Refining clinical judgment competence in nursing education in the Philippines: A mixed-methods study on the impact of the Philips 66 brainstorming technique in case-based learning

Design

The quantitative phase employed a true experimental pre-test/post-test design, with Trial Registry Number NCT06646068 and registered with the Philippine Council for Health Research and Development (DOST-PCHRD) / Health Research and Development Information Network (HERDIN) as PHRR241010-007605.

Samples

This phase recruited 60 fourth-year nursing students (aged 20 and above) enrolled in the Bachelor of Science in Nursing program. A random sampling approach was used to allocate the students into two groups: 30 were assigned to the intervention group participating in the Philips 66 case-based learning sessions. Another 30 students were assigned to the control group, receiving the standard nursing curriculum. The allocation process involved listing the students and randomly assigning the first five groups of six to the intervention group and the subsequent five groups of six to the control groups. Inclusion criteria for the samples included being in the fourth year of the nursing program and having completed the required clinical rotations and nursing leadership courses. Students in earlier years of the nursing program or those who had not completed the clinical requirements were excluded from the study. Senior nursing students were selected because their greater experience in clinical settings would better equip them to effectively participate in the research and apply clinical judgment skills to case-based scenarios.

Intervention

The intervention group participated in a modified case-based learning (CBL) approach incorporating the Philips 66 brainstorming technique. This approach aimed to enhance student engagement, promote deeper analysis of case scenarios, and improve clinical judgment skills.

• Case Presentation: Both the intervention and control groups received the same case presentation.

• Individual Reflection: Participants engaged in a six-minute individual reflection period, using their clinical judgment to follow the START and JUMPSTART disaster triaging protocols and create a preliminary care plan based on the NANDA framework.

• Group Brainstorming: Participants engaged in a six-minute brainstorming session using the Philips 66 technique to discuss and refine their ideas.

• Presentation: Designated leaders from the intervention group presented their proposed triage category, the rationale for chosen assessments, and key elements of their nursing care plan within a six-minute timeframe.

• Debriefing: An instructor-led debriefing session followed, addressing the strengths and weaknesses of both approaches.

• Supervision: Five clinical instructors supervised the intervention with expertise in disaster nursing. The instructors provided guidance and feedback and ensured consistent implementation of the Philips 66 technique across all intervention groups.

• Total Session Duration: Approximately 60-66 minutes

• The intervention sessions were conducted twice times per week over five weeks.

• Assessment of Clinical Judgment: The instructors evaluated both groups using the Lasater Clinical Judgment Rubric (LCJR), aligned with Tanner’s Clinical Judgment Model. The rubric assessed how well students noticed cues, interpreted data, responded with a care plan, and reflected on intervention effectiveness, all in connection to the clinical judgment process (Rogers & Franklin, 2023; Tanner, 2006).

Data Collection Procedure

After receiving ethical approval, the research team comprised five clinical instructors, a fourth-year level coordinator, a nursing faculty administrator, and the lead researcher (experienced in Philips 66 techniques) to plan the study’s execution. The collaborative effort aimed to integrate the Philips 66 brainstorming technique with case-based learning within five groups. This involved detailed discussions on the study protocol, the selection of clinical scenarios for the Philips 66 sessions, and the training of instructors in the technique to ensure fidelity in implementation. Data collection for the quantitative phase commenced on March 12, 2024, following this preparatory phase. The quantitative phase, including the pre-test and post-test assessments, was completed before transitioning to the qualitative phase.

To ensure the integrity and consistency of the intervention across groups, several measures were implemented. First, all five clinical instructors received training on the Philips 66 technique and were provided with a standardized script for delivering the intervention. Second, regular supervision and feedback were given to the instructors to maintain consistent implementation and address any concerns. Third, adherence to intervention protocols was closely monitored, ensuring compliance with procedures, duration, and guidance for participants.

A different set of instructors conducted the pre-test and post-test assessments to avoid bias. The instructors who conducted the intervention were not involved in the assessment process. This helped to ensure that the examinations were administered objectively and without any influence from the intervention.

Instruments

A multifaceted approach was employed to comprehensively evaluate both student clinical judgment skills and their perspectives on the intervention. The Lasater Clinical Judgment Rubric (LCJR) (Benner et al., 2009; Lasater, 2007), a well-established tool validated for simulated scenarios and real-world settings (Brentnall et al., 2022; Lee, 2021), was used to assess pre- and post-intervention clinical judgment. The LCJR utilizes a four-point rating scale, with 1 denoting “Beginning,” 2 signifying “Developing,” 3 representing “Accomplished,” and 4 indicating “Exemplary” performance in clinical judgment (Lasater, 2007). Authorization to utilize the Lasater Clinical Judgment Rubric (LCJR) was granted by its creator.

Importantly, a recent study by Rogers and Franklin (2023) highlighted the LCJR’s effectiveness in scoring written reflections, which aligns perfectly with this study where students’ written analyses of case scenarios were assessed using the LCJR. The LCJR is grounded in Tanner’s Clinical Judgment Model, which emphasizes the process of noticing, interpreting, responding, and reflecting on clinical situations (Tanner, 2006). The LCJR was chosen over other potential instruments due to its comprehensive assessment of clinical judgment skills and its validation in various settings. While other instruments may assess some aspects of clinical judgment, the LCJR offers a holistic evaluation that includes all four stages of Tanner’s model. Additionally, the LCJR has been validated in simulated and real-world scenarios, making it a reliable tool for assessing clinical judgment in nursing students (Brentnall et al., 2022; Manik & Callaway, 2023; Yang et al., 2019).

In addition to the LCJR, a specifically designed online questionnaire was developed to capture student motivation, engagement, and confidence levels related to clinical judgment development. This questionnaire utilized a five-point Likert scale to measure confidence, with 1 indicating “Not at all confident,” 2 signifying “Slightly confident,” 3 representing “Neutral,” 4 denoting “Moderately confident,” and 5 indicating “Extremely confident.” The questionnaire addressed factors influencing student interest, participation, and self-belief in their learning activities. The tool underwent a rigorous validation process, including a content validation assessment by four experts—two level four clinical instructors and two senior experts from the College of Nursing at the university. Following a four-point rating scale, these experts evaluated the questionnaire for relevance, clarity, simplicity, and ambiguity. The Content Validity Index (CVI) was calculated based on the expert ratings following the method outlined by Polit and Beck (2006) and Lynn (1986), while the Item-Content Validity Index (I-CVI) for each item was determined by the proportion of experts rating the item as moderately or highly relevant. The I-CVI scores ranged from 0.75 to 1.0, reflecting a strong level of expert agreement. The overall Scale-Content Validity Index (S-CVI/Ave) was 0.90, indicating high content validity, while the Universal Agreement Index (S-CVI/UA) reached 1.0, confirming unanimous agreement on the essential items, which aligns with the acceptable threshold established by Yusoff (2019) for a group of experts.

Additionally, a pilot test was conducted with two groups of six students (n = 12) to ensure the clarity and effectiveness of the questionnaire. Feedback from this pilot test was used to further refine the instrument. Five clinical instructors were employed to evaluate each group separately to reduce bias in the main study. The final version of the questionnaire was designed to provide comprehensive insights into students’ perspectives on their clinical judgment development, aligning with Tanner’s emphasis on the reflective component of clinical judgment.

Statistical Analysis

Due to potential non-normality confirmed by Shapiro-Wilk tests (W = 0.492–0.751, p <0.01) and the relatively small sample size (n = 60, with 30 participants each in the intervention and control groups), non-parametric statistical methods were utilized to verify the robustness of the analysis using SPSS version 29. Descriptive Statistics were initially calculated to summarize participant characteristics, including age, gender, and baseline LCJR scores.

For the primary analysis, participants were divided into five focus groups of six members each using the Philips 66 technique. Kruskal-Wallis H tests were conducted to compare overall LCJR scores across the focus groups and to evaluate differences between the intervention and control groups, determining significant differences in clinical judgment skills. Mann-Whitney U tests were used to examine specific areas of clinical judgment, such as noticing, interpreting, responding, and reflecting. Wilcoxon signed-rank tests analyzed improvements within each group by comparing pre-and post-intervention LCJR scores.

Design

The qualitative phase utilized in this study focus group discussions (FGDs) to explore students’ experiences with the Philips 66 technique, focusing on how it influenced their clinical judgment development, collaborative learning, and engagement.

Participants

Thirty students from the intervention group were selected to participate in FGDs to explore their experiences with the Philips 66 technique.

Data Collection

FGDs were conducted from May 1-15, 2024, guided by semi-structured interview questions (Polit & Beck, 2021), aimed to explore students’ insights on the impact of the Philips 66 technique on their clinical judgment development in clinical and community settings. Five FGDs were conducted with students from the intervention group, consisting of approximately six students per group. Data saturation was reached after five focus group discussions, as no new themes or information emerged during the coding and thematic analysis process (Braun & Clarke, 2006). This ensured that the data collected provided a comprehensive understanding of student experiences with the intervention.

Data Analysis

Thematic analysis following the guidelines outlined by Braun and Clarke (2006) was used. FGD recordings were transcribed verbatim, and the transcripts were carefully reviewed to gain a general understanding of the data. Key phrases and sentences were identified and coded using a combination of open, axial, and selective coding. Codes were then grouped together to form themes that captured the essence of the student experiences. These themes were defined and refined based on their significance and relevance to the research question. Finally, the data were reviewed to ensure their accuracy in representing student experiences and validate the identified themes (Dawadi, 2020).

Quantitative Results

The intervention group consistently outperformed the control group across all LCJR categories and subcategories, with higher mean rank scores in all areas, as shown in Table 2. In Noticing skills, the intervention group achieved significantly higher mean ranks in Focused Observation (H(9) = 35.31, p <0.001), Recognizing Deviations (H(9) = 39.96, p <0.001), and Information Seeking (H(9) = 41.68, p <0.001). For Interpreting skills, the intervention group scored significantly higher in Prioritizing Data (H(9) = 42.59, p <0.001) and Making Sense of Data (H(9) = 36.90, p <0.001).

In Responding skills, the intervention group had significantly higher scores in Calm, Confident Manner (H(9) = 45.295, p <0.001), Well-Planned Intervention/Flexibility (H(9) = 40.017, p <0.001), and Being Skillful (H(9) = 38.498, p <0.001). For Reflecting skills, the intervention group outperformed the control in Evaluation/Self-Analysis (H(9) = 27.22, p <0.001) and Commitment to Improvement (H(9) = 30.09, p <0.001), indicating enhanced self-reflection and continuous learning.

Detailed Analysis of Skill Categories

Mann-Whitney U tests were conducted to explore specific areas where the intervention impacted LCJR skills. The results are presented in Table 3, which details the Mann-Whitney U statistic, significance level (p-value), and medians for both the intervention and control groups for each skill category.

The LCJR skill areas where the intervention group outperformed the control group were shown by higher median scores and statistically significant Mann-Whitney U test results (p <0.05). In Noticing skills, the intervention group significantly improved in focused observation (median 3 vs. 2.5, p <0.001) and recognizing deviations (median 3 vs. 2.5, p <0.004). Information-seeking skills also showed significant gains despite similar median scores of 3 (p <0.019). In Interpreting skills, the intervention group had an advantage in prioritizing data (p <0.05), though no significant differences were found in making sense of data or drawing conclusions (p ≥0.05). In Responding skills, the intervention group excelled in maintaining calmness (median 4 vs. 2.5, p <0.002), clear communication (median 4 vs. 2.5, p <0.021), planning interventions (median 3.5 vs. 2, p <0.005), and self-perceived skillfulness (median 3.5 vs. 3, p = 0.005). In Reflecting skills, they showed progress in self-evaluation (median 3.5, p = 0.011) and commitment to learning (median 3.5 vs. 2.5, p <0.005), although some improvements in commitment were not statistically significant (p = 0.073).

Table 4 shows that the intervention group (Philips 66 with CBL) showed highly significant improvements (p <0.001) with large effect sizes (Cohen’s d ranging from 0.597 to 0.635), demonstrating a substantial positive impact on all facets of clinical judgment as defined by the LCJR: Noticing, Interpreting, Responding, and Reflecting. This indicates a significant and meaningful impact of the intervention on their clinical judgment competence.

Table 5 shows that the control group (traditional CBL), on the other hand, demonstrated mixed results. While significant improvements were observed in information seeking (p <0.001, Cohen’s d = 0.54), evaluation/self-analysis (p <0.001, Cohen’s d = 0.56), and commitment to improvement (p <0.001, Cohen’s d = 0.617), all with large effect sizes, no significant changes were found in other areas of clinical judgment, such as focused observation, recognizing deviations, prioritizing data, making sense of data, maintaining a calm and confident manner, and communicating clearly. These areas showed no statistically significant changes (p >0.05), with negligible to small effect sizes (Cohen’s d ranging from 0 to 0.18). Overall, these results revealed the superior efficacy of Philips 66-enhanced CBL in fostering clinical judgment competence compared to traditional CBL in nursing education.

Table 6 summarizes the impact of the Philips 66 with CBL intervention on student nurses' clinical judgment, collaboration, and motivation, using a Wilcoxon Signed-Rank test to compare their performance before and after the intervention. The test results showed significant improvements across all assessed areas (p <0.001) with large effect sizes (r >0.49), indicating a substantial impact of the intervention. Negative Z-scores confirmed consistent improvements, such as the Z-score of -4.96 for “Team Data Analysis (Time Pressure),” with a large effect size (r = 0.64). These results demonstrate the effectiveness of the Philips 66 with the CBL approach in enhancing decision-making, data analysis under time pressure, and collaborative skills in a clinical setting. Students showed better teamwork, ethical consideration in decision-making, and increased engagement in learning activities related to clinical judgment and decision-making.

The results in Table 7 show a significant positive impact of the Philips 66 with CBL intervention on self-reported outcomes among nursing students. There were notable increases in confidence, engagement, collaboration, teamwork, and efficiency from pre- to post-intervention. Change magnitudes ranged from +2.00 (confidence level) to +2.77 (efficiency), indicating substantial improvements. The most pronounced gains were in collaboration (+2.48) and efficiency (+2.77), with post-intervention scores reaching near or at the maximum on the 5-point Likert scale, suggesting a ceiling effect. While the increase in confidence was smaller (+2.00), it still indicated a meaningful boost from an already high baseline score. Overall, these results highlight the effectiveness of the Philips 66 with CBL intervention in enhancing various aspects of nursing students' learning experience and self-perceived competencies.

Qualitative Results

Focus group discussions revealed three key themes related to students’ experiences with the Philips 66 intervention:

Quantitative Evidence for Enhanced Clinical Judgment

Non-parametric statistical methods were used due to possible limits in data normality and a moderate sample size (n = 60). The Shapiro-Wilk test confirmed significant deviations from normality across all groups (W = 0.492–0.751, p <0.01), necessitating non-parametric tests, which are suitable for smaller samples and do not assume normal distribution (Field, 2013). The Kruskal-Wallis H test was used to compare LCJR scores between groups, and Mann-Whitney U tests explored specific skill areas. Wilcoxon signed-rank tests further examined within-group improvements across clinical judgment categories. The intervention group demonstrated significant improvements in recognizing critical details within case scenarios. These findings correlate with a qualitative theme during the follow-up phase: “Fostering Collaboration and Shared Learning.” In interviews, students expressed that the Philips 66 technique fostered the integration of diverse viewpoints, enhancing their ability to identify essential case aspects (Bester et al., 2024; Walker, 2021). This link suggests that the collaborative nature of the Philips 66 technique encourages students to sharpen their observational skills, thereby improving their clinical judgment. As noted in previous research by Silva et al. (2018), structured collaborative methods like Philips 66 are particularly effective in developing essential decision-making skills in clinical settings.

Specific Clinical Judgment Skills

The clinical judgment scores between the intervention and control groups showed significant differences across all LCJR categories (H(1) = 15.34, p <0.01). Specifically, the Mann-Whitney U tests indicated a substantial improvement in recognizing essential clinical details (U = 321.5, p <0.01) and maintaining focus during observations (U = 299.4, p = 0.03). These findings are bolstered by the qualitative data, where students in the intervention group discussed the value of group brainstorming sessions in honing their focus and concentration during clinical decision-making. As they articulated, “Building Confidence and Communication Skills” emerged as a core theme, where the challenge of clearly articulating their thoughts boosted their confidence in group discussions (U = 284.7, p <0.01). The qualitative responses help explain why these areas showed significant quantitative improvements; the group dynamics of Philips 66 push students to clarify and defend their reasoning, resulting in enhanced focus and communication. However, no statistically significant differences were found in analyzing and drawing conclusions (U = 357.6, p = 0.14). While the intervention group showed improvement, it was not significant compared to the control. This aligns with the student’s reflections that complex clinical decision-making requires analytical and intuitive thinking—skills that are not always easily developed in short-term interventions (Benner et al., 2009; Johansen & O'Brien, 2016). Nurses often make rapid decisions based on incomplete data, and it was clear from the qualitative data that some students felt the need for more time and practice to integrate these skills fully. Additionally, the interviews revealed the influence of contextual factors, such as educational environment and pre-existing experience, on students’ clinical judgment. This finding aligns with prior research, which suggests that structured clinical judgment frameworks, like Philips 66, should be accompanied by ongoing development and refinement (Macauley et al., 2017; Shlash & Mohammed, 2022). These insights suggest that while the Philips 66 method helps enhance specific judgment skills, additional scaffolding and continuous practice may be needed to fully develop students’ ability to analyze and draw complex clinical conclusions.

Reflective and Time Management Skills

The intervention also promoted improvement in self-evaluation and reflection, with students in the intervention group demonstrating a marked ability to reflect on their decision-making processes. This outcome corresponds to the theme of “Enhancing Efficiency and Time Management,” which surfaced in the qualitative phase. The time-constrained nature of the Philips 66 sessions encouraged students to make swift yet thoughtful decisions while reflecting critically on their process afterward. This finding supports Collins et al. (2020), who indicated that structured reflection activities could foster critical self-analysis in clinical practice. The quantitative results show a clear link to these reflective practices, with students improving their ability to assess their own performance and adjust their strategies accordingly.

Within-Group Improvement and Effect Sizes

The positive learning outcomes observed in both traditional CBL and the Philips 66 method indicate significant improvements across all LCJR classifications for both intervention and control groups. Statistical analyses revealed large effect sizes (r ≥0.50) for the Philips 66 method, indicating a strong impact on clinical judgment skills (Flora, 2020). Specifically, the intervention group’s skills in noticing and interpreting clinical information improved markedly, suggesting that the Philips 66 method effectively enhances students’ abilities to gather and interpret critical data. While both groups showed progress in responding and reflecting skills, the intervention group exhibited slightly larger effect sizes in these areas. This finding points to potential advantages of the Philips 66 method in developing and applying specific clinical judgment skills, warranting further investigation in future studies. The combination of the Philips 66 method with CBL has proven beneficial in fostering noticing and interpreting skills. These results support the conclusion that this pedagogical approach can be a valuable tool for enhancing clinical judgment development in nursing education.

Learning Process Perceptions

Focus group discussions provided qualitative insights that complemented the quantitative findings, offering students a more comprehensive understanding of their learning experiences. The first theme identified—fostering collaboration and shared learning—aligns well with the quantitative results highlighting improved noticing skills. Exposure to diverse viewpoints facilitated students’ ability to identify crucial details in case scenarios (Murayama et al., 2019). The structured format of the Philips 66 method encouraged participation from all group members, ensuring inclusivity and active engagement. This aligns with the work of Turan et al. (2019), who noted that critical thinking enhances decision-making. Structured approaches like the Philips 66 method stimulate the critical thinking necessary for effective decision-making, reinforcing the connection between the method and improved noticing skills. Tanner (2006) and Manetti (2019) further emphasize that clinical judgment is multifaceted and crucial for detecting subtle cues in patient conditions, which directly correlates with improved decision-making—a theme echoed in the qualitative findings of this study.

The second key theme, enhancing efficiency and time management, highlights how students prioritized information and made quick decisions while reflecting on real case scenarios under time constraints. The Philips 66 method helped students maintain focus, ensuring that major and critical aspects were addressed, thereby improving responding skills on the LCJR despite time pressures. This method encouraged concise thought processes during brief brainstorming sessions, enhancing the interpretation phases. Additionally, the theme of building confidence and communication skills emerged as students articulated their ideas more clearly and concisely during time-limited activities. Engaging in structured brainstorming enhanced their confidence (Shohani et al., 2023), fostering attentive and active listening as they exchanged ideas. This theme reflects students’ growing confidence in expressing their thoughts and opinions (Abdelkader et al., 2021; Tabriz et al., 2024), aligning with quantitative findings that indicate better-responding skills.

Furthermore, the importance of student satisfaction and confidence in simulation classes cannot be overstated when designing effective educational interventions. As noted by Cho and Kim (2023), structured methods like the Philips 66 technique are critical in enhancing these outcomes, reinforcing the benefits of incorporating collaborative strategies in nursing education.

Learner-Centered Approach and the Philips 66 Method

Integrating the Philips 66 method with CBL cultivates an interactive and engaging educational environment, encouraging learners to actively collaborate with their instructors. This learner-centered approach enhances communication skills and critical thinking and promotes shared learning experiences (Iffah & Hudzaifah, 2022; Sapeni & Said, 2020). Research by Suprijanto (2012) supports the effectiveness of the Philips 66 method in creating a supportive learning atmosphere in nursing education (Nyqvist et al., 2020; Suryani et al., 2016; Venugopal-Wairagade, 2016). The qualitative insights gained from focus groups complement the quantitative data, illustrating how the Philips 66 method empowers undergraduate nursing students to express concerns, build on their existing knowledge, and voice their needs (Linsenmeyer, 2021; Lombardi et al., 2024; Takele, 2020; Tseng, 2020; Widiastuti et al., 2022; Yuliani et al., 2019). Students reported that the structured brainstorming technique of the Philips 66 method enhances their learning experience beyond mere content delivery, facilitating the exploration of innovative strategies and fostering continuous development (Yao et al., 2023).

When comparing various learner-centered methods, such as the Buzz Group Technique (Avendo et al., 2024; Lubis et al., 2023), the Philips 66 approach stands out due to its focus on small group discussions that promote active participation and diverse viewpoints. The structured nature of these discussions helps reduce student anxiety by providing clear expectations and a safe environment for idea sharing, which aligns with the positive outcomes observed in the quantitative analysis (Yao, 2021). Moreover, Hung et al. (2020) emphasize that learner-centered education can transform students from passive observers into engaged contributors, particularly in challenging contexts like disaster nursing.

The qualitative data revealed that the Philips 66 method empowers students with greater autonomy and responsibility, addressing their practical and motivational needs and resulting in heightened engagement. This engagement aligns with the improved learning outcomes demonstrated in the quantitative findings, underscoring the method’s effectiveness in fostering skills essential for nursing practice. Furthermore, the Philips 66 method invites participation from all students, including those who may be more reserved, thus promoting an inclusive idea-sharing atmosphere. The Philips 66 method and CBL emphasize the critical development of teamwork and critical thinking skills, vital for success in nursing education and practice.