# The delicate dance of debriefing: exploring how behavioural marker systems influence the socio-emotional dynamics of simulation practice

## TL;DR

This study explores how behavioral marker systems affect the emotional and social aspects of debriefing in healthcare simulation training.

## Contribution

It introduces a framework showing how these systems shape relational and affective dynamics during debriefing.

## Key findings

- Behavioral marker systems can depersonalize feedback and strengthen trust when used sensitively.
- Inconsistent or rigid use of the tool risks damaging trust and professional identity.
- The systems support learner agency by making feedback specific and actionable.

## Abstract

Debriefing is central to simulation-based education and has been described as both a form of feedback and a broader relational process. While behavioural marker systems (BMS) to assess behavioural (non-technical) skills have been developed to enhance feedback transparency, little is known about how their use shapes the emotional and social dynamics of debriefing. Drawing on feedback literacy and educational alliance frameworks, this study explored how behavioural marker systems influence the emotional and social aspects of debriefing within healthcare simulation.

This constructivist study involved trainee pharmacists and facilitators participating in a national simulation program in Scotland. Participants used the Pharmacists’ Behavioural Skills BMS, then reflected within online semi-structured interviews. Transcripts were analysed using template analysis. Initial coding was informed by feedback literacy and educational alliance frameworks and refined iteratively through team discussion. The metaphor of dance was used to capture nuance and provide relatable examples of the relational and affective dimensions of practice.

Ten trainee pharmacists and six facilitators participated. Five interrelated themes were identified: emotional vulnerability (the first tentative steps); clarity of expectations (trusting the choreography); identity work (the dancer in the mirror); peer critique (dancing in sync); agency and ownership (leading the dance). The behavioural marker system supported learning by depersonalising critique, legitimising peer feedback and enhancing trust through transparency. It also affirmed professional identity and fostered learner agency by making feedback specific and actionable. However, risks were identified when the tool was applied inconsistently, perceived as inauthentic or used in ways that emphasised negative descriptors.

Within simulation, behavioural marker systems are not sterile scaffolds but dynamic social instruments that shape the relational and emotional conditions of debriefing. When applied sensitively, they can depersonalise feedback and strengthen the educational alliance, supporting learners to take ownership of their development. Used rigidly or inconsistently, they risk damaging trust and fragile professional identities. Facilitators should introduce such tools as developmental guides, explicitly aligning them to professional practice and balancing structure with responsiveness to learners’ emotional and relational needs.

The online version contains supplementary material available at 10.1186/s41077-026-00411-4.