainders are incorporated into the solution) to identify causal patterns that affect CPS skills.


The result of PLS-SEM

Evaluation of the reflection measurement model

Except for the perspective-taking, the Cronbach’s alpha in the other dimensions was generally more than 0.7, reaching the standard recommended by Cohen (Table 1) [100]. After examining the external loads in the external model, we observed that most of the loads were more than 0.7, while the PD1 project was still less than 0.7. After checking the Cronbach’s alpha and average variance extracted (AVE), we confirmed that this factor had no negative effect on our research [98], and was thus retained the project. The sample size of the model is small (less than 300), and the items considered by perspective-taking are 2 (less than 3), so Cronbach’s alpha is easily less than 0.6. The alpha of perspective-taking is more than 0.5, which is still in a slightly plausible range. Therefore, we kept the item of perspective-taking. Secondly, the square root of AVE was greater than 0.5, which accords with the convergence validity [101]. In addition, we used the Fornell-Larker criteria to evaluate the discriminant validity (Table 2).

Table 2 Discriminant Validity using Fornell-Larcker criterion

Evaluation of formative measurement models

The results showed that the VIF of all constructs was lower than the threshold of 3.3 (see Additional file. 1) [98]. In order to further analyze, this study evaluated the quality by blindfolding program (Q2) and standardized root mean square residual (SRMR). The results showed that SRMR = 0.079, not exceeding 0.09 [102]. The blindfold program showed that Q2 was greater than 0, which verified the predictive correlation of the research model [103].

Structural model evaluation

Evaluation of the structural model showed that the R² value was reasonable for exploratory research. Meanwhile, the direct pathway effect of fantasy, algorithmic thinking, creativity, and cooperativity on CPS skills was not significant (p > 0.05), and the pathway effect of personal distress on empathic concern was also not significant (p > 0.05). The other variables showed significant influences on CPS skills (p < 0.05) (Table 3). After deleting the insignificant pathways, we built a structural model between the CPS skills and the influencing factors (critical thinking, cooperativity, creativity, algorithmic thinking, empathic concern, fantasy, perspective-taking, and personal distress) (Fig. 3). Compared with the hypothetical model, mediating effects of empathic concern and critical thinking were observed; however, personal distress only had a direct effect on CPS skills, which was consistent with the previous view that empathic concern and personal distress should be discussed [51].

Table 3 Results of hypotheses testing
Fig. 3
figure 3

Path model and partial least square structural equation modeling (PLS-SEM) estimates

The result of fsQCA

The results of necessity showed that only cooperativity and creativity are necessary conditions for critical thinking (see Additional file. 2, Additional file. 3, and Additional file. 4).

FsQCA assessed the complex causal combination that led to improved CPS skills (Tables 4, 5, 6 and 7). The solution provided clues for each different pathway to the result, with all consistency values being higher than 0.8, and most coverage values being between 0.240 and 0.839 [104].

Table 4 Configurations for CPS skills
Table 5 Configurations for Empathic concern
Table 6 Configurations for Critical Thinking
Table 7 Configurations for CPS skills

As shown in Table 4, there are six approaches to the final model of complex conditions that lead to high CPS skills, among which the top three in terms of coverage are: (1) To achieve high CPS skills through high critical thinking, cooperativity, creativity, algorithmic thinking, empathic concern, personal distress, and perspective-taking (consistency = 0.974, coverage = 0.354). (2) Under conditions of high critical thinking, cooperativity, algorithmic thinking, and creativity, combined with high empathic concern, personal distress, and fantasy, the CPS skills can be improved (consistency = 0.950, coverage = 0.352). (3) A high level of critical thinking, cooperativity, algorithmic thinking, creativity, personal distress, perspective-taking, and fantasy (consistency = 0.950, coverage = 0.340) can promote the improvement of CPS skills.

To examine the mediating effect of empathic concern and critical thinking on the CPS skill, we analyzed the complex causality of fantasy, personal distress, perspective-taking, and empathic concern. The results showed in Table 5 indicated that the complex causal statement of fantasy, personal distress, perspective-taking, and empathic concern is one way, i.e., high perspective-taking and fantasy improves empathic concern skill (consistency = 0.821; coverage = 0.612), which supports the H7b and H7c assumptions in the SEM model. By contrast, the results of analyzing the complex causal relationship of creativity, cooperativity, and algorithmic thinking for critical thinking showed that there is a pathway for the complex causal statement of creativity, cooperativity, algorithmic thinking, and critical thinking (consistency = 0.867, coverage = 0.760), which will lead to improved critical thinking ability. This supported the hypotheses of H8a, H8b, and H8c in the SEM model.

The results of further analysis of the complex causal relationship between empathic concern and critical thinking for improved CPS skills (Table 7) showed that high empathic concern and critical thinking (consistency = 0.890, coverage = 0.550) will lead to improved CPS skills. This supported the H7d and H8d assumptions in the SEM model.

Discussion and conclusion

Theoretical implication

To improve its ability to deal with complex practical problems, education has been committed to providing teaching measures that can stimulate subjects’ rational and irrational thinking. Healthcare professionals who utilize reflective learning must apply empathetic concern and critical thinking to confront challenges with high-quality solutions. Although previous studies confirmed the positive effects of empathic concern [19], and critical thinking [17] on CPS skills through symmetrical analysis, few studies have tested empathic concern and critical thinking at the same time. There is a dearth of studies that specifically investigate the factors that affect CPS skills in the context of reflective learning. And the previous studies on the factors influencing CPS skills mainly adopted traditional symmetric methods (such as regression and SEM), which did not fully capture the complexity behind the factors of influencing CPS skills. For instance, Hwang discovered that collaboration plays a crucial role in problem-solving, whereas communication may not be essential. In contrast, Kocak holds a contrasting perspective [21, 105]. The factors affecting the CPS skills are often based on multiple causalities rather than a single causal relationship. Therefore, based on the theory of multi-dimensional empathy [38] and 21st-century skills [21], we analyzed the data of 136 medical students undergoing reflective learning using PLS-SEM and fsQCA, and constructed a hypothetical model to examine the relationships between the CPS skills and influence factors (critical thinking, cooperativity, creativity, algorithmic thinking, empathic concern, fantasy, perspective-taking, personal distress).

The PLS-SEM results (Table 3) showed that a variety of attributes can affect the CPS skills, among which critical thinking and empathic concern play an intermediary role between most antecedents and CPS skills. The fsQCA results partly verified the mediating effect of critical thinking and empathetic concern (Tables 5 and 6). In the PLS-SEM results (Table 3), personal distress was identified to directly affect the CPS skills; and the effect of personal distress on empathic concern was not shown in the fsQCA solution (Table 5), which proved that personal distress directly affects the CPS skills without the intermediary of empathetic concern. This result is similar to that of Jeon [106]; however, he believed that there is a negative correlation between personal distress and problem solving, which might be related to the different learning patterns (reflective learning) used in this study. Personal distress is a necessary process in reflective learning because the motivation of prosocial behavior eases our uncomfortable state of mind by reducing the disgusting and awakening cues sent out by others [107]. Reflection urges us to face these emotions and draw lessons from them. Hoffman noted that excessive personal distress can turn others-oriented motivation into self-directed motivation, thus reducing the occurrence of prosocial behavior [54], which emphasizes the differential treatment of personal distress in different learning modes. In addition, perspective-taking was identified to affect the CPS skills directly (Table 3; C1 in Table 4) and indirectly (Table 3; C1 in Table 5). Therefore, some of the results obtained from fSQCA validated the conclusions of PLS-SEM to some extent (Table 8).

Table 8 Comparison between the results of PLS-SEM and fsQCA

The fsQCA results provided more configuration solutions of complex causality, which extended the results of PLS-SEM and further revealed the complexity of affecting the CPS skills. For example, the fsQCA results in Table 7 not only proved the mediating effect of empathetic concern and critical thinking, but also suggest that they work together to affect the CPS skills. This demonstrates that CPS skills are impacted by both rational and irrational thinking, and positive emotions play a critical role in fostering CPS skills [108]. In Table 4 cooperativity, creativity, algorithmic thinking, critical thinking, and personal distress all appear in forward solutions with high coverage (C1, C2, C3 in Table 4). This suggested that personal distress, cooperativity, creativity, algorithmic thinking, and critical thinking can be regarded as the core conditions to affect the CPS skills, and these conditions make an important contribution in the context of reflective learning. Researches by Chen [77], Garrett [75], Geisinger [70] and Ellis [17] respectively believed that collaboration, creativity, algorithmic thinking and critical thinking play an important role in CPS skills, and Sze [109] believed that personal distress could have a positive impact on prosocial behavior and altruism. The studies above provide are similar to our perspective.

Critical thinking is not only one of the basic skills in the 21st Century but also a key ability in reflective learning [110, 111]. The process of questioning and reorganizing critical thinking is key to reflective learning. The complex structure of the problem-solving process requires critical thinking skills to find different solutions [30, 112,113,114]. Table 4 higher coverage solutions (C1, C2, C3, NC1, NC2, NC3 in Table 4) and Table 7 higher coverage solutions (C1, NC1 in Table 7) showed that critical thinking ability training is helpful to improve a subject’s CPS skills. By contrast, a lack of critical thinking training is not conducive to improving CPS skills (NC1, NC2, NC3 in Table 4; NC1 in Table 7). Critical thinking is widely considered to be a competency closely linked to CPS skills [29], and our study approves this perspective. Moreover, cooperativity, creativity, and algorithmic thinking also appear in the forward solutions with high coverage (C1, C2, C3 in Table 4), combined with the mediating effect of critical thinking on cooperativity, creativity, algorithmic thinking, and the CPS skills. It is logical that the antecedents of critical thinking, such as cooperativity, creativity and algorithmic thinking, also play a positive role in the CPS skills. The result is similar to the findings of Özgenel [115], who believed that critical thinking and creative thinking affected problem-solving skill through decision-making style. These results suggested that we should pay attention to the cultivation of a critical thinking ability, especially through the cultivation of cooperativity, creativity, and algorithmic thinking, which positively and significantly improve a subject’s ability to solve complex problems.

Empathetic concern relationship with the complex configuration between its antecedent variables provides new ideas and insights to improve our ability to solve complex problems. Empathic concern, as a key factor of prosocial behavior [43], is also of positive significance to CPS skills in this study. The higher coverage solutions (C1, C2, C3 in Table 4; NC1, NC2, NC3 in Table 4; C1 in Table 7; NC1 in Table 7) showed that training in empathic concern is beneficial to improve a subject’s CPS skills, while a lack of empathic concern training is not conducive to improving CPS skills (NC1, NC2 in Table 4; NC1 in Table 7). By contrast, fantasy (C2, C3 in Table 4) and perspective-taking (C1, C3 in Table 4) appeared among the forward solutions with higher coverage in Table 4. Combined with the mediating effect among empathic concern, fantasy, perspective-taking, and the CPS skills, it is not difficult for us to understand that the empathic concern antecedent variable: fantasy, and perspective-taking, also have positive significance for the CPS skills. This result aligns with the research findings of Hashmi [57] and Davenport [66]. Moreover, in the absence of empathetic concern, the pathway support of the combination of fantasy, perspective-taking, and personal distress for CPS skills also verified this positive significance from the other side (C3 in Table 4). However, personal distress (C1, C2, C3 in Table 4) appears independently in the forward solution, with high coverage in Table 4, which verifies the direct effect of personal distress on the CPS skills, which was consistent with the results of PLSSEM. These further confirmed the theory of Dorner and Funke, who suggested that complex and dynamic non-routine situations across different domains require a collection of self-regulating psychological processes and a creative combination of knowledge and strategies, and is influenced by motivation and emotion, especially in a high-stakes environment[24]. In addition, according to the observation of the reverse solution of Table 4, the combination of negative perspectivetaking and negative personal distress will be conducive to the low-level CPS skills (NC1, NC2, NC3, NC5 in Table 4). Interestingly, fantasy appeared not only in the forward solution with high coverage (C2, C3 in Table 4), but also in the inverse solution with high coverage (NC2, NC3 in Table 4), which seemed to suggest that the contribution of fantasy to improving CPS skills is neutral, which requires further research.

Consistent with the principle of causal asymmetry, fsQCA suggested that solutions generated by the same attributes in different areas might have the opposite impact on CPS skills, depending on how they combine or interact with other attributes. The lack or negation of some positive factors will lead to improved CPS skills, while the existence of some negative factors might also lead to similar results, depending on how they are configured with the other factors. For example, solution 4 in Table 4 shows that in the absence of critical thinking, cooperativity, algorithmic thinking, creativity, and fantasy, a combination of empathetic concern, personal distress, and perspective-taking could also have a positive effect on the improvement of CPS skills. There is a paucity of literature exploring the effects of empathetic concern, personal distress, and perspective-taking on CPS skills under conditions of low levels of critical thinking, cooperativity, algorithmic thinking, creativity, and fantasy. These insights provide new ideas for exploring improvements in CPS skills. Although PLS-SEM can verify the predetermined relationship between previous factors and the results of interest, it cannot provide these insights.

In addition, considering the complex nature of problem-solving skill under the condition of reflective learning, it is necessary to check the linear and nonlinear relationships between structures to fully understand the strategies and methods to improve CPS skills. In this study, as an ideal approach, PLS-SEM was used to identify the linear (symmetric) causal relationship between the improvement of CPS skills and influence factors. The fSQCA was used to identify the nonlinear (asymmetric), heterogeneous, and dynamic interactions between antecedents and behavioral results. The fSQCA improved identifying sufficient causal conditions for outcomes. The comprehensive application of PLS-SEM and fsQCA helped capture complex multiple causalities in the improvement of CPS skills, which makes theoretical contributions in terms of analytical techniques.

Practical implications

Aquino believes that the implementation of reflective learning strategies is conducive to the improvement of CPS skills [116], which is of practical significance for the design of learning strategies and training tools, including reflective learning. The PLS-SEM results showed that perspective-taking, as an important condition for affected CPS skills, not only plays a role through the intermediary effect of empathetic concern, but also directly affects the CPS skills. The researchers and learners can train subjects to think for others in the form of team communication and exchange of views. For the sake of others, it is necessary to think about CPS skills solutions from multiple angles and more comprehensively, by thinking about problems from the standpoint and perspective of others. Therefore, it is necessary to adopt evidence-based strategies for training to improve the CPS skills.

While the fsQCA results confirmed the PLS-SEM results, in turn its complex configuration helps researchers and learners to make more informed decisions about learning methods to improve CPS skills. The derived pathways indicated that there is more than one causal configuration that can improve CPS skills, and how to improve depends on a combination of attributes. For example, our results showed that the high level of critical thinking and its antecedent attributes, combined with the high level of empathic concern, personal distress, and perspective-taking, will lead to improvement of the CPS skills. The lack of critical thinking, cooperativity, algorithmic thinking, creativity, and fantasy, which to some extent emphasizes the utility of empathic concern, personal distress, and perspective-taking (Table 4 solution 4), make it necessary to pay attention to training medical students in empathic concern, personal distress, and perspective-taking using reflective learning. Aligned with our own research, it was acknowledged reflective learning as a potent method to enhance empathy [37]. Medical reflection should focus on cultivating the ability to speculate on materials and self-views, and at the same time, understand decision-making from the situation of others and feel the emotions of others to trigger empathy. Improvement of CPS skills should not only emphasize the reduction of personal distress, but also should look at the role of personal distress critically. At the same time, it also reminds us that we should fully consider the training situation of the subjects in the design of learning strategies. Critical thinking and its antecedents are regarded as the key solutions in fsQCA, which suggests that we can focus on the reflective learning mode when we train subjects for critical thinking, creativity, cooperativity, and algorithmic thinking. We should also consciously use this kind of thinking to solve problems in the process of reflective learning. In the design of other learning strategies, training in critical thinking ability and its antecedent variables, cooperativity, creativity, and algorithmic thinking, can effectively help subjects to improve their CPS skills.

Based on our understanding of how empathic concern and critical thinking work together to improve the CPS skills, we suggest that real and complex problems in life be taken as examples in the choice of reflective teaching strategies, to involve a series of related skills and characteristics, and fully exercise the two modes of thinking. This is because, in reflective learning, subjects internalize the thinking skills taught by others into their own thinking skills, cultivating the ability to monitor and reflect on the whole problem-solving process, and helping subjects to extract useful strategies, experiences, and patterns into their cognitive structure, thereby improving their CPS skills and accumulating more experience for possible intuitive thinking. This is more suitable for problems based on real-life, which is in line with the medical learning problem-based learning and case-based learning models.


In this study, a hypothetical model of the relationship between the CPS skills and influencing factors (critical thinking, cooperation, creativity, algorithmic thinking, empathic concern, fantasy, perspective-taking, and personal distress) was constructed and validated. The model confirmed the mediating effect of critical thinking and empathic concern on the CPS skills, the direct effect of personal distress, and the direct and indirect effect of perspective-taking on the CPS skills. Besides, fsQCA results provided a variety of configurations that enhanced the improvement of CPS skills. The findings not only enriched the theoretical system of affecting CPS skills, but also provided practical guidance for the development of learning strategies and assessment tools aimed at improving CPS skills.

Limitations and future research

Although this study enriches the theoretical and practical knowledge concerning the relationship between CPS skills and critical thinking, empathic concern, and other variables, it also has some limitations. First, the subjects were beginners in terms of reflective learning under the guidance of teachers, and lack experience in reflective learning, which might affect the accuracy and applicability of variables to some extent. In future research, we will improve these shortcomings, practice reflective learning practices in more subjects, and validate the model in a broader learning strategy, which would be very meaningful. Second, based on the model of this study, it is necessary to enrich the paths and develop a variety of learning and training tools to improve the CPS skills in the future research. The development of assessment tools for factors related to the measurement of CPS skills will facilitate targeted training and realize personalized learning practice guidance.

Data Availability

The data sets used and / or analyzed in this study have not been made public. If there is a reasonable need, they can be obtained from and provided by the corresponding author of this article.



Complex problem-solving


Organisation for Economic Co-operation and Development


Partial least square structural equation modeling


Fuzzy set qualitative comparative analysis


Average variance extracted


Variance inflation factor


Interpersonal Reactivity Index


Computational Thinking Scale


Structural equation modeling.


  1. Co-operation OfE, Development. PISA 2012 results: Creative problem solving: Students’ skills in tackling real-life problems (Volume V). In.: OECD Publishing Pisa; 2014.

  2. Amirian K. P-833-To study the effect of problem-solving skill education on first year high school male students in songhor koliayi township in academic year. Eur Psychiatry. 2012;27(S1):1–1.

    Article  Google Scholar 

  3. Ayalew MM. Multilevel analysis of entrepreneurial intention of engineering graduating students in Ethiopia. J Appl Econ. 2021;24(1):366–91. 1992.

    Article  Google Scholar 

  4. Elliott TR. Social problem-solving abilities and adjustment to recent-onset spinal cord injury. Rehabil Psychol. 1999;44(4):315.

    Article  Google Scholar 

  5. Woods DR, Hrymak AN, Marshall RR, Wood PE, Crowe CM, Hoffman TW, Wright JD, Taylor PA, Woodhouse KA, Bouchard CK. Developing problem solving skills: the McMaster problem solving program. J Eng Educ. 1997;86(2):75–91.

    Article  Google Scholar 

  6. Lohman MC, Finkelstein M. Designing groups in problem-based learning to promote problem-solving skill and self-directedness. Instr Sci. 2000;28(4):291–307.

    Article  Google Scholar 

  7. Puplampu V. Nursing students’ and faculty members’ experiences of comfort during transition to context-based learning. Int J Nurs Educ Scholarsh. 2017;14(1).

  8. Chen SL, Huang TW, Liao IC, Liu C. Development and validation of the simulation learning effectiveness inventory. J Adv Nurs. 2015;71(10):2444–53.

    Article  Google Scholar 

  9. Miller GP, Molina-Ray C. Beyond technology dependence: critically reflexive thinking in higher education. J Leadersh Stud. 2010;4(1):74–7.

    Article  Google Scholar 

  10. Gadbury-Amyot CC, Godley LW, Nelson JW Jr. Measuring the level of reflective ability of predoctoral dental students: early outcomes in an e‐portfolio reflection. J Dent Educ. 2019;83(3):275–80.

    Article  Google Scholar 


  12. Kellogg RT. The psychology of writing. Oxford University Press; 1999.

  13. Atkins S, Murphy K. Reflection: a review of the literature. J Adv Nurs. 1993;18(8):1188–92.

    Article  Google Scholar 

  14. Lau AKL, Chuk KC, Wei So WK. Reflective practise in clinical teaching. Nurs Health Sci. 2002;4(4):201–8.

    Article  Google Scholar 

  15. Illeris K. Læring (Nordgård, Y.). In.: Oslo: Gyldendal akademisk; 2012.

  16. Barton G, Ryan M. Multimodal approaches to reflective teaching and assessment in higher education. High Educ Res Dev. 2014;33(3):409–24.

    Article  Google Scholar 

  17. Ellis S, Carette B, Anseel F, Lievens F. Systematic reflection: implications for learning from failures and successes. Curr Dir Psychol Sci. 2014;23(1):67–72.

    Article  Google Scholar 

  18. Bulman C, Schutz S. Reflective practice in nursing. John Wiley & Sons; 2013.

  19. Whittock T. Reflexive teaching, reflexive learning. Teach High Educ. 1997;2(2):93–102.

    Article  Google Scholar 

  20. Nuninger W, Picardi C, Goy A, Petrone G. Multi-perspective concept mapping in a digital integrated learning environment: Promote active learning through shared perspectives. Educational Technology and the New World of Persistent Learning.edn.: IGI Global; 2019: 114–44.

  21. Kocak O, Coban M, Aydin A, Cakmak N. The mediating role of critical thinking and cooperativity in the 21st century skills of higher education students. Think Skills Creativity. 2021;42:100967.

    Article  Google Scholar 

  22. Newell A, Simon HA. Human problem solving. Volume 104. Prentice-hall Englewood Cliffs, NJ; 1972.

  23. Buchner A. Basic topics and approaches to the study of complex problem solving. Complex problem solving: The European perspective 1995:27–63.

  24. Dörner D, Funke J. Complex problem solving: what it is and what it is not. Front Psychol. 2017;8:1153.

    Article  Google Scholar 

  25. Fischer A, Neubert JC. The multiple faces of complex problems: a model of problem solving competency and its implications for training and assessment. J Dynamic Decis Mak. 2015;1:6–6.

    Article  Google Scholar 

  26. Funke J, Fischer A, Holt DV. Competencies for complexity: problem solving in the twenty-first century. Assessment and teaching of 21st century skills.edn.: Springer; 2018: 41–53.

  27. Akpinar Ö. The Effect of Empathy levels of Female School of Physical Education and Sports Students on Problem solving skill levels. Asian J Educ Train. 2020;6(3):406–11.

    Article  Google Scholar 

  28. Doleck T, Bazelais P, Lemay DJ, Saxena A, Basnet RB. Algorithmic thinking, cooperativity, creativity, critical thinking, and problem solving: exploring the relationship between computational thinking skills and academic performance. J Computers Educ 2017, 4(4):355–69

  29. Ananiadoui K, Claro M. 21st century skills and competences for new millennium learners in OECD countries. 2009.

  30. Daud D, Santoso RH. Device learning development using Cabri 3D with problem-solving method based on oriented critical thinking ability and learning achievements of junior high school students. In: 5th Asia Pasific Education Conference (AECON 2018): 2018: Atlantis Press; 2018: 23–28.

  31. Benham MK. The practitioner-scholars’ view of school change: a case-based approach to teaching and learning. Teach Teacher Educ. 1996;12(2):119–35.

    Article  Google Scholar 

  32. Argelagos E, Pifarré M. Improving information problem solving skills in secondary education through embedded instruction. Comput Hum Behav. 2012;28(2):515–26.

    Article  Google Scholar 

  33. Kim KT. The structural relationship among digital literacy, learning strategies, and core competencies among south korean college students. Educational sciences: theory and practice. 2019;19(2):3–21.

    Article  Google Scholar 

  34. Wink MN, LaRusso MD, Smith RL. Teacher empathy and students with problem behaviors: examining teachers’ perceptions, responses, relationships, and burnout. Psychol Sch. 2021;58(8):1575–96.

    Article  Google Scholar 

  35. Leppma M. The effect of loving-kindness meditation on empathy, perceived social support, and problem-solving appraisal in counseling students. 2011.

  36. Zheng S, Masuda T, Matsunaga M, Noguchi Y, Ohtsubo Y, Yamasue H, Ishii K. Cultural differences in social support seeking: the mediating role of empathic concern. PLoS ONE. 2021;16(12):e0262001.

    Article  Google Scholar 

  37. Imperato A, Strano-Paul L. Impact of reflection on empathy and emotional intelligence in third-year medical students. Acad Psychiatry. 2021;45(3):350–3.

    Article  Google Scholar 

  38. Davis MH. A multidimensional approach to individual differences in empathy. 1980.

  39. Kim H, Han S. Does personal distress enhance empathic interaction or block it? Pers Indiv Differ. 2018;124:77–83.

    Article  Google Scholar 

  40. Decety J, Lamm C. Human empathy through the lens of social neuroscience. TheScientificWorldJOURNAL. 2006;6:1146–63.

    Article  Google Scholar 

  41. Batson CD, O’Quin K, Fultz J, Vanderplas M, Isen AM. Influence of self-reported distress and empathy on egoistic versus altruistic motivation to help. J Personal Soc Psychol. 1983;45(3):706.

    Article  Google Scholar 

  42. Nomura K, Akai S. Empathy with fictional stories: reconsideration of the fantasy scale of the interpersonal reactivity index. Psychol Rep. 2012;110(1):304–14.

    Article  Google Scholar 

  43. Vaish A. Empathy and prosocial behavior. 2020.

  44. Stocks EL, Lishner DA, Waits BL, Downum EM. I’m embarrassed for you: the effect of valuing and perspective taking on empathic embarrassment and empathic concern. J Appl Soc Psychol. 2011;41(1):1–26.

    Article  Google Scholar 

  45. Archer RL, Diaz-Loving R, Gollwitzer PM, Davis MH, Foushee HC. The role of dispositional empathy and social evaluation in the empathic mediation of helping. 1981.

  46. Ampuero D, Miranda CE, Delgado LE, Goyen S, Weaver S. Empathy and critical thinking: primary students solving local environmental problems through outdoor learning. J Adventure Educ Outdoor Learn. 2015;15(1):64–78.

    Article  Google Scholar 

  47. Moitra M, Buch R, Damor R. Problem solving skills among adolescents in Surat city: a reality check. Natl J Community Med. 2019;10:571–4.

    Google Scholar 

  48. Ringle CM, Wende S, Becker J-M. SmartPLS 3. Boenningstedt: SmartPLS GmbH 2015, 584.

  49. Ragin CC, Strand SI, Rubinson C. User’s guide to fuzzy-set/qualitative comparative analysis. Univ Arizona. 2008;87:1–87.

    Google Scholar 

  50. Carrera P, Oceja L, Caballero A, Muñoz D, López-Pérez B, Ambrona T. I feel so sorry! Tapping the joint influence of empathy and personal distress on helping behavior. Motivation and Emotion. 2013;37(2):335–45.

    Article  Google Scholar 

  51. Eisenberg N, Eggum ND. Empathic responding: Sympathy and personal distress. The social neuroscience of empathy 2009, 6(2009):71–830.

  52. Rodríguez-Nogueira Ó, Moreno-Poyato AR, Álvarez-Álvarez MJ, Pinto-Carral A. Significant socio-emotional learning and improvement of empathy in physiotherapy students through service learning methodology: a mixed methods research. Nurse Educ Today. 2020;90:104437.

    Article  Google Scholar 

  53. Reynolds F. Communication and clinical effectiveness in rehabilitation. Elsevier Health Sciences; 2004.

  54. Hoffman ML. Empathy and moral development: implications for caring and justice. Cambridge University Press; 2001.

  55. Joireman J. Empathy and the self-absorption paradox II: self-rumination and self-reflection as mediators between shame, guilt, and empathy. Self and Identity. 2004;3(3):225–38.

    Article  Google Scholar 

  56. Stanovich K. Rationality and the reflective mind. Oxford University Press; 2011.

  57. Hashmi S, Vanderwert RE, Paine AL, Gerson SA. Doll play prompts social thinking and social talking: representations of internal state language in the brain. Dev Sci. 2021;e13163.

  58. Van Reet J. Pretense, Imagination, and Fantasy. 2021.

  59. Zipes J. Why fantasy matters too much. CLCWeb: Comp Literature Cult. 2008;10(4).

  60. Brown MM, Thibodeau RB, Pierucci JM, Gilpin AT. Supporting the development of empathy: the role of theory of mind and fantasy orientation. Soc Dev. 2017;26(4):951–64.

    Article  Google Scholar 

  61. Weibel D, Martarelli CS, Häberli D, Mast FW. The fantasy questionnaire: a measure to assess creative and imaginative fantasy. J Pers Assess. 2018;100(4):431–43.

    Article  Google Scholar 

  62. Bauer RH, Gilpin AT, Thibodeau-Nielsen RB. Executive functions and imaginative play: Exploring relations with prosocial behaviors using structural equation modeling. Trends in Neuroscience and Education 2021, 25:100165

  63. Becker R. Empathie. Potenziale entdecken.edn.: Springer; 2016: 65–84.

  64. Falk DR, Johnson DW. The effects of perspective-taking and egocentrism on problem solving in heterogeneous and homogeneous groups. J Soc Psychol. 1977;102(1):63–72.

    Article  Google Scholar 

  65. Johnson DW. Role reversal: A summary and review of the research. Int J Group Tensions 1971.

  66. Davenport SW, Rentsch JR. Managing conflict through team member schema accuracy: a fresh perspective on perspective taking. J Theoretical Social Psychol. 2021;5(4):449–63.

    Article  Google Scholar 

  67. Bethune C, Brown JB. Residents’ use of case-based reflection exercises. Can Fam Physician. 2007;53(3):470–6.

    Google Scholar 

  68. Hsu C-C, Wang T-I. Applying game mechanics and student-generated questions to an online puzzle-based game learning system to promote algorithmic thinking skills. Comput Educ. 2018;121:73–88.

    Article  Google Scholar 

  69. Gürbüz H, Evlioğlu B, Erol ÇS, Gülseçen H, Gülseçen S. What’s the weather like today?”: a computer game to develop algorithmic thinking and problem solving skills of primary school pupils. Educ Inform Technol. 2017;22(3):1133–47.

    Article  Google Scholar 

  70. Geisinger KF. 21st century skills: what are they and how do we assess them? Appl Measur Educ. 2016;29(4):245–9.

    Article  Google Scholar 

  71. Futschek G, Moschitz J. Developing algorithmic thinking by inventing and playing algorithms. Proceedings of the 2010 constructionist approaches to creative learning, thinking and education: Lessons for the 21st century (constructionism 2010) 2010:1–10.

  72. Runco MA, Pritzker SR. Encyclopedia of creativity. Academic press; 2020.

  73. Sternberg RJ, Lubart TI. The concept of creativity: prospects and paradigms. Handb creativity. 1999;1:3–15.

    Article  Google Scholar 

  74. Korkmaz Ö, Çakir R, Özden MY. A validity and reliability study of the computational thinking scales (CTS). Comput Hum Behav. 2017;72:558–69.

    Article  Google Scholar 

  75. Garrett RM. Issues in science education: problem-solving, creativity and originality. Int J Sci Educ. 1987;9(2):125–37.

    Article  Google Scholar 

  76. Chen C, Kasof J, Himsel AJ, Greenberger E, Dong Q, Xue G. Creativity in drawings of geometric shapes: a cross-cultural examination with the consensual assessment technique. J Cross-Cult Psychol. 2002;33(2):171–87.

    Article  Google Scholar 

  77. Chen C-C, Swan K. Using innovative and scientifically-based debate to Build e-Learning Community. Online Learn. 2020;24(3):67–80.

    Article  Google Scholar 

  78. Claes E, Schrooten M, McLaughlin H, Csoba J. Community service learning in complex urban settings: challenges and opportunities for social work education. Social Work Education 2021:1–19

  79. Nazirova G, Yulchiboeva D, Khaydarov O. The main factors of formation and development of Professional competence of Teachers of Preschool Educational Organizations. REVISTA GEINTEC-GESTAO INOVACAO E TECNOLOGIAS. 2021;11(3):1698–708.

    Article  Google Scholar 

  80. Gibbs G. Learning by doing: a guide to teaching and learning methods. Further Education Unit; 1988.

  81. Kelly M. Enhancing Cognitive Empathy. North Carolina State University; 2021.

  82. Pang Y, Song C, Ma C. Effect of different types of empathy on prosocial behavior: Gratitude as mediator. Front Psychol 2022, 13.

  83. Siem B. The relationship between empathic concern and perceived personal costs for helping and how it is affected by similarity perceptions. J Soc Psychol 2021:1–20

  84. Underwood B, Moore B. Perspective-taking and altruism. Psychol Bull. 1982;91(1):143.

    Article  Google Scholar 

  85. Fatma A, Polat S, Kashimi T. Relationship between the problem-solving skills and empathy skills of operating room nurses. J Nurs Res. 2020;28(2):e75.

    Article  Google Scholar 

  86. Contreras JA, Edwards-Maddox S, Hall A, Lee MA. Effects of reflective practice on baccalaureate nursing students’ stress, anxiety and competency: an integrative review. Worldviews on Evidence‐Based Nursing. 2020;17(3):239–45.

    Article  Google Scholar 

  87. Coyne SM, Padilla-Walker LM, Holmgren HG, Davis EJ, Collier KM, Memmott-Elison MK, Hawkins AJ. A meta-analysis of prosocial media on prosocial behavior, aggression, and empathic concern: a multidimensional approach. Dev Psychol. 2018;54(2):331.

    Article  Google Scholar 

  88. O’Brien E, Konrath SH, Grühn D, Hagen AL. Empathic concern and perspective taking: Linear and Quadratic Effects of Age across the Adult Life Span. The Journals of Gerontology: Series B. 2013;68(2):168–75.

    Article  Google Scholar 

  89. Gülseven Z, Kumru A, Carlo G, De Guzman MR. The roles of perspective taking, empathic concern, and Prosocial Moral reasoning in the self-reported prosocial behaviors of Filipino and turkish young adults. J Cross-Cult Psychol. 2020.

    Article  Google Scholar 

  90. Wrigglesworth S. Understanding reflective practice. Nurs Standard (2014+). 2016;31(8):72.

    Article  Google Scholar 

  91. Amerson R, Livingston WG. Reflexive photography: an alternative method for documenting the learning process of cultural competence. J Transcult Nurs. 2014;25(2):202–10.

    Article  Google Scholar 

  92. Davies SM, Reitmaier AB, Smith LR, Mangan-Danckwart D. Capturing intergenerativity: the use of student reflective journals to identify learning within an undergraduate course in gerontological nursing. J Nurs Educ. 2013;52(3):139–49.

    Article  Google Scholar 

  93. Stocker M, Burmester M, Allen M. Optimisation of simulated team training through the application of learning theories: a debate for a conceptual framework. BMC Med Educ. 2014;14(1):1–9.

    Article  Google Scholar 

  94. Parrish DR, Crookes K. Designing and implementing reflective practice programs–key principles and considerations. Nurse Educ Pract. 2014;14(3):265–70.

    Article  Google Scholar 

  95. Tee KN, Leong KE, Abdul Rahim SS. The mediating effects of critical thinking skills on motivation factors for mathematical reasoning ability. Asia-Pacific Educ Researcher. 2018;27:373–82.

    Article  Google Scholar 

  96. Pellas N, Vosinakis S. The effect of simulation games on learning computer programming: a comparative study on high school students’ learning performance by assessing computational problem-solving strategies. Educ Inform Technol. 2018;23(6):2423–52.

    Article  Google Scholar 

  97. Sırakaya M, Alsancak Sırakaya D, Korkmaz Ö. The impact of STEM attitude and thinking style on computational thinking determined via Structural equation modeling. J Sci Edu Technol. 2020;29(4):561–72.

    Article  Google Scholar 

  98. Hair JF Jr, Hult GTM, Ringle CM, Sarstedt M. A primer on partial least squares structural equation modeling (. PLS-SEM): Sage publications;; 2021.

  99. Kallmuenzer A, Kraus S, Peters M, Steiner J, Cheng C-F. Entrepreneurship in tourism firms: a mixed-methods analysis of performance driver configurations. Tour Manag. 2019;74:319–30.

    Article  Google Scholar 

  100. Cohen J. Statistical power analysis for the behavioral sciences (revised ed.). In.: New York: Academic Press; 1977.

  101. Fornell C, Larcker DF. Evaluating structural equation models with unobservable variables and measurement error. J Mark Res. 1981;18(1):39–50.

    Article  Google Scholar 

  102. Henseler J, Dijkstra TK, Sarstedt M, Ringle CM, Diamantopoulos A, Straub DW, Ketchen DJ Jr, Hair JF, Hult GTM, Calantone RJ. Common beliefs and reality about PLS: Comments on Rönkkö and Evermann (2013). Organizational research methods 2014, 17(2):182–209.

  103. Chin WW. The partial least squares approach to structural equation modeling. Mod methods Bus Res. 1998;295(2):295–336.

    Google Scholar 

  104. Woodside AG. Moving beyond multiple regression analysis to algorithms: calling for adoption of a paradigm shift from symmetric to asymmetric thinking in data analysis and crafting theory. Volume 66. Elsevier; 2013. pp. 463–72.

  105. Hwang G-J, Lai C-L, Liang J-C, Chu H-C, Tsai C-C. A long-term experiment to investigate the relationships between high school students’ perceptions of mobile learning and peer interaction and higher-order thinking tendencies. Education Tech Research Dev. 2018;66:75–93.

    Article  Google Scholar 

  106. Jeong H. Critical thinking disposition, problem solving process, and empathy among nursing students. Adv Sci Technol Lett. 2015;103:44–8.

    Article  Google Scholar 

  107. Batson CD. Prosocial motivation: Is it ever truly altruistic? Advances in experimental social psychology. Volume 20,edn.: Elsevier; 1987: 65–122.

  108. Isen AM. Some ways in which positive affect influences decision making and problem solving. Handb emotions. 2008;3:548–73.

    Google Scholar 

  109. Sze JA, Gyurak A, Goodkind MS, Levenson RW. Greater emotional empathy and prosocial behavior in late life. Emotion. 2012;12(5):1129.

    Article  Google Scholar 

  110. Boyaci S, Atalay N. A Scale Development for 21st Century Skills of Primary School students: a validity and reliability study. Int J Instruction. 2016;9(1):133–48.

    Article  Google Scholar 

  111. Herout L. Reflexion of the Methods and Forms of University Education in Economy Oriented Study Programmes in the Czech Republic. In: ICERI2015 Proceedings: 8th annual International Conference of Education, Research and Innovation: 2015; 2015.

  112. Aein F, Hosseini R, Naseh L, Safdari F, Banaian S. The effect of problem-solving-based interprofessional learning on critical thinking and satisfaction with learning of nursing and midwifery students. J Educ Health Promotion. 2020;9.

  113. Giannakopoulos P, Buckley S. Do problem solving, critical thinking and creativity play a role in knowledge management? A theoretical mathematics perspective. In: Proceedings of the 10 th European Conference on Knowledge Management: 2009; 2009: 327–337.

  114. GOGUS A, Göğüş NG, BAHADIR E. Intersections between critical thinking skills and reflective thinking skills toward problem solving. Pamukkale Üniversitesi Eğitim Fakültesi Dergisi. 2019;49:1–19.

    Article  Google Scholar 

  115. Özgenel M. Modeling the relationships between school administrators’ creative and critical thinking dispositions with decision making styles and problem solving skills. Educational Sciences: Theory & Practice. 2018;18(3).

  116. Aquino HI, Ching DA. Effects of Reflective Learning Resource Material on Achievement of Mathematics Learning Outcome. Int J Educational Manage Dev Stud, 3(1):132–48

Download references


The authors would like to thank the teachers and students who participated (including the teachers and students of Shulan International Medical College, Zhejiang Shuren University, China), and SmartPLS 3.0 and fsQCA 3.1 for their assistance in analysis of data of this process.


This study was funded by the Provincial Industry-University Cooperation Collaborative Education Project (NO.318 [2022] of the Zhejiang Development Reform Society), the Scientific and technological Innovation activity Plan and New Seedling Talent Plan for College students in Zhejiang Province in 2023, the First-class curriculum project of Zhejiang Province of China (NO.195 [2022] of the Zhejiang Education Office Letter, NO.352 [2022] of the Zhejiang Education Office Letter), the First batch of ideological and political demonstration courses of Zhejiang Province of China (NO.47 [2021] of the Zhejiang Education Letter), and the High-level pre-level program of Zhejiang Shuren University in 2019.

Author information

Authors and Affiliations



ZLX and JYL conceived the project with the input of YW and KDC. YW, ZLX, and JYL collected and analyzed the relevant data for this study. YW and ZLX are the main authors of this study. All the authors read and approved the manuscript.

Corresponding author

Correspondence to Ke-Da Chen.

Ethics declarations

Ethics approval and consent to participate

Ethical approval was obtained and document informed consent was waived by the Ethics Committee of Zhejiang Shuren University (202201016). All procedures in this study adhered to the World Medical Association (WMA) Declaration of Helsinki (2013) ethical guidelines.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no conflict of interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Wang, Y., Xu, ZL., Lou, JY. et al. Factors influencing the complex problem-solving skills in reflective learning: results from partial least square structural equation modeling and fuzzy set qualitative comparative analysis. BMC Med Educ 23, 382 (2023).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: