Summary statement: In the absence of theoretical or empirical agreement on how to establish and maintain engagement in instructor-led health care simulation debriefings, we organize a set of promising practices we have identified in closely related fields and our own work. We argue that certain practices create a psychologically safe context for learning, a so-called safe container. Establishing a safe container, in turn, allows learners to engage actively in simulation plus debriefings despite possible disruptions to that engagement such as unrealistic aspects of the simulation, potential threats to their professional identity, or frank discussion of mistakes. Establishing a psychologically safe context includes the practices of (1) clarifying expectations, (2) establishing a "fiction contract" with participants, (3) attending to logistic details, and (4) declaring and enacting a commitment to respecting learners and concern for their psychological safety. As instructors collaborate with learners to perform these practices, consistency between what instructors say and do may also impact learners' engagement.

We report on our experience with an approach to debriefing that emphasizes disclosing instructors' judgments and eliciting trainees' assumptions about the situation and their reasons for acting as they did. To highlight the importance of instructors disclosing their judgment skillfully, we call the approach "debriefing with good judgment." The approach draws on theory and empirical findings from a 35-year research program in the behavioral sciences on how to improve professional effectiveness through "reflective practice." This approach specifies a rigorous self-reflection process that helps trainees recognize and resolve pressing clinical and behavioral dilemmas raised by the simulation and the judgment of the instructor. The "debriefing with good judgment" approach is comprised of three elements. The first element is a conceptual model drawn from cognitive science. It stipulates that the trainees' "frames"--comprised of such things as knowledge, assumptions, and feelings--drive their actions. The actions, in turn, produce clinical results in a scenario. By uncovering the trainee's internal frame, the instructor can help the learner reframe internal assumptions and feelings and take action to achieve better results in the future. The second element is a stance of genuine curiosity about the trainee's frames. Presuming that the trainee's actions are an inevitable result of their frames, the instructor's job is that of a "cognitive detective" who tries to discover, through inquiry, what those frames are. The instructor establishes a "stance of curiosity" in which the trainees' mistakes are puzzles to be solved rather than simply erroneous. Finally, the approach includes a conversational technique designed to bring the judgment of the instructor and the frames of the trainee to light. The technique pairs advocacy and inquiry. Advocacy is a type of speech that includes an objective observation about and subjective judgment of the trainees' actions. Inquiry is a genuinely curious question that attempts to illuminate the trainee's frame in relation to the action described in the instructor's advocacy. We find that the approach helps instructors manage the apparent tension between sharing critical, evaluative judgments while maintaining a trusting relationship with trainees.

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The authors present a four-step model of debriefing as formative assessment that blends evidence and theory from education research, the social and cognitive sciences, experience drawn from conducting over 3,000 debriefings, and teaching debriefing to approximately 1,000 clinicians worldwide. The steps are to: 1) note salient performance gaps related to predetermined objectives, 2) provide feedback describing the gap, 3) investigate the basis for the gap by exploring the frames and emotions contributing to the current performance level, and 4) help close the performance gap through discussion or targeted instruction about principles and skills relevant to performance. The authors propose that the model, designed for postsimulation debriefings, can also be applied to bedside teaching in the emergency department (ED) and other clinical settings.

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Yates, seminar participants at Harvard, MIT, and Boston College, three anonymous reviewers, the associate editor, Joe Porac, and the managing editor, Linda Johanson.This article examines the role that the quantity of nonnovel events plays in precipitating disaster through the development of a formal (mathematical) system-dynamics model. Building on existing case studies of disaster, we develop a general theory of how an organizational system responds to an on-going stream of non-novel interruptions to existing plans and procedures. We show how an overaccumulation of interruptions can shift an organizational system from a resilient, self-regulating regime, which offsets the effects of this accumulation, to a fragile, self-escalating regime that amplifies them. We offer a new characterization of the conditions under which organizations may be prone to major disasters caused by an accumulation of minor interruptions. Our analysis provides both theoretical insights into the causes of organizational crises and practical suggestions for those charged with preventing them.-Major disasters have long interested organization theorists (Perrow, 1984; Shrivastava, 1987; Weick, 1993b; Vaughan, 1996), and their causes continue to be an active area of inquiry. Accidents like the nuclear catastrophe at Chernobyl or Union Carbide's gas leak at Bhopal are major social events responsible for immeasurable human suffering and environmental damage. There are few more compelling opportunities for organization theory specifically, and the social sciences in general, to prevent suffering and contribute to humanity. Moreover, major disasters provide a unique opportunity to study organizational processes in situations that are far from equilibrium. Just as the designers of bridges and airplanes test their systems under extreme conditions that are rarely, if ever, experienced during actual use, major catastrophes provide a similar opportunity to learn more about the vulnerability and resilience of human and social systems.The literature on disaster and its flip side, safety, includes indepth case studies (e.g., Shrivastava, 1987; Weick, 1993b; Vaughan, 1996), studies of learning from accidents and error (e.g., Cook and Woods, 1994;Carroll, 1995), theories of highhazard or accident-prone organizations (Turner, 1976; Sagan, 1993; Perrow, 1994), theories of high-reliability organizations (Roberts, 1990; Schulman, 1993; Weick, Sutcliffe, and Obstfeld, 1999), and theories of how to manage accident and error (e.g., Reason, 1997). A significant insight emerging from this literature is that major disasters often do not have proportionately large causes. Theorists increasingly recognize that small events can link together in unexpected ways to create disproportionate and disastrous effects (Weick, 1993a; Perrow, 1994; Vaughan, 1996; Reason, 1997). Perrow (1984) suggested that as production technologies become increasingly sophisticated and interconnected with other systems, the likelihood of chain reactions, in which one problem reverberates t...

The DASH scores showed evidence of good reliability and preliminary evidence of validity. Additional work will be needed to assess the generalizability of the DASH based on the psychometrics of DASH data from other settings.

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