Debriefing with Good Judgment:
Combining Rigorous Feedback
with Genuine Inquiry
Jenny W. Rudolph, PhDa,c,*, Robert Simon, EdDc,d,e,
Peter Rivard, PhDb, Ronald L. Dufresne, PhDf,
Daniel B. Raemer, PhDc,d,e
aDepartment of Health Policy and Management, Boston University School of Public Health,
715 Albany Street, Boston, MA 02118–2526, USA
bCenter for Organization, Leadership and Management Research, VA Boston Healthcare
System, 150 South Huntington Avenue (152M), Boston, MA 02130, USA
cCenter for Medical Simulation, 65 Landsdowne Street, Cambridge, MA 02139, USA
dHarvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
eMassachusetts General Hospital, Department of Anesthesia and Critical Care,
55 Fruit Street, Boston, MA 02114, USA
fDepartment of Management, Haub School of Business, St. Joseph’s University,
5600 City Avenue, Philadelphia, PA 19131, USA
Reflection on one’s own practice is a crucial step in the experiential learn-
ing process. It helps trainees develop and integrate insights from direct ex-
perience into later action [1,2]. Subsequent to participating in a simulated
case, debriefing or after-action review provides a way for clinicians using
medical simulation to do this reflection. There is convergence in the debrief-
ing literature on some of the important goals and processes of such debrief-
ing. The goals are to allow trainees to explain, analyze, and synthesize
information and emotional states to improve performance in similar situa-
tions in the future. The process for achieving these goals usually follows a
series of steps, such as processing reactions, analyzing the situation, gener-
alizing to everyday experience, and shaping future action by lessons learned
How to create a debriefing environment in which trainees feel both chal-
lenged and psychologically safe enough  to engage in rigorous reflection
* Corresponding author. Department of Health Policy and Management, Boston
University School of Public Health, 715 Albany Street, Boston, MA 02118–2526.
E-mail address: email@example.com (J.W. Rudolph).
1932-2275/07/$ - see front matter ? 2007 Elsevier Inc. All rights reserved.
25 (2007) 361–376
is generally left unspecified. Sharing critical judgments is an essential part of
learning in simulation and debriefing. Yet, instructors often avoid giving
voice to critical thoughts and feelings because they do not want to seem con-
frontational and they worry that criticism might lead to hurt feelings or de-
fensiveness on the part of the trainee. Voicing critical judgment poses
a dilemma for many instructors (eg, ‘‘How can I deliver a critical message
and share my expertise while avoiding negative emotions, preserving social
face and maintaining my relationship with the trainee?’’). This article offers
an approach to debriefing that addresses this dilemma.
By ‘‘rigorous reflection’’ we mean a debriefing process that brings to the
surface and helps resolve the clinical and behavioral dilemmas and areas of
confusion raised by the simulation experience. Drawing on a 35-year re-
search program on improving professional effectiveness in the business
world through ‘‘reflective practice’’ [11–17], this article articulates a model
of debriefing for medical simulation exercises. The research program from
which the approach is adapted has studied and helped thousands of practic-
ing business executives and managers improve their personal and interper-
sonal effectiveness through the discipline of reflective practice.1The debriefing
model adapted from this work has three primary components. The first
component is a conceptual framework, drawn from research in cognitive
science and on reflective practice, that guides the instructor on how to
illuminate the mental models that were salient in guiding trainees’ actions
during the simulation. The second is an underlying debriefing stance that
unites the apparently contradictory values of curiosity about and respect
for the trainee and the value of clear evaluative judgments about trainee
performance. The third component is a way of talking (combining advocacy
and inquiry) that enacts the underlying stance.
The basis of this article is the literature in the field of reflective practice
and the authors’ experience with exercising the debriefing with good judg-
ment approach. All of the authors use this approach regularly and four
have together conducted approximately 2000 debriefings using this method.
Over the last 2 years they have trained nearly 300 medical educators to use
this approach. Most medical educators are able reliably to demonstrate
competence after approximately 2 days of lecture and practice; expertise
seems to require considerably longer to develop. Of the approximately 20
teaching faculty who regularly use simulation as an educational technique
at the authors’ simulation center, approximately half use the debriefing
with good judgment approach. The other half has not yet been trained in
its use. Faculty who are comfortable with the technique find their skills quite
stable and robust in the face of a great variety of trainees.
1‘‘Reflective practice’’ is a term coined by the late MIT professor Donald Scho ¨ n, to de-
scribe the discipline of examining the values, assumptions, and knowledge-base that drives
one’s own professional practice [11,12,19,20].
RUDOLPH et al
Reflective practice: method and theory
Reflective practice is a method used to scrutinize one’s own professional
work practices and the taken-for-granted assumptions that underlie them.
It is often accomplished in a collaborative setting : in this case, the rel-
evant setting is the simulation debriefing wherein colleagues and trainees
are helped to develop crisis resource management, clinical, and reflective
practice skills. Researchers at Harvard University and the Massachusetts
Institute of Technology developed the method as part of their investiga-
tion of how to support students in their professional schools and also
to help experienced professionals to develop self-correcting versus self-
sealing practice habits . They found that reflective practitioners, who
learned to scrutinize their taken-for-granted assumptions and mental
routines, were able to self-correct and improve their professional skills.
Those without skill in this self-scrutiny, however, tended to seal out or
ignore disconfirming data and maintained ineffective habits of practice
The theory underlying reflective practice draws on cognitive science, so-
cial psychology, and anthropology. The central idea is that people make
sense of external stimuli through internal cognitive frames, internal images
of external reality [20–25]. Terms for these images are myriad: ‘‘frames of
reference,’’ ‘‘schemata,’’ and ‘‘mental models,’’ to name a few. People do
not passively perceive an objective reality, but engage in sensemaking by
which they actively filter, create, and apply meaning to their environment
[26–28]. For example, a diagnosis becomes a frame for subsequent actions,
as do assumptions, such as, ‘‘It’s not a good idea to discuss mistakes here,
or ‘‘I must have a bag-mask apparatus to ventilate this patient.’’ Fig. 1
shows the relationships among frames, actions, and simulation results.
leads to new
Fig. 1. Frames are invisible, but inferable; they are in the mind of trainees and of instructors.
Actions (including speech) are observable. Most results (eg, vital signs, order or chaos) are also
DEBRIEFING WITH GOOD JUDGMENT
These frames, in turn, shape the actions people take. Both clinical frames
and social or interpersonal frames can play crucial roles in medical decision
making. A trauma physician facing a patient with a ventilation problem, for
example, takes one set of actions if they frame the symptoms as a physical
obstruction of the airway and another if their diagnosis is reactive airway
disease. A nurse who holds the frame that reporting an error leads to pun-
ishment reports errors at a very different rate than one who believes the re-
port is used to improve work processes . Or, in an example used
throughout this article, consider an anesthesiologist who is called to manage
an unresponsive patient in a setting where a bag-mask apparatus is not read-
ily available. They hold the frame that they can only resuscitate using the
device with which they are most familiar, a bag mask, and delay treatment
while the patient descends into hypoxemia and arrest. The model suggests
that people’s actions, including those of this anesthesiologist, are an inevita-
ble result of how they frame the situation they face.
Importantly, even mistakes are usually the result of intentionally rational
actions [23,27,30]. That is, the actions make perfect sense given how the per-
son was framing the situation at that moment. Continuing the example of
the anesthesiologist, the instructor may be surprised that instead of consid-
ering passive oxygenation or delivering a mouth-to-mask ‘‘rescue breath,’’
the anesthesiologist trainee searched relentlessly for a bag-mask apparatus
while the patient desaturated. These actions make perfect sense, however,
when the instructor understands that the trainee held the belief that basic
life support cannot be achieved without a bag-mask device, mouth-to-
mouth was out of the question, and passive oxygenation is something that
he has never learned. It is the instructor’s job during a debriefing to help
the trainee bring these frames to the surface; analyze their impact on actions;
and craft new frames (eg, if I do not find a bag-mask apparatus quickly, I
have other options for ventilating) and actions (giving mouth-to-mask
breaths, or apply oxygen and mechanically optimize the airway opening).
In practice, the instructor asks questions during the debriefing to elicit these
‘‘Results,’’ in the reflective practice model, are seen to be prompted by the
actions the trainee takes. Results are states (eg, the patient’s cardiac rhythm,
whether the trainee ended up knowing the cause of the clinical problem, or
whether there was chaos or order in the clinical environment). The instruc-
tor and the trainee usually have an implicit idea of what the desired results
were. For example, the patient remains stable and does not go into cardiac
arrest, the trainee and others know why the patient arrested in the first
place, or the resuscitation ran smoothly. Learning occurs when instructor
and trainee explore the frames-actions-results causal sequence in reverse.
The instructor then explores with the trainee what frames and linked actions
led to the actual results and then, as depicted in the feedback arrows in
Fig. 1, collaborates with the trainee in developing alternative frames and ac-
tions for the future .
RUDOLPH et al
Debriefing stance: moving from judgmental debriefing to debriefing
with good judgment
Although it may be obvious how discovering trainees’ frames can en-
hance debriefing in medical simulation, the importance of identifying and re-
vealing the instructor’s frames is less obvious. Crucial to the process of
a rigorous debriefing that is both nonthreatening and direct is instructors’
learning to identify and examine their own frames related to the simulation
they observed. Without an understanding of their own frames, instructors
are handicapped in their ability to help illuminate a trainee’s frames. The
reasons for this are twofold. First, the instructors must be able to draw
from their own experience the frames and actions they themselves might
have deployed in a similar situation and to disclose these to the participant.
Second, instructors have to be willing to test the validity of their own frames
about the trainee’s performance with trainees. To explain how this works,
the authors start by describing and contrasting instructors’ underlying
frames when they are using judgmental, nonjudgmental, and debriefing with
good judgment approaches (Table 1).
The judgmental approach to debriefing
Imagine or recall the instructor whose voice, dripping with disdain, in-
quires of a group of students, ‘‘Can anyone tell me what went wrong
here?’’ or ‘‘Can anyone tell me Pat’s big mistake?’’ The judgmental ap-
proach, whether laced with harsh criticism or more gently applied, places
truth solely in the possession of the instructor, error in the hands of the
trainee, and presumes that there is an essential failure in the thinking
or actions of the trainee. In the last 15 years, the discourse in medical
journals suggests that many clinicians concerned about reducing medical
error and improving patient safety have sought to move health care
away from the ‘‘shame and blame’’ approach captured in this style of
questioning [31,32]. A judgmental approach to debriefing, especially one
that includes harsh criticism, can have serious costs: humiliation, damp-
ened motivation, reluctance to raise questions about later areas of confu-
sion, or exit of talented trainees from the specialty or clinical practice
altogether. But the shame and blame approach has an important virtue:
the trainee is rarely left in doubt about what the instructor believes are
the salient issues.
The nonjudgmental approach to debriefing
Some instructors shy away from a shame and blame approach to express-
ing their critical feelings and move toward a nonjudgmental approach. The
central dilemma facing instructors who want to move away from this judg-
mental approach is how to deliver a critical message while avoiding negative
emotions and defensiveness, preserving social face, and maintaining trust
DEBRIEFING WITH GOOD JUDGMENT
Contrasting judgmental, nonjudgmental, and good judgment approaches to debriefing
Judgmental Nonjudgmental Debriefing with Good Judgment
The effective instructor
Primary focus of
How the trainee is seen
Gets the trainee to change
External: the actions or
inactions of the other person
A mistake maker; a doer
Gets the trainee to change
External: the actions or inactions
of the other person
A mistake maker; a doer of actions
Creates a context for learning (and change)
Internal: the meanings and assumptions
of both instructor and trainee
A meaning maker whose actions are the
consequence of specific assumptions and
Possibly neither, either, or bothWho has the truth
of the situation?
Who does not
The instructorThe instructor
The trainee; ‘‘I (the instructor)
will set you straight’’
The trainee; ‘‘I (the instructor)
will find the kindest way of filling
you in on how to do this right.’’
The instructor: ‘‘I see what you are doing
or not doing, and given my view, I don’t
get it’’; or ‘‘Given my view, it seems
problematic; what am I missing here?’’
Genuine report of puzzlement and inquiry into
how the trainee’s actions can make sense.
RUDOLPH et al
Basic stance toward
self and trainee
‘‘I’m right’’ or ‘‘You’re wrong.’’‘‘I’m right’’ or ‘‘You’re wrong’’
but, ‘‘I don’t want you to get
defensive so how do I tell you the
bad news and get you to change
in a nice way?’’
‘‘I’m setting you straight’’
Respect for self (I have a take on what
happened in this simulation; that does
lead me to think there were some
‘‘I’m setting you straight’’Respect for trainee (you are also a smart,
well-trained practitioner, trying to do the
right thing, who has your own view on the
I am going to approach this as a genuine
puzzle; not paralysis or indecision, but
holding my own view tentatively. I seek
clarity by honest inquiry (we both may learn
something or change our minds); ‘‘Help me
understand why you.?’’
‘‘I noticed X. I was concerned about that
because Y. I wonder how you saw it?’’
‘‘I’m teaching you’’‘‘I’m teaching you’’
Typical message ‘‘Here’s how you
‘‘What do you think
you could have done better?’’
Adapted from Kegan R, Lahey LL. How the way we talk can change the way we work. San Francisco (CA): Jossey-Bass; 2001. p. 134–5; with permission.
DEBRIEFING WITH GOOD JUDGMENT
and psychological safety.2Instructors using a nonjudgmental approach of-
ten resolve the dilemma by using protective social strategies, such as the
sandwich approach in which a compliment is followed by a criticism, which
is, in turn, followed by another compliment; filtering out critical insights; or
by avoiding the problem topic altogether [33,34]. Another common way for
instructors to avoid the judgmental approach is to choose silence and ex-
press no critical thoughts or feelings. When people choose silence or non-
judgmental approaches that obscure their expert critique, important
insights or feelings related to the trainee’s performance remain murky or un-
expressed. This deprives the trainee clinicians, and their organizations, of in-
formation that could improve how they work . Avoiding critical
thoughts and feelings also limits debriefings to safe-appearing, nonthreaten-
ing topics and leaves crucial areas of learning untouched .
Many instructors, ourselves included, have used a Socratic approach in
which leading questions are asked and a kind tone of voice is used to
guide the trainee to the critical insight the instructor holds but is reluctant
to state explicitly. In his critique of this approach, Argyris  has termed
it ‘‘easing in.’’ The authors have found that when the instructor holds
a critical judgment, open-ended or Socratic questions that camouflage
the judgment may backfire. The trainee may become confused by the
question or (justifiably) suspicious about the instructor’s unexplained
Although the nonjudgmental approach has the advantage of being non-
blaming, and avoids some of the hurt and humiliation generated by the
judgmental approach, it has serious weaknesses. Despite a desire to seem
nonjudgmental, hints of one’s views often leak by subtle cues, such as facial
expression, tenor, cadence, and body language. Furthermore and most im-
portantly, it is not nonjudgmental. Although the surface tone of nonjudg-
mental debriefing may be softer than the judgmental approach, as
illustrated in Table 1, the underlying assumptions are the same: I’m right;
I have the complete picture; my job is to hand off the correct knowledge
or behavior to you, the trainee. Whereas the judgmental approach often hu-
miliates directly, the nonjudgmental approach conveys nonverbally that
mistakes are not discussible, or possibly shameful [36,37], undermining
the very values (mistakes are puzzles to be learned from rather than crimes
to be covered up) instructors aim to endorse with the nonjudgmental
2Psychological safety is a person’s sense that the immediate environment is safe for inter-
personal risk taking; that trying out new ways of talking or acting will not be ridiculed; that
mistakes will be worked on together as a source of learning instead of being treated as
a crime to be punished or covered up [10,23].
RUDOLPH et al
Debriefing with good judgment approach
The debriefing with good judgment approach shifts the focus of debrief-
ing in several ways.3First, it focuses on creating a psychologically safe con-
text that enables adult learners (including the instructor) to move toward
key learning objectives, determined either unilaterally by the instructor or
collaboratively with the trainee. Second, the focus of the debriefing widens
to include not only the trainee’s actions, but also the meaning-making sys-
tems of the trainee (ie, their frames, assumptions, and knowledge). Third,
the instructor’s sense-making system about the simulation also becomes
part of the debriefing terrain and open to question (see Table 1). The in-
structor has an expert’s view of the situation that he or she shares to initiate
dialog with the trainee, but it may not be the only valid view. Instructors’
stating their main concerns in a debriefing is especially important in the do-
main of health care simulation where being indirect about crucial errors can
perpetuate clinical mistakes and undermine patient safety when the trainee
returns to the real clinical environment.4In this approach, in contrast to the
nonjudgmental approach, the instructor shares critical or appreciative in-
sights about the simulation explicitly. Then these insights are tested and ex-
plored with trainees step-by-step as illustrated in the next section and in Box
1. This ‘‘good judgment’’ approach is one that values the expert opinion of
the instructors, while at the same time valuing the unique perspective of each
trainee. The idea is to learn what frames drive trainee behaviors so that both
their failures and successes can be understood as an ingenious, inevitable,
and logical solution to the problem as perceived within their frames. This
3We offer a brief rationale of why we arrived at this framework. When our center started
12 years ago we relied on a nonjudgmental approach. To maintain a positive relationship
with trainees, we thought it necessary to withhold judgment and use open-ended and leading
questions in the hopes that the participants would arrive at the conclusions we were reluctant
to say. We began to become uncomfortable with the approach when we realized that we were
not ‘‘walking our talk.’’ That is, we were saying that mistakes were discussable and a source
of learning, yet we found that we tended to cover them up or shy away from discussing
them. This conflicted with our commitment and stated mission to make errors discussable
and enhance patient safety. We thought to ourselves, ‘‘If we can’t discuss errors here in a sim-
ulation center, how can we expect others in the medical world to do it?’’ We believed that if
we were going to advocate for patient safety, then we had to find a way to discuss errors
openly; by the same token, we had to find a way respectfully to insert our clinical and behav-
ioral expertise into our debriefings. We migrated to a position of ‘‘debriefing with good judg-
ment,’’ which allowed us, it seemed, the best of all worlds: it fit with educational theory; it
allowed our participants to make mistakes and believe that they were still worthwhile and in-
telligent; it allowed us to use our clinical and behavioral expertise; and it fostered deep learn-
ing among our participants and instructors.
4In cases where the instructor has significant concerns about the trainee’s clinical judg-
ment or motives, concerns that might merit remedial training, counseling, or discipline, these
are best treated in a follow-up. That is, if the instructor needs to convey that certain clinical
approaches or social behaviors are not tolerated in the program, that messageda very im-
portant onedis a good topic for a postdebriefing conversation.
DEBRIEFING WITH GOOD JUDGMENT
is where the instructor’s stance is like that of an anthropologist, curious
about different worldviews or frames and about the resulting actions.
Transparent talk in debriefing: enacting the good judgment approach
The debriefing with good judgment frames outlined in Table 1 are
enacted by the style of speaking used by the instructor. Like all frames, men-
tal models, or schemata, the values underlying the good judgment approach
are invisible; the only way to see them is when they are transformed into
Box 1. Example of using advocacy-inquiry to elicit trainee’s
Instructor says,‘‘So, Damon, Inoticed thatyousteppedawayfrom
deteriorating. I was thinking there possibly were alternative
meansto oxygenate thepatient (advocacy). So I’m curious: how
were you seeing the situation at that time? (inquiry)’’
monitor decline earlier and I knew it was not going to get better
on its own. I did not care what the actual reading was, which is
why I figured I really needed ventilation equipment.’’
An instructor might then say, ‘‘Okay, that seems reasonable. I saw
oxygenating the patient (advocacy). Can you help me
understand what you were considering at the time? (inquiry)’’
When Damon replies, ‘‘Well, since breathing comes before
circulation, I needed the manual resuscitator before doing
anything else,’’ the instructor is starting to surface the trainee’s
frame that he can only help a patient breathe if he has a bag-
mask apparatus, and a valuable discussion point, linked
specifically to the trainee’s need, emerges. The instructor can
now pursue such questions as: Does one always need a
bag-mask apparatus to oxygenate a patient? What other
options does one have? Will apneic oxygenation be sufficient
in the short run? Will chest compressions provide adequate
ventilation? What are the risks and benefits of mouth-to-mouth,
mouth-to-mask, mouth-to-tube, or other rescue methods? If
one is committed to manual ventilation, how does one manage
personnel to get the proper equipment in the room
RUDOLPH et al
actions, and speaking is a powerful action for instructors. One particularly
effective style of debriefing speech is to pair advocacy with inquiry. An ad-
vocacy is an assertion, observation, or statement, whereas an inquiry is
a question. When pairing the two together, the instructor acts as a conversa-
tional scientist, stating in the advocacy his or her hypothesis, and then test-
ing the hypothesis with an inquiry. For example, an instructor might say,
‘‘So, Damon, I noticed that you stepped away from the patient to find the
bag-mask apparatus as the vital signs were deteriorating. I was thinking
there possibly were alternatives means to oxygenate the patient (advocacy).
So I’m curious: how were you seeing the situation at that time? (inquiry).’’
Here, the instructor is using advocacy plus inquiry to elicit the invisible
frames that guided the trainee’s actions. This is the generic approach that
instructors can use in any scenario: Step (1) notice a relevant result; step
(2) observe what actions seemed to lead to the result; and step (3) use advo-
cacy-inquiry to discover the frames that produced the results.
Compare this utterance with a judgmental version (‘‘Damon, I can’t be-
lieve it took you 90 seconds to notice that he was desaturating!’’) or a non-
judgmental ‘‘guess what I’m thinking’’ version (‘‘So, Damon, what was
this patient’s saturation when you went to look for the bag-mask appara-
tus?’’) The judgmental version, although getting the instructor’s point across,
precludes the instructor learning what frames or assumptions set Damon on
a particular path of action; it also may humiliate Damon. The nonjudgmen-
tal version leaves Damon uncertain about what the instructor is thinking or
why he is being asked this question; the result will likely be confusion or de-
fensiveness. He may correctly detect that the instructor already knows the
answer to the question and has a judgment that is lurking in the background.
The advocacy-inquiry utterance clearly and directly stated the instructor’s
perspective and concerns, and set out to bring to light the meaning-making
process that had Damon focused on finding missing equipment.
The advocacy-inquiry version helps surface Damon’s frames. For exam-
ple, consider the debriefing between Damon and his instructor illustrated in
Box 1. This example, taken from one of the authors’ actual debriefings,
shows how advocacy-inquiry spoken with an honest sense of curiosity helps
trainees like Damon learn from simulations by digging deeper into the
frames that drive their actions. It also helps the instructor learn about the
trainees’ thought process and provides a lever for deeper teaching. To be
clear, this technique is not about talking nicely. On the contrary, it places
the instructors’ thoughts, judgments, and feelings front-and-center. The dif-
ference is that by treating the instructor’s views as requiring public testing
(by saying their viewpoint in the advocacy and then inviting a different view-
point with the inquiry), the instructor increases mutuality by opening his or
her own views to challenge and making himself or herself vulnerable to
learning. Additionally, by pairing this advocacy with true inquiry, the in-
structor increases mutuality by respecting the trainee enough to value his
or her (the trainee’s) perspective, and this, in turn, improves learning.
DEBRIEFING WITH GOOD JUDGMENT
Example debriefing dialog to establish individual then group frames
To the group: It looked to me
like it was confusing. How did
So, it looked to me as though
that confusion may have prevented
you from effectively executing respiratory
resuscitation and, then, later the ACLS
algorithm. How did you all see it?
Diana, it looked to me like you might
have been the leader. Did you feel
that was your job?
Group: Several members agree. Establish a problematic result (confusion, lack of role clarity).
Group: Yes, the confusion
was a problem .
Establish clinical consequences. This shows why lack of role
Diana: Yes, I was the leader sort
of, but we never said anything
about it. And then later, it seemed
that Suresh was more in charge.
Explore actions that may have lead to the resulting confusion.
I noticed that too. You looked like
you were managing the event, but
no one ever said anything.
I was thinking that it would have
helped for either you or someone
in the group to state explicitly that
you were the leader. I am wondering
why that did not happen?
Diana: Well, I was not too sure
of myself. I mean, the other people
are pretty much equal to me and I did
not want to seem bossy and unlikable.
Also, I was unsure about whether I
would do a good job and maybe I
would look stupid.
Diana’s frame is established (eg, If I am a peer with others it’s
awkward for me to step up as leader).
RUDOLPH et al
Anyone else have a thought? Eliza: I would have felt much better if
I knew Diana was in charge. I certainly
did not want to do it and we needed
someone to be in charge. But, I did
not want to put Diana on the spot.
Ricardo: I would have
been relieved and grateful
to Diana. Someone has to
run it! I guess I could have
just confirmed that Diana
was the leader.
Diana: Yes, I can see that is
probably a good idea. Then
I do not have to look too bossy
and I have people on the team
who know they have to help me.
Beginning to understand Eliza’s frame (eg, If asking someone to
lead means putting them on the spot, I should not do it).
In my experience, I have occasionally
heard someone running an event like
this say, ‘‘I’ll run this event, but you
all have to help me.’’ I am curious what
you all would have thought if Diana had
said something like that?
Turning to Diana: Diana, do you have a
thought on this?
Group beginning to reframe (eg, Even if I am a bit unsure what
to do, it is better to speak up than say nothing).
Diana moves to a new frame (eg, It is okay to say I want to be the
leader if I pair it with a request for help).
The debriefer’s goal is that trainees understand the importance of role clarity and establishing an event manager for resuscitations. The example shows how
the debriefer (1) helps to identify an important problem (establishing an event manger); (2) uncovers one student’s frame; (3) explores other students’ frames;
(4) facilitates reframing; and (5) offers a new action to deal more effectively with establishing an event manager in the future.
DEBRIEFING WITH GOOD JUDGMENT
Table 2 provides an example of how to apply the debriefing with good
judgment approach. The table shows how the frames-actions-results concep-
tual model, the instructor’s judgments, and advocacy-inquiry fit together to
discover the frames that led to a respiratory arrest and chaos in a scenario
requiring a cardiac resuscitation.
The debriefing with good judgment approach is designed to increase the
chances that the trainee hears and processes what the instructor is saying
without being defensive or trying to guess the instructor’s critical judgment.
The debriefing with good judgment appellation is not meant to imply that
the judgmental or nonjudgmental approach do not have good judgment
as their basis. The authors believe that all three approaches often start
with some important evaluative insight held by the instructor. We chose
the salutary name ‘‘debriefing with good judgment’’ to highlight the positive
attributes of the approach. These are, providing trainees with a clear signal
about the instructor’s point of view while reducing the potential noise (mis-
understandings or defensiveness) that too often is associated with the judg-
mental and nonjudgmental approaches. The judgmental approach poses
a substantial risk of embarrassing or humiliating the student and the non-
judgmental approach may send confusing and mixed messages to the
learner. Both approaches can obfuscate or reduce the clarity of the instruc-
tor’s message and the trainee’s frames.
The debriefing with good judgment approach has two constraints. The
most important is that the model presumes that the trainee is operating
with good will and is trying to do the right thing. In those rare cases where
the trainee is willfully negligent or malevolent, the model does not work. In
those circumstances, other techniques are superior (counseling, goal setting,
discipline, and so forth). Second, instructors may find difficulty with this ap-
proach when dealing with trainees who come from cultures in which defer-
ring to authority and elders is of paramount importance and inhibits their
disclosing views that may seem to contradict those of the instructor. To sup-
port the method in this context, explicit preparation regarding the goals and
norms of the simulation environment is required, and sometimes even that is
In debriefing the heat and drama of a high-fidelity clinical simulation, it is
easy to focus primarily on trainees’ actions. The debriefing with good judg-
ment approach, however, highlights three additional areas of importance.
First, it is vital that instructors ask questions like those of an anthropologist,
which help bring to the surface and clarify the invisible sense-making pro-
cess, the cognitive frames, and the emotions that governed the trainee’s ac-
tions. Second, instructors work to become aware of, and explicitly narrate,
their own invisible judgments and concerns about crucial elements of the
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scenario. But instead of treating their own judgments or concerns as the sin-
gle truth, they test their views against the trainees’ view of the same issue.
This does not mean that instructors relinquish their expertise, or disguise
their judgments in a sandwich of niceties; rather, they state their view of
the situation as a hypothesis and use that as a springboard to legitimize
and explore the trainees’ view. By understanding how trainees’ frames, as-
sumptions, and beliefs drive the actions they take, instructors can match
their teaching objectives with problems that are most salient to the trainee.
Finally, the debriefing with good judgment approach helps trainees and in-
structors learn of unintended consequences of common clinical and social
frames and assumptions.
The authors are grateful to the US Department of Veterans Affairs’ Merit
Review Entry Program, the Josiah Macy, Jr. Foundation, the Risk Manage-
ment Foundation of the Harvard Medical Institutions, Richard Nielsen,
Boston College, Carroll School of Management, and the Harvard-MIT Di-
vision of Health Sciences and Technology for support in developing the
ideas and material in this article. They also express thanks to the partici-
pants in the Institute for Medical Simulation instructor workshops for giv-
ing a forum and their patience to try out and refine these concepts. A version
of this article has appeared previously in Simulation in Healthcare, under the
title ‘‘There’s no such thing as non-judgmental debriefing: a theory and
method for debriefing with good judgment.’’ Simulation in Health Care
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