Imagine an instructor disdainfully asking a group of trainees “Can anyone tell me what went wrong?”. The judgmental approach, whether gently applied or mixed with harsh criticism, puts truth in the possession of the instructor alone, error in the hands of the trainee, and assumes that there is an essential flaw in the trainee's thinking or actions. This style can have significant costs: humiliation, reduced motivation, or reluctance to raise issues related to other areas. However, the shame-and-blame approach has one advantage: the trainee is rarely left in doubt about the instructor's standpoint regarding the main issues.

The main dilemma facing instructors who want to move on from the judgmental approach is how to deliver a critical message, avoid negative emotions and defensiveness, and preserve professional identity. The dilemma is often solved by the use of protective social strategies, such as sugar-coating errors, sandwiching criticism between two compliments, skirting around charged issues, or completely avoiding the subject. Many instructors, including ourselves, have used the Socratic approach in which leading questions are asked using a friendly tone of voice to lead the trainee to the critical insight held by the instructor but who is reluctant to explicitly communicate (facilitation).

Although the nonjudgmental approach has the advantage of avoiding direct blaming and the hurt and humiliation of the judgmental style, it has a serious weakness. Contrary to expectations, when the instructors do not give their opinions and use open questions or the Socratic method to camouflage their judgments, the trainee often feels confused about the nature of the question or suspicious of the instructor's unclear motives (“What have I done that the instructor isn’t telling me about?”). Despite the desire to appear nonjudgmental, the implicit opinion of the instructor often appears through subtle cues, such as facial expression, tone and cadence of voice, or body language. Thus, it is clear that this approach is not really nonjudgmental. Although the tone of the debriefing may seem softer, the underlying frame of the instructor is the same as before: “I’m right, I have the full picture, and my job is to hand over the correct knowledge and behavior to you, the trainee.” Although the judgmental approach often directly humiliates the trainee, the nonjudgmental approach may also have the same effect and even have other negative effects. The trainee may be left thinking that the mistake is so serious that the instructor is avoiding talking about it. Even worse, this style can discourage discussing mistakes, which is exactly the opposite of the aim of simulation and debriefing. What has to be developed is a climate in which mistakes are riddles or puzzles to solve in groups rather than errors to be covered up.8

This approach is based on the open sharing of opinions or personal points of view and assumes that the trainees are doing their best. It demands the highest standards from the trainees (or colleagues) and assumes that their responses deserve great respect. For example, if the simulation center's mission is to transform mistakes into sources of learning to improve patient safety, it is inappropriate for instructors to cover them up and to shy away from discussing them, and to avoid expressing their own opinion or to ask open or leading questions in the hope that the trainees can reach the conclusions that instructors are reluctant to express. If mistakes cannot be analyzed and discussed in a simulation center, how can other people be expected to discuss them in the clinical setting? To promote patient safety, a way is needed to openly discuss mistakes. Thus, the debriefing approach called “with good judgment” was developed; the name itself highlights the need for instructors to discover their own good judgment. This style allows trainees to make and discuss mistakes while feeling valued and capable. It also allows instructors to show their expertise and offer constructive criticism, such that trainees and instructors are able to merge their own experience with the new knowledge due to the creation of a meaningful learning environment.9

We present a case example: a trainee cardiologist is called to the radiology department because a patient hospitalized for bilateral pneumonia and stable angina has undergone a decrease in their level of consciousness while undergoing chest X-ray. When the trainee arrives, the patient does not respond to stimuli and has marked labial cyanosis, shallow breathing, and a radial pulse of 100 bpm. The trainee immediately requests a resuscitation bag and face mask. The apparatus is not available in the room and while it is being located the patient goes into respiratory arrest. Once again the trainee requests the apparatus and, after a few minutes of waiting while the room is searched, again checks the pulse, which has now decreased to 30 bpm.

This case example represents a clinical simulation for training in emergency situations. Following the simulation, a cardiologist trained as a simulation instructor conducts a debriefing. The cardiologist helps the trainee to explore and reveal the frames that led to nonventilation and extreme bradycardia in order to improve their performance in similar situations in the future. As frames are invisible, the only way they can be identified is to help the trainees to describe them, based on their actions and the observed results. Pairing advocacy with inquiry is a particularly effective style of debriefing speech. Advocacy can be implemented by assertion, observation, or statement. Ideal advocacy combines the actions (or inactions) observed by the instructor (“I observe that...”) with good judgment about their clinical consequences (“I think that...”). Inquiry is shown by an attitude of genuine curiosity that leads the trainees to reflect on and share the frames that underlay their actions (“I ask myself...”). Table 2 shows the process followed by the instructor to uncover the trainees’ frames.

The debriefing style shown in Table 2 can be contrasted with a judgmental version (“I can’t believe it took you so long to realize the patient was desaturating!”) or with a nonjudgmental version, that is, one in which the participant has to guess what the instructor is thinking (“How was the patient's respiration when you went to find the apparatus?” or “Do you think something can be improved?”). Although the judgmental version clearly and directly expresses the instructor's point, the trainee does not learn what frames led to the specific course of action and the trainee could even feel humiliated. The nonjudgmental version leaves the trainee uncertain about what the instructor thinks and also considerably extends the debriefing time, since the trainee does not know the reason for the question. The final result can easily be one of confusion and even defensiveness. The trainee may correctly detect that the instructor already knows the answer to the question and has a hidden perspective (or judgment). This approach contrasts with advocacy-inquiry discourse, which directly and clearly states the instructor's perspective and concerns, and establishes the context for understanding the thought processes that focused the trainee on finding the apparatus. This technique does not consist in making polite conversation, but places the instructor's thoughts, judgments, and feelings at the center of the action. This is an example of how to help trainees to achieve the highest standards of performance, while holding them in the greatest regard.

The with-good-judgment style shifts the focus of debriefing in several ways. On the one hand, it focuses on creating a learning environment for adults (including the instructor) in which they can learn important lessons that will help them to achieve goals. Furthermore, the focus is widened to not only include the trainees’ actions, but also the systems they use to make sense of the actions (frames). Furthermore, to make sense of the action, the instructor's frames also form part of the debriefing and are tested and explored with trainees.10

However, debriefing with good judgment has some limitations. Firstly, the approach assumes that trainees are acting in good faith and are trying to do their best. Secondly, when conducted in cultures in which deference to authority or senior staff is the norm, trainees may be inhibited and may not disclose their own views because they could seem to contradict the views of those with greater authority. The approach can be supported in this setting by explicitly preparing the norms and aims of the simulation, although even this is sometimes insufficient.