Participants were Australian registered paramedics and New Zealand paramedics eligible for national registration. Student participants were undertaking accredited undergraduate paramedicine studies in Australian or New Zealand universities.
Participants were recruited through paramedicine and student social media groups, professional associations, employer groups, and universities offering paramedicine courses. The study was promoted on Facebook, Twitter and LinkedIn for six weeks in August and September 2020. Professional groups, major employers, and student paramedicine associations in Australia and New Zealand were all asked to assist with promoting the study. Based on estimated sample calculations, recruitment continued for six weeks or until a sample size of 250 was reached.
There were 328 surveys attempted and 237 completed (Table 1). Following removal of responses that took too long or failed the attention or random-responding checks, there were 204 valid responses available for analysis (Table 2).
Number of responses received and considered for analysis.
Number of surveys attempted 328
Number of surveys completed 237
Number of responses greater 2 standard deviations in length 1
Number failed attention check 4
Number failed random check 28
Number available for analysis 204
Paramedic (n=103) Student (n=101) All participants (N=204)
Female 45 (43.7%) 60 (59.4%) 105 (51.5%)
Male 51 (49.5%) 37 (36.6%) 88 (43.1%)
Other 7 (6.8%) 4 (4.0%) 11 (5.4%)
Age (Years: Mean [SD]) 38.7 [11.1] 25.7 [8.53] 32.2 [11.8]
Experience (Years: Mean [SD]) 12.0 [9.43] NA 12.0 [9.43]
Cognitive Reflection Test
The Cognitive Reflection Test (CRT; Frederick, 2005) is the most commonly used tool to assess intuitive versus effortful reasoning by measuring the ability to override an intuitively attractive but incorrect response and determine the correct answer. Since the original three-item version was first created in 2005, the CRT has been used and validated in a variety of settings and evolved over time (Patel et al., 2019). We used a 7-item version with reworked versions of the classic items plus additional non-numeric items (Table 3) (Newton et al., 2021).
Cognitive Reflection Test items used in this study.
The ages of Mark and Adam add up to 28 years total. Mark is 20 years older than Adam. How many years old is Adam? Intuitive answer: 8;
Correct answer: 4
If it takes 10 seconds for 10 printers to print out 10 pages of paper, how many seconds will it take 50 printers to print out 50 pages of paper?
Intuitive answer: 50;
Correct answer: 10
On a loaf of bread, there is a patch of mould. Every day, the patch doubles in size. If it takes 40 days for the patch to cover the entire loaf of bread, how many days would it take for the patch to cover half of the loaf of bread?
Intuitive answer: 20;
Correct answer: 39.
If you’re running a race and you pass the person in second place, what place are you in?
Intuitive answer: first;
Correct answer: second
A farmer had 15 sheep and all but 8 died. How many are left? Intuitive answer: 7;
Correct answer: 8
Emily’s father has three daughters. The first two are named April and May. What is the third daughter’s name?
Intuitive answer: June;
Correct answer: Emily
How many cubic metres of dirt are there in a hole that is 3m deep x 3m wide x 3m long? Intuitive answer: 27;
Correct answer: 0
Comprehensive Thinking Styles Questionnaire (CTSQ)
The Comprehensive Thinking Styles Questionnaire (CTSQ; Newton et al., 2021) measures preferences for both intuitive and effortful thinking as well as open- and close-mindedness. The instrument has potential to be used as a common measurement standard for assessing thinking styles. However, as a very new development it has not been used in a variety of domains.
The CTSQ has 24 items and four subscales (Table 4): Actively Open-minded Thinking (AOT), Close-Minded Thinking (CMT), Preference for Intuitive Thinking (PIT), and Preference for Effortful Thinking (PET). The items are scored on a 6-point Likert scale (ranging from 1 [strongly disagree] to 6 [strongly agree] with no neutral response option.
Comprehensive Thinking Scale Questionnaire: subscale definitions and items
Name of Scale Description Items
Actively Open-minded Thinking (AOT)*
Assesses the tendency to weigh new evidence against a preferred belief. 1. It is important to be loyal to your beliefs even when evidence is brought to bear against them.
2. Whether something feels true is more important than evidence.
3. Just because evidence conflicts with my current beliefs does not mean my beliefs are wrong.
4. There may be evidence that goes against what you believe but that does not mean you have to change your beliefs.
5. Even if there is concrete evidence against what you believe to be true, it is OK to maintain cherished beliefs.
6. Regardless of the topic, what you believe to be true is more important than evidence against your beliefs.
Close-minded Thinking (CMT) Assesses the conviction that an individual’s beliefs are correct, especially in contrast to alternatives. 7. I think there are many wrong ways, but only one right way, to almost anything.
8. In my experience, the truth is often black and white.
9. Truth is never relative.
10. The truth does not change.
11. Either something is true or it is false; there is nothing in-between.
12. There is no middle ground between what is true and what is false.
Preference for Intuitive Thinking (PIT) Assesses an individual’s preference to base decisions on gut feelings and trust in their own intuition when making decisions. 13. I like to rely on my intuitive impressions.
14. I believe in trusting my hunches.
15. When I make decisions, I tend to rely on my intuition.
16. Using my "gut-feelings" usually works well for me in figuring out problems in my life.
17. Intuition is the best guide in making decisions.
18. I often go by my instincts when deciding on a course of action.
Preference for Effortful Thinking (PET)* Assesses an individual’s tendency to engage in and enjoy effortful cognitive activity. 19. I’m not that good at figuring out complicated problems.
20. Thinking is not my idea of an enjoyable activity.
21. I try to avoid situations that require thinking in depth about something.
22. I am not a very analytical thinker.
23. Reasoning things out carefully is not one of my strong points.
24. Thinking hard and for a long time about something gives me little satisfaction.
The items are scored on a 6-point Likert scale (ranging from 1 (strongly disagree) to 6 (strongly agree) with no moderate response option. To compute a score for the measure, calculate the mean of each subscale.
* The Active Open-minded Thinking and Preference for Effortful Thinking subscales are reverse scored.
Survey materials were implemented in Qualtrics (Provo, UT), with recruitment and participation entirely internet-based. After viewing a participant information sheet and providing consent, participants completed the 7-item CRT with items in random order, followed by an additional question asking if the participant had seen the questions before. Participants then completed the CTSQ items in random order, followed by questions to check for attention and random responding. Finally, participants provided demographic information. Other than demographic questions to confirm their professional status and experience, none of the instructions or questions were specific to paramedic practice. The survey materials and data can be found at (URL).
The study protocol was considered and approved by the Australian National University Human Research Ethics Committee (2017/141). No inducements or payments were offered for participation. No personal data was collected for the study and the researchers were unable to identify individual responses.
In order to detect a correlation of at least 0.2 with 80% power at a significance level of 0.05 (two-tailed), 193 participants were required (Cohen, 1988). Correlation of 0.2 was selected based on previous research correlating CRT performance with CTSQ scales (Newton et al., 2021). The target of 250 allowed for a proportion of responses to be removed for inattention, incompleteness, or random responding.
Statistical analysis was conducted using ‘R’ version 4.0.5 (R Core Team, 2021). Frequency data are reported as count (percentage). Continuous variables are reported as mean (SD). Comparisons of categorical data were conducted using Chi-square test and continuous variables were compared using the relevant parametric test with P-values set at .05 two-tailed..
All data analysis was conducted on complete surveys after removing participants who responded inappropriately to the attention-check and random responding items. In addition, any survey that took longer than two standard deviations of the mean response time was removed.
The CRT was scored by one point for each correct answer (range: 0-7), with a higher score indicating a higher degree of cognitive reflection, or put another way, a greater ability to override an incorrect intuitive response.
To compute a score for the CTSQ, the mean was calculated for each subscale. The Active Open-Minded Thinking and Preference for Effortful Thinking subscales are reverse scored, so a higher score for all subscales indicates higher preference for that style.
Paramedics play important roles in healthcare systems globally, yet little is known about their decision-making. There is evidence that individual differences in thinking style can predict differences in decisions and judgements (Phillips et al., 2016). Despite this, there have been few studies of thinking style in healthcare professionals, and all have measured only the intuition-effortful axis. Our study was the first to also measure open- and close-mindedness in paramedics, constructs implicated in understanding the relationship between intuition and effortful thinking (Stanovich, 2018). We used the CRT to measure participants’ willingness and ability to override their intuition and correlated their performance with self-reported thinking styles.