Table 3.

The potential contributions and risks of BMS, and implications for practice

	Potential contributions of BMS	Risks of BMS utilisation	Implications for simulation practice
Emotional vulnerability: The first tentative steps	By grounding critique in predefined categories and observable behaviours, BMS can depersonalise feedback and reduce the risk of humiliation.	If applied rigidly, BMS may heighten the sense of being scored or judged, increasing performance anxiety and inhibiting learning.	BMS can be used to normalise error and emphasise behaviours as developmental, not as summative judgments. This requires careful facilitation that frames the BMS as a guide for growth and improvement and not a rigid feedback rubric.
Clarity of expectations: Trusting the choreography	Trust is enhanced when the BMS provides consistent and visible categories, observable anchors, and a shared vocabulary for making the basis of feedback transparent.	Trust is undermined if the BMS, or some elements of it, feel confusing, irrelevant to clinical practice or inconsistently applied, causing learners to doubt both the tool and those using it.	Facilitators should invite learners to co-create the BMS that will be used in their simulation sessions. Introducing a BMS prior to use, accompanied by clear rationale and training, can bolster trust by demonstrating alignment with professional standards.
Identity work: The dancer in the mirror	BMS-based feedback can help learners see themselves as competent, align their behaviours with professional expectations, and feel pride in their growth and development.	If feedback is based disproportionally on negative behavioural descriptors, it risks undermining learners’ fragile professional identities, leaving them with self-doubt.	Facilitators should be cognisant of balancing affirmations with developmental suggestions, ensuring that positive aspects are emphasised even when significant scope for improvement is identified. Facilitators should also be attuned to using BMS to highlight identity growth alongside performance gaps.
Peer critique: Dancing in sync	Shared language, a structured framework and explicit exemplars can legitimise peer-to-peer observations through an agreed professional lens, reducing social discomfort.	Peer critique remains socially charged and uncomfortable, and use of BMS may exacerbate a sense of peer comparison.	BMS should be introduced as a framework to enable constructive peer feedback. Assisting learners to use BMS with an emphasis on descriptive rather than evaluative language can enhance peer feedback quality and reduce interpersonal tension.
Agency and ownership: Leading the dance	BMS can promote agency by making feedback specific and actionable, supporting learner agency in setting goals and planning change.	If learners perceive the system as externally imposed, they may disengage, feeling that they don’t have ownership of the strategies for improvement.	Learners and facilitators should co-interpret behavioural observations in debriefings, encouraging ownership and collaborative goal setting. This works well within an established debriefing model that allows space for learner reflections and discussion.

BMS Behavioural marker system