Critical incidents

Accreditation bodies have included professional dispositions as part of teacher preparation and candidate evaluation, yet many ESOL teacher educators are understandably confused about how to assess them in their programs. Teacher educators are charged with fostering the qualities and dispositions that will help their teacher candidates be successful in the classroom. Yet how do we change attitudes and dispositions in teacher candidates who may enter preparation programs with a mindset that will be detrimental to diverse students? This paper reflects on the authors' own practice in addressing professionalism in general and professional dispositions in particular, and suggests effective practices in addressing them, including the importance of modeling the practices during teacher training so teacher candidates can learn to apply them to their own practice. The authors use detailed descriptions, evaluations, and implications of a critical incident of an ESOL teacher candidate's field experience; offer suggestions and specific activities that can be used by teacher educators to address professionalism; and, based on their experiences as program directors, raise compelling arguments for the use of critical incident analysis and evaluation in teacher preparation programs.

This all hazards project  will explore “The Threat of Argoterrorism.” The project will define argoterrorism as an operational term for all levels of government services and the practical term relevant to the general population. The project will explore how real the threat of argoterrorism may be and the likelihood of such an attack taking place. The project will breakdown the nexus of argoterrorism and in what capacity it will affect its intended targets, directly, secondarily, and indirectly.
The project will discuss the roles of the government and private sectors and their perspective emergency management cycles of preparation, mitigation, preparedness, response and recovery, in terms of how they each will execute their plan of action through strategic partnerships, interoperability, and incident management. The project will analyze a command structure for an  incident involving argoterrorism and discuss lessons learned from previous successful or failed attempts, or practical exercises of argoterrorism.
The project will examine the actual threat of argoterrorism, the likely or expected perpetrators of this threat, and their methods and resources to execute this threat successfully, and what would need to be implemented to thwart an argoterrorism critical incident from materializing, and if the  United States is ultimately prepared to endure an argoterrorism attack.

Purpose -Customer satisfaction formation represents a dynamic phenomenon, especially in extended service encounters. A single service encounter may have an extended duration and feature several service interactions, which the customer can evaluate independently. This paper aims to offer a dynamic perspective on satisfaction formation, which indicates that what matters is not only the interactions a customer confronts but also when these interactions occur. Design/methodology/approach -Research from social psychology provides a foundation for hypothesizing different effects of positive and negative critical incidents. Negative critical incidents likely are more important for overall satisfaction if they occur at the end of a service encounter. Positive critical incidents should have stronger effects at the beginning. In a 2 £ 2 experimental design, participants considered a five-day holiday hotel experience. Findings -The data support the predicted dominance of a recency effect for negative critical incidents, such that a negative critical incident has a greater negative impact on customers' overall satisfaction when it occurs at the end of a service encounter instead of at the beginning. For positive critical incidents, no significant differences arose between primacy and recency effects. Practical implications -The results highlight the importance of process designs of service experiences. Managers should pay particular attention to avoiding service failures at the end of a service encounter. Originality/value -Unlike research that only assesses satisfaction formation for service encounters from a non-dynamic perspective, this study posits the importance of the order of interactions within a service encounter.

The aim of this article is to explore how the practice of critical reflection within an informal management learning process can be facilitated through the application of reflective processes and tools.  A distinction is drawn between reflection as a form of individual development (of, say, the reflective practitioner), and critical reflection as a route to collective action and a component of organisational learning and change.  Critical reflection, however, is not a process that comes naturally to many managers and may have to be learned or facilitated, often through informal learning processes such as coaching, mentoring and action learning. The aim of this paper is to discuss some of the tools available to informal learning facilitators, in helping a client towards a more critically reflective understanding of their situation and organisation.  These include processes such as storytelling, and reflective and reflexive conversations, and the use of tools such as reflective metaphors, critical incident analysis, reflective journals, repertory grids and concept mapping.  Such tools provide an aid to critical reflection, the process that mediates between experience, knowledge and action.

Ce chapitre rend compte de l'étude menée auprès d'une équipe de conseillères et conseillers en emploi d'un service de placement étudiant d'une institution postsecondaire. Souhaitant se munir d'un cadre de référence commun, enrichir leur pratique d'accompagnement ainsi que leurs stratégies d'intervention, ces professionnels ont sollicité la contribution des auteurs (Bourassa, Fournier, Goyer et Veilleux). Cette recherche, qui s'est échelonnée sur un peu plus d'une année, a produit des résultats qui permettent de satisfaire à la fois le développement des pratiques et l'avancement des connaissances scientifiques. Les auteurs présentent d'abord les considérants épistémologiques sur lesquels s'appuie cette étude. Sur le plan méthodologique, on voit ensuite comment ils ont mis à contribution de manière judicieuse et originale le groupe focalisé et la méthode des incidents critiques pour atteindre leurs objectifs. Enfin, les auteurs discutent des retombées progressives et subséquentes de cette démarche de recherche sur les conseillers et conseillères et le service dans lequel ils évoluent, mais également sur l'avancement des connaissances au sujet de ce qui fait la spécificité et la complexité de leurs pratiques d'intervention professionnelle.

Eight years after the 1993 standoff between federal law enforcement agents and the Branch Davidians, "Waco" has become a shorthand reference to the tragedy that claimed the lives of more than eighty people. After internal investigations by the Department of the Treasury and the Department of Justice, two trials, two sets of congressional hearings, the publication of numerous books and articles, and the production of documentary films,we are no closer to bringing closure to Waco than we were in 1993. To understand why Waco has not gone away, it is useful to combine a model of conflict that focuses attention on the motivational power of symbols and narrative with a model of trauma that operates at the collective and not just the individual level.

This study aims to examine the public discourse about incidents in "high reliability organizations" (organizations with high adaptability capacities allowing them to operate without incident for long periods in a risky environment (Rochlin, 1993)) and its relation to Organizational mindfulness, which is defined as "rich awareness of discriminatory details generated by organizational processes" (Weick & Sutcliffe, 2006). Following the methodology commen in the high reliability organizations research, two cases were selected: " Ze'elim A" (a training accident in which five Israeli reserve soldiers were killed as a result of wrong artillery targeting) and "Ze'elim B "(a training accident which killed five soliders of an elite commando unit by a missile shot at a manned compound). The cases served as comperative case studies using the built-in comparison between them. Utilizing the concept that the media not only reports about the events but also shape it, the research method included content analysis, assisted by a specialized computer application, about articles that were published in the media concerning these training accidents using both theoretical pre-defined categories and inductive, ad-hoc, categories (in the tradition of 'grounded theory'), in an effort to analyze the cultural construction of high-reliability organizations and the mechanisms of organizational mindfulness active within them, an examination that havn't been done before. Later a half-open interview with leading reporters in Israel were conducted and coded using the same coding scheme in order to cross validate the study's findings. The study findings allow the expansion of concepts and terminology that I have chosen to review using the public discourse concerning high-reliability organizations and organizational mindfulness. In addition, the study generated through intergrative analysis an insight about the crucial impact of the "high reliability" image on "high reliability" organizations' ability to survive and the defense machanisms they develop to maintain this image - "high reliability of second order". Combining the expanded theoretical categories with the proposed impact model of the public-private discourse also offers interesting insights about high-reliability organizations that were studied in particular and organizational research field in general

מחקר זה שם לו למטרה לבחון את השיח הציבורי אודות תאונות בארגונים עתירי מהימנות, ארגונים בעלי יכולת הסתגלות גבוה שמאפשרת להם לפעול ללא תקלות בסביבה מסוכנת (Rochlin, 1993), ויחסו לתיאוריה של קשיבות ארגונית (Organizational mindfulness), אשר מוגדרת כ"יכולת המשותפת ליצור מודעות עשירה בפרטים מבחינים ויכולות פעולה" (Weick & Sutcliffe, 2006). בהתאם למתודולוגיה הנהוגה בתחום, נבחרו שני מקרי בוחן: "אסון צאלים א'" (תאונת אימונים אשר בה נהרגו חמישה חיילי מילואים כתוצאה מטיווח ארטילרי מוטעה) ו"אסון צאלים ב'" (תאונת אימונים אשר בה נהרגו חמישה לוחמי סיירת מטכ"ל כתוצאה מירי טיל לעבר מתחם מאוייש), אשר שימשו לחקר מקרה תוך שימוש בהשוואה המובנית ביניהם. מתוך התפיסה שהדיווח התקשורתי איננו רק מספר את המתרחש אלא גם מעצב אותה, שיטת המחקר כללה ניתוח תוכן כמותי ואיכותי, בעזרת בתוכנת מחשב ייעודית, של קטעים אשר פורסמו בתקשורת אודות תאונות אימונים אלו תוך שימוש הן בקטגוריות תיאורטיות מוגדרות מראש והן בקטגוריות אינדוקטיביות (במסורת ה"תיאוריה מעוגנת בשדה"), זאת במטרה לבצע ניתוח ההבניה התרבותית של ארגונים עתירי מהימנות ומנגנוני הקשיבות הארגונית הפועלים בהם. לאחר מכן נעשה שימוש בראיונות חצי פתוחים עם פרשנים וכתבים צבאיים מובילים שקודדו גם הם, על מנת ליצור הצלבה של הממצאים. בחינת זירת השיח הציבורי סביב ארגונים עתירי מהימנות, אפשרה להראות את מחזור החיים ואת מפל ההשפעות של תקרית ארגונית ולהרחיב את התיאוריות הנוגעות בקשיבות ארגונית ובארגונים עתירי מהימנות. בכך אני מקווה שאפשרתי העשרה של התיאוריות מהן יצאתי לדרך בשיקוף התפיסה הציבורית של הארגונים כעתירי מהימנות והביטויים השונים של קשיבות ארגונית סביבם ובתוכם. תובנה אינגרטיבית מרכזית שהמחקר מראה, היא בדבר חשיבותה של התדמית הארגונית כ"ארגון עתיר מהימנות" לשרידות הארגון והתפתחות של מנגנוני הגנה (אשר חלקם קשורים גם לתיאוריה של קשיבות ארגונית) על מנת לשמר את התדמית הארגונית, עד כדי התפתחותה של "עתירות מהימנות בדרגה שניה" המכוונת כלפי התדמית הארגונית. ממצאים נוספים מובאים בגוף העבודה.

Despite major advances in the creation of diagnostic constructs for trauma-related disorders there exists, at present, no comprehensive theoretical model for psychological trauma. Historically, trauma theories have related psychological trauma either to biological or to intrapsychic factors. More recently, trauma is increasingly being related solely to the dysregulation of (neuro)physiological processes. Two recent therapeutic modalities, Eye Movement Desensitization and Reprocessing and Somatic Experiencing, attribute trauma to the blocking or dysregulation of an innate capacity for self-regulation. This project seeks to critically analyze the growing tendency to reduce psychological trauma to physiological processes; to test the hypothesis that psychological trauma is caused by the blocking of an innate capacity for self-regulation by using a third therapeutic modality that engages this capacity directly; to explore the psychological mechanisms of the processing of traumatic memories; and to prepare an alternative trauma model, based on agency. 
Method. Study 1 uses ontological and epistemological arguments to show that psychological trauma cannot be reduced to physiological processes alone and describes an alternative to physicalist reductionism based on agency and anthroposophy. Study 2 is a survey, based on self-report questionnaires, that screened 61 firefighters from Santa Catarina for exposure to critical incidents and PTSD symptoms. Study 3 is a clinical case study, investigating the use of Rebirthing Breathwork for the treatment of a firefighter with PTSD.
Results. Study 1 proposes the ontological basis for an alternative trauma model, based on the concept of agency and on the fourfold image of the human being developed by Rudolf Steiner. Study 2: the exposure to potentially traumatic events in the sample of firefighters was 100%. Depending on the method used to interpret the results of the PTSD Checklist for DSM-5, 3-5 firefighters obtained a provisional PTSD diagnosis. A correlation was found between the appraisal of critical incidents and several sociodemographic and job-related factors related to age, education and whether or not the participant was on active duty. Study 3: the PTSD diagnosis of only one of the firefighters with a provisional diagnosis was confirmed by a clinical interview; the firefighter diagnosed with PTSD responded well to the treatment and is in remission after 8 sessions of Rebirthing Breathwork. 
Conclusion. Study 1: the fourfold image of the human being developed by Rudolf Steiner may prove a fruitful basis from which a more comprehensive trauma model can be developed; this needs to be explored further. Study 2 confirms previous research that PTSD-symptoms are higher in firefighters than in the general population. In the case study (Study 3) the treatment of PTSD with Rebirthing-Breathwork proved successful. Quantitative and qualitative findings from the treatment support the hypothesis of an innate capacity for self-regulation as well as a processing model proposed by the researchers.

This article explores the reflections of critical incidents of eight beginning English as a foreign language teachers and one of their trainers in Mexico. Based upon narrative inquiry and through the use of journals, critical incidents and how they have impacted beginning teachers in their thinking were specifically looked at. From the data we found seven emerging themes which basically revolve around the relationships that are established between the teacher and the students, the emerging professional identities of the beginning teachers, and the tutor’s reflection on knowledge transfer. Results showed how these teachers reflected upon their teaching practice and how the critical incidents helped them to analyze and evaluate their teaching process.

Organizational scholars have long been interested in organizations which exemplify high reliability. While such organizational studies have provided valuable clues to the ways in which such organizations form and function, this paper argues that a more nuanced study of high reliability processes within team contexts is warranted. This study focuses on organizational teams which are faced with the challenges of maintaining high levels of reliability. Of particular interest is how teams manage adverse events which disrupt the team's process and how they make adaptations immediately to restore their functionality. In this study, I: (1) explore the existing literature surrounding high reliability organization and resilience, (2) present a qualitative analysis of Special Weapons and Tactics (SWAT) teams to explore and identify factors surrounding adaptation within the critical moment, and (3) discuss the implications of these factors in the theory and research surrounding high-reliability teams. The findings of this study find strong connection with the work of Weick and serve to advance and clarify previous characteristics associated with high reliability organizing; however, by using the small group as the unit of analysis for the study additions to concepts traditionally associated with high reliability organizing can be noted: (1) the ability to control variability during team function, (2) accepting the value of the unexpected, and (3) the value and implications of continuous forward progress.

SÍNTESIS: Este trabajo tiene por objetivo realizar una propuesta fundamentada para la formación inicial y permanente del profesorado a través de una «pauta para el análisis de los incidentes críticos» que puedan producirse en el aula, a la que, a lo largo del artículo, nos referiremos por sus siglas: PANIC. Con el fin de justificar y argumentar dicha propuesta, se revisan, en primer lugar, las ventajas e inconvenientes de los principales modelos de formación de profesorado dominantes para, en un segundo momento, defender una formación que promueva un cambio más profundo, relativo a las concepciones, estrategias y sentimientos del docente, es decir, un cambio que afecte a su identidad profesional. Una modificación de esta naturaleza requiere identificar una unidad de análisis e intervención compleja, contextualizada y en la que se entrecrucen los distintos factores enunciados. Por su propia naturaleza, los incidentes críticos contienen esas características y así lo han reconocido distintas propuestas formativas centradas en ellos. Tras revisar y asimilar las mismas a los modelos de formación examinados al inicio del artículo, se concluye presentando una nueva propuesta formativa que trata de compensar algunas carencias de las iniciativas anteriores.

Nursing students are at high risk of injury while on clinical placement. The incidence of injury is three times higher in comparison to other healthcare workers, with a prevalence ranging from 25% up to 33,2%. Lack of knowledge and of experience in delivering nursing care, anxiety and unfamiliarity with the clinical environment all represent risk factors for injury. This study describes the number and type of injuries occurring in an organizational setting where nursing students are trained in simulation laboratories before being exposed to a real clinical environment. An eight year retrospective observational study (2009 to 2017) was conducted on a non-probabilistic population of 1,403 nursing students from a university in the north of Italy. Incident reports were anonymised and entered in a database. Overall the percentage of students who reported an injury (6,2%) was much lower than the one reported in the literature. The nursing programme curriculum of the above mentioned univer...

This cross-border contribution seeks to shed light on potential answers and solutions for selected critical incidents (CI) happening to tertiary students during social encounters in various settings. For these purposes, two well-defined CIs were chosen that allow for a wide range of possible interpretations. Against the background of the international Erasmus+ project entitled 'Critical Incidents in Intercultural Communication and Promoting Diversity' five project partner countries, namely Czechia, Finland, Germany, Italy, and Austria have participated in this exploratory study to identify how the respective societal sample may interpret the critical incidents at hand and how they affect their personal and professional growth. At each partner institution, a purposive sample consisting of 33 student participants was asked to elaborate on the CIs and provide possible answers and further introspection of their train of thought. In a second step, a thematic analysis was conducted to allow for the extraction of subthemes and the creation of a thematic map. The findings were then sketched in line with specific cultural theories to verify if prevalent and hard-wired assumptions are still valid at a generation of young born into a globally interconnected world. This is all the more relevant in view of the dynamic VUCA world where volatile, uncertain, complex and ambiguous situations dominate our digitalized and globalized knowledge society. To account for these complexities, it was sought to not only look at societal cultures as a source of possible interpretations. In addition, it was attempted to also take account of demographic, cognitive, disciplinary, and functional diversity. As such, it was possible to obtain a profound and differentiated picture of potential societal answers that incorporate a broad potpourri of possible explanations of how to approach specific CIs, including their use for didactical purposes.

RESUMEN El propósito de la investigación presentada, fue propiciar la construcción del conocimiento profesional, por medio del análisis de incidentes críticos en las prácticas iniciales de pedagogía básica. En el contexto de implementación de nuevas políticas en la formación docente, el replantear de qué manera los futuros docentes construyen su conocimiento profesional, se hace necesario para evaluar y fortalecer las trayectorias desde la FID. El diseño metodológico se adscribe dentro de la investigación-acción, la cual constó de tres ciclos, cada uno caracterizado de la aplicación de cuestionario de preguntas abiertas, entrevista semiestructurada y grupo de discusión. Las participantes resultaron ser mujeres, convocadas sin diferenciación de género, involucrándose al proyecto voluntariamente. Los resultados plantean que una de las barreras en la formación práctica es la falta de herramientas pedagógicas para responder a situaciones críticas en el aula, pero, por otro lado, un factor que fortalece su formación es la convicción de su vocación docente para permanecer en la carrera. Los incidentes críticos de mayor influencia en las participantes, se refieren a las relaciones de convivencia en el aula, en que el actor en común es el docente mentor. Se concluye con la reflexión y discusión grupal, en que se adapta una pauta de análisis de casos, que promovería la construcción de conocimiento profesional a través del análisis de incidentes críticos. Palabras clave: formación inicial docente, incidente crítico, prácticas iniciales, práctica reflexiva, investigación-acción.

Nursing students are at high risk of injury while on clinical placement. The incidence of injury is three times higher in comparison to other healthcare workers, with a prevalence ranging from 25% up to 33,2%. Lack of knowledge and of experience in delivering nursing care, anxiety and unfamiliarity with the clinical environment all represent risk factors for injury. This study describes the number and type of injuries occurring in an organizational setting where nursing students are trained in simulation laboratories before being exposed to a real clinical environment. An eight year retrospective observational study (2009 to 2017) was conducted on a non-probabilistic population of 1,403 nursing students from a university in the north of Italy. Incident reports were anonymised and entered in a database. Overall the percentage of students who reported an injury (6,2%) was much lower than the one reported in the literature. The nursing programme curriculum of the above mentioned univer...

According to sociocultural theory (SCT), corrective feedback (CF) entails a negotiation process whereby writing instructors support second language (L2) writers in self-correction and provide a level of guidance needed for writers to actively engage in revision tasks (Aljaafreh & Lantolf, 1994). Drawing on SCT, this collaborative self-study details the CF experiences of one writing instructor and four L2 students. Focusing on six "critical incidents" occurring within the instructor's teaching context (a developmental writing course in a Northeastern U.S. university), the authors investigate L2 writers' responses to written (WCF) and negotiated oral CF. During these incidents, students engaged with different forms of CF. The authors' analysis of these incidents draws attention to the micro- and macro-contextual features that complicate students' uptake and perceptions about differing forms of CF. Findings reveal the importance of face-to-face negotiation in ...

This study explored the characteristics of the international educator through a qualitative analysis of initial decisions to teach abroad. Using interview data from thirty Anglophone educators based across three international schools in China and the Netherlands, the investigation looked beyond surface motives to explore the deeper values which propelled educators overseas. Dominant characteristics included a high value ascribed to travel, as well as a high value ascribed to change and/or risk. How international educators came to ascribe these values was often explained through critical incidents during their formative or young adult years. Analysis of critical incidents suggest that early or repeated exposure to travel, including study abroad experiences, contribute significantly to the development of predispositions towards international employment.

This study compares university students’ beliefs about studying abroad with those presumed by their professors. The participants were 20 second-year Japanese university students enrolled in the College of Intercultural Communication, in which all students spend their fourth semester abroad. In their third semester, students completed a questionnaire designed to assess their reasons for studying abroad as well as their beliefs about the potential challenges and benefits of spending a semester in another culture. This questionnaire incorporated a possible selves approach, which is relatively new in the field of SLA. Eight faculty members in the department completed the same questionnaire in order to determine the extent to which their beliefs about students' reasons for and concerns about studying abroad aligned with actual students' self reports. This paper also includes a review of literature related to the benefits and challenges of studying abroad.

Making sense of musicians’ professional learning pathways is of crucial importance to understanding their career progressions, their routes into creative employment, and the relevance of various policies to their professional lives. However, this is a far cry from understanding how critical reflection catalyzes diverse learning routes, especially when considering evidence originating from postgraduate musicians’ own accounts of their journeys into job creation. In this study, we invited five postgraduate classical musicians who were invested in professional learning through performance programs in higher education to contribute these types of personal perspectives. The article explores the value of postgraduate musicians’ own accounts of their journeys and illustrates how a more nuanced understanding of them can be arrived at through the use of visual-based tools, for example, Rivers of Musical Experience and Dixit Cards. This constructivist intervention prompted both group and indi...

This study is an exploration of the life-changing decisions and changes which the participants underwent, and which led them to pursue an education in English language teaching (or languages). The foremost objective of this study was to highlight the critical incidents from the past, present, and teaching practice of transnational students in a BA in TESOL program who are also English teachers in central Mexico. Through a narrative analysis, critical incidents in the lives of transnational student/teachers were identified. The findings of this research showed how the participants could explore their identity formation process through the critical incidents.

No matter how strong their academic aptitude, no matter how supportive their family home, no matter how extensive their formal education, no business leader starts his or her career fully competent to lead a business corporation: they have a lot to learn. Earlier studies have shown that business leaders learn from experience, that they do so in often accidental and ad-hoc ways, that this required self-directed enquiry and reflection that ultimately led to sense-making within a particular social context, and that overcoming challenges and difficulties at work often trigger their self-generative learning capacities. Many studies in the management discipline have focused either on what it takes to be a business leader (normative) or what business leaders do (empirical), but little is known about the development of business leadership competence. This paper proposes that highly accomplished business leaders encounter specific ‘formative events’ throughout their career that play a central role in the development of their social identities, and their capacities to deal with change. Business leadership is all about dealing with change, and this provides opportunities for self-discovery, social learning and enables learning-to-learn agility. ‘Groundedness’ and ‘adaptability’ together are the secrets to business leadership success. These two qualities are characteristic of the outlook of all great business leaders, and are acquired during critical, perspective-changing incidents, often accompanying significant change, throughout their lives. This paper explores the conceptual roots of these concepts and shows that the life-stories of highly accomplished business leaders attest to them on every page.

Five student-teachers at a Japanese university participated in a two-week teaching practicum in Thailand. The program was designed to assist them in developing their own theory of practice for CLIL. Student-teachers designed and conducted CLIL-inspired lessons which were compatible with the schools' foreign language learning goals and the 4Cs (Content, Communication, Cognition, Culture) of CLIL. The unique characteristic of this practice was the use of ePortfolios to grasp the type of CLIL practices that the student-teachers developed and a Lesson Study Application for smartphones and tablets to record observations and later see how those principles developed over the course of their practicum. All student-teachers developed principles related to Content and Communication. Furthermore, two of the five student-teachers articulated principles related to Culture. Principles for Cognition were not formulated to the same extent as the other components. This paper will articulate the student-teachers' theory of practice and describe how their principles developed.

Organizational scholars have only recently begun to consider the study of groups as a building block of high reliability organizations (Wesner, In Press). This study focuses on organizational teams faced with the challenges of maintaining high levels of reliability. As Wesner establishes, high reliability teams have the unique ability to facilitate rapid adaptation when faced with critical incidents. This study takes that line of research a step further by investigating how teams learn from, and begin to anticipate, critical events and the factors associated with each. In this study, I (1) explore existing literature surrounding the impact of knowledge consciousness and temporality considerations on team and individual level adaptation, (2) present a qualitative analysis of Special Weapons and Tactics (SWAT) teams to identify what teams learn from experiencing critical events and how these teams begin to integrate knowledge and training activities to anticipate critical events before they occur, and (3) discuss the implications of these findings in the theory and research surrounding high reliability teams. The findings of this study find strong connection with the work of Weick, and Perrow while serving to advance and clarify previous characteristics associated with high reliability organizing, temporality, and decision making behaviors.

Research has shown that human error in anaesthesia is a major contributor to critical incident in anaesthesia, what is unclear is how this occurs and what impact these incidents have on patients. The purpose of this thesis was to examine human error in anaesthesia using Reason’s (1990) framework of error and Swiss Cheese Model to identify the stages of anaesthesia in which errors occur, the frequency and severity of those errors, and the role of fatigue, stress, and usability in human error in anaesthesia. A two stage process was used to collect information on human error in critical incident. The first stage consisted of a task analysis and Flanagan’s (1954) critical incident analysis which allowed for the collection of information on the anaesthetic process, this information led to suggestions for a questionnaire to be used to collect data which could be quantitatively analyzed. In the second stage, a questionnaire was constructed and taken online by participants sent invitations from their respective District Health Board in New Zealand. A small sample size of data was acquired (n=12 responses) of which 8 were complete and used. Results were analyzed by a critical incident analysis. Human error was found to occur during all stages of anaesthesia with induction representing the most incidents and emergence the least. Incidents involving human error were found to be rare, occurring between once per yearly quarter to a few times per lifetime. Most incidents were found to be near misses, and almost a quarter of incidents were found to be of harm, of these only one was judged to be of moderate harm. Fatigue and stress were found to be associated with half of incidents, and equipment design was found to only be associated with a few incidents. This investigation is effective in highlighting examples of modern critical incidents of anaesthesia. These results indicate that fatigue and stress possibly play large roles in contributing to human error in anaesthesia and may be good areas for future research.

No matter how strong their academic aptitude, no matter how supportive their family home, no matter how extensive their formal education, no business leader starts his or her career fully competent to lead a business corporation: they have a lot to learn. Earlier studies have shown that business leaders learn from experience, that they do so in often accidental and ad-hoc ways, that this required self-directed enquiry and reflection that ultimately led to sense-making within a particular social context, and that overcoming challenges and difficulties at work often trigger their self-generative learning capacities. Many studies in the management discipline have focused either on what it takes to be a business leader (normative) or what business leaders do (empirical), but little is known about the development of business leadership competence. This paper proposes that highly accomplished business leaders encounter specific 'formative events' throughout their career that play a central role in the development of their social identities, and their capacities to deal with change. Business leadership is all about dealing with change, and this provides opportunities for self-discovery, social learning and enables learning-to-learn agility. 'Groundedness' and 'adaptability' together are the secrets to business leadership success. These two qualities are characteristic of the outlook of all great business leaders, and are acquired during critical, perspective-changing incidents, often accompanying significant change, throughout their lives. This paper explores the conceptual roots of these concepts and shows that the life-stories of highly accomplished business leaders attest to them on every page.

Teacher reflection has been shown to have a positive influence on educators’ professional growth. This article features the author’s autobiographical reflection on his eight years working at an elementary school within a predominantly migrant Mexican American Hispanic community, with specific attention paid to his mistakes while implementing a lesson on the indigenous Huichol culture of Mexico. Through the author’s critical self-reflection, a number of common missteps in multicultural instruction are discussed, including the selection of lessons that call for shallow reproductions of cultural artifacts, the error of false assumptions of cultural homogeneity, and the culturally-insensitive practice of assuming privileged roles of academic authority that treat indigenous people as exoticized subjects unable to describe themselves and their lived experiences. The article concludes with a synthesis of lessons learned from the author’s errors, and encourages other educators to engage in similar teacher reflection to further their own growth as culturally sensitive educators.

In this collaborative autoethnographic piece, we present voices through critical incident technique replaying the same event at an academic conference, all seeking to understand how and why the disruption of voice occurs and what to do to counter it. We contextualize these experiences in the ideal of "sustainability of qualitative inquiry" through a feminist reflexive process, problematizing the potential for critical qualitative inquiry. We question how ownership of power, knowledge, education and voice within academic spaces can be embodied by women and other underrepresented groups. In the end, we provide a set of three potential solutions for conference committees and individuals to critically self-reflect upon to create more social justice in qualitative research spaces. Such considerations are particularly important in times of social distancing, where considerations for inclusivity for all are imperative.

On August 25, 1981, a shock wave hit the Eastman Kodak Company in Rochester, NY. On the other side of the world in Tokyo, Sony Corporation demonstrated its new Mavica camera at a press conference filled with interested onlookers. Mavica stood for MAgnetic Video CAmera, and while the device appeared much like 35mm single lens reflex cameras from many other companies, this camera used no film and was fully electronic in operation. The camera required only three AA batteries to operate. The Mavica captured images in a similar fashion to video recorders; the unit used a microchip to record still video images. The output quality matched the maximum level available in televisions and video monitors (Carter, n.d). Besides the camera itself, Sony introduced a larger system to support the device that included lenses, floppy disks called Mavipaks, and a playback device called the Mavipak Viewer. The Mavica announcement provoked a wide range of reactions at Eastman Kodak. The company's president, Colby Chandler, dismissed the new camera claiming that the company had already developed a digital image capture device and could design and build its own competitor to Sony's electronic camera. He also cited the company's long-standing strength in film and the market demand for quality color prints. However, Sony's announcement caused panic among some members of Eastman Kodak's senior management team who felt that this signaled the end of chemical-based film technology and photography (Swasy, 1997). Given the rise of this new development, how should managers at Eastman Kodak respond? Eastman Kodak Invents the First Digital Camera Engineers and managers within Eastman Kodak had been familiar with developments in filmless cameras for years. It was within its own research labs in December, 1975, that the first digital camera was developed (Lloyd & Sasson, 1978). With meager resources, a small team led by Steve Sasson created a system for storing images, and used newly developed microprocessors to record and transmit the images. When completed, the camera weighed eight pounds and recorded 10,000 pixel (or 0.01 megapixel) images on a cassette tape that could hold thirty pictures. Demonstrations of the camera's ability to take pictures and display them on a video screen generally received encouraging reactions from engineers and managers within Eastman Kodak. The digital camera that Sasson's team developed clearly demonstrated a completely digital imaging system that dispensed with film and chemical processing. However, some people within Eastman Kodak expressed concern with the new device as the image quality produced by the camera paled in comparison to film-based photos. The camera was limited to black-and-white and took 23 seconds to display each image (Gennuth, 2012; "History of the camera," 2013). Sasson's work on the first digital camera was more of an experiment than a product development effort and many technical hurdles remained before it could be marketed. Sasson believed that it would be another 15 to 20 years before the technology could reach an acceptable level of refinement and quality (Gennuth, 2012). This estimate was based on his assessment of the trajectory of performance and cost of the necessary electronic components and the minimum acceptable level of image quality demanded by consumers, believed to be the equivalent of two megapixels (two hundred times the resolution of his camera). Eastman Kodak continued to actively work on developing the technology and solving the problems required to bring filmless, electronic photography to consumers, including refinements in the image sensors that would be the new "film" in any future digital camera. The goal was to enter the market when the technology was ready. Eastman Kodak in 1981 In 1981, Eastman Kodak held a commanding position in both domestic and international markets, with a dominant market share of 77. …

Making sense of musicians’ professional learning pathways is of crucial importance to understanding their career progressions, their routes into creative employment, and the relevance of various policies to their professional lives. However, this is a far cry from understanding how critical reflection catalyses diverse learning routes, especially when considering evidence originating from postgraduate musicians’ own accounts of their journeys into job creation. In this study, we invited 5 postgraduate classical musicians who were invested in professional learning through performance programmes in higher education to contribute these types of personal perspectives. The paper explores the value of postgraduate musicians’ own accounts of their journeys, and illustrates how a more nuanced understanding of them can be arrived at through the use of visual-based tools, e.g., Rivers of Musical Experience and Dixit Cards. This constructivist intervention prompted both group and individual critical reflections, as well as sense-making processes that enabled the participants to become more informed about the (typically overlooked or neglected) critical incidents that differently catalyse professional learning pathways. All of the participants articulated sociocultural influences that were situated along historical, present, and future points of departure and arrival, helping them to create meaning and understanding of themselves and their (at times unsettling) professional learning pathways. From the ensuing thematic analyses, we identified a commonality of themes across life phases with three key influential groups of people (parents, peers, and professionals) that strongly affected their professional learning pathways and learner identity-construction. The results indicate that the relationships between these phases and people are complex. The research illuminates the previously unexplored connection between the meaning-making trajectories that are instantiated through critical reflection, and adds to our understanding of the development of musicians’ professional learning pathways and learner identities.

Text pojednává o zlomových událostech, které hrají roli v utváření profesní identity učitelů expertů. Události jsou nahlédnuty skrze rekonstrukci procesu budování profesní identity ve vyprávění učitelů. Koncept profesní identity je použit pro vysvětlení profesních otázek, které musí učitel řešit při svém rozvoji. Profesní identita je definov247ána jak skrze vidění sebe ve vlastním jednání, tak skrze vidění sebe druhými ve vyprávění a jednání aktérů školy. Učitelé ve svých vyprávěních při rekonstrukci profesní dráhy nepopisují příběh v celistvé podobě, ale zaměřují se na jednotlivé dílčí epizody, které jsou podle jejich mínění vý-znamné. V mnoha případech dochází ke „zjednodušení“ komplexnosti prožitého do podoby vyprávění drobné události se zlomovým významem. Cílem textu je zaměřit se pouze na zlomové události popisující profesní neúspěch učitele v úspěšné dráze učitele experta a podívat se na to, jak učitelé experti zpětně popisují své dílčí neúspěchy a problémy a jak tyto neúspěchy zdůvodňují. Zajímá nás tedy, jaké možné interpretace učitelé těmto zlomovým událostem udělují a jak je interpretuje autor textu.

Une technique de recueil de données qualitatives peu utilisée en SIC, la technique des incidents critiques, a été utilisée au cours d'une étude menée auprès de 62 cadres sur leurs pratiques de connexion aux outils de communication mobiles. Reposant sur la narration d'événements critiques en lien avec les usages des TIC, les résultats mettent en évidence les apports et les limites de cette méthode.

In this collaborative autoethnographic piece, we present voices through critical incident technique replaying the same event at an academic conference, all seeking to understand how and why the disruption of voice occurs and what to do to counter it. We contextualize these experiences in the ideal of "sustainability of qualitative inquiry" through a feminist reflexive process, problematizing the potential for critical qualitative inquiry. We question how ownership of power, knowledge, education and voice within academic spaces can be embodied by women and other underrepresented groups. In the end, we provide a set of three potential solutions for conference committees and individuals to critically self-reflect upon to create more social justice in qualitative research spaces. Such considerations are particularly important in times of social distancing, where considerations for inclusivity for all are imperative.

Background and aim of the study: Nursing students are at high risk of injury while on clinical placement. The incidence of injury is three times higher in comparison to other healthcare workers, with a prevalence ranging from 25% up to 33,2%. Lack of knowledge and of experience in delivering nursing care, anxiety and unfamiliarity with the clinical environment all represent risk factors for injury. This study describes the number and type of injuries occurring in an organizational setting where nursing students are trained in simulation laboratories before being exposed to a real clinical environment. Methods: An eight year retrospective observational study (2009 to 2017) was conducted on a non-probabilistic population of 1,403 nursing students from a university in the north of Italy. Incident reports were anonymised and entered in a database. Results: Overall the percentage of students who reported an injury (6,2%) was much lower than the one reported in the literature. Conclusions...

Being the target of constant discrimination and marginalization can often cause intense negative psychological reactions and shame for undocumented students. The following qualitative study describes past and current undocumented Latinx students’ experiences of educational inequality in higher education influenced by labels associated with “being undocumented.” In this study we used a constructivist theoretical perspective which enabled us to focus on undocumented participants’ perspectives, experiences, meaning-making processes, values, and beliefs. Data was collected through hour-long, semi-structured interviews with five undocumented students. Student narratives were analyzed using a multi-layered analysis approach: (1) narrative, (2) thematic, and (3) critical incident analysis. Findings for this study provided insight on the narratives of carrying labels, themes associated with various labels, and critical incidents in the narratives and lives of undocumented students. Through ...

This article explores the reflections of critical incidents of eight beginning English as a foreign language teachers and one of their trainers in Mexico. Based upon narrative inquiry and through the use of journals, critical incidents and how they have impacted beginning teachers in their thinking were specifically looked at. From the data we found seven emerging themes which basically revolve around the relationships that are established between the teacher and the students, the emerging professional identities of the beginning teachers, and the tutor’s reflection on knowledge transfer. Results showed how these teachers reflected upon their teaching practice and how the critical incidents helped them to analyze and evaluate their teaching process.

6 Dec 2020
The September 11, 2001 terrorist attack was the largest and deadliest terrorist incident in history. Law enforcement officers, firefighters and the media, who have always been distinguished by controversial and hostile relations, then showed an exemplary example of cooperation and mutual assistance. All forces were concentrated on rescuing people and delivering information about the number and names of the dead and wounded, as well as the reasons for the attack. However, the following actions of these structures, which in the first place should have been focused on suppressing the general panic and fear, unfortunately, did not contribute to this. The media continued to broadcast dramatic stories, and law enforcement officers continued to make emotional statements. As a result, the panic became paranoia and lasted for years, and even now it is present, followed by many multimillion dollar innovations at airports with additional levels of security and a common American prejudice and intolerance towards Muslims.