A rehabilitation intervention to promote physical recovery following intensive care: a detailed description of construct development, rationale and content together with proposed taxonomy to capture processes in a randomised controlled trial.

Background: increasing numbers of patients are surviving critical illness, but survival may be associated with a constellation of physical and psychological sequelae that can cause on going disability and reduced health-related quality of life. Limited evidence currently exists to guide the optimum structure, timing, and content of rehabilitation programmes. There is a need to both develop and evaluate interventions to support and expedite recovery during the post-ICU discharge period. This paper describes the construct development for a complex rehabilitation intervention intended to promote physical recovery following critical illness. The intervention is currently being evaluated in a randomised trial (ISRCTN09412438; funder Chief Scientists Office, Scotland). Methods: the intervention was developed using the Medical Research Council (MRC) framework for developing complex healthcare interventions. We ensured representation from a wide variety of stakeholders including content experts from multiple specialties, methodologists, and patient representation. The intervention construct was initially based on literature review, local observational and audit work, qualitative studies with ICU survivors, and brainstorming activities. Iterative refinement was aided by the publication of a National Institute for Health and Care Excellence guideline (No. 83), publicly available patient stories (Healthtalkonline), a stakeholder event in collaboration with the James Lind Alliance, and local piloting. Modelling and further work involved a feasibility trial and development of a novel generic rehabilitation assistant (GRA) role. Several rounds of external peer review during successive funding applications also contributed to development. Results: the final construct for the complex intervention involved a dedicated GRA trained to pre-defined competencies across multiple rehabilitation domains (physiotherapy, dietetics, occupational therapy, and speech/language therapy), with specific training in post-critical illness issues. The intervention was from ICU discharge to 3 months post-discharge, including inpatient and post-hospital discharge elements. Clear strategies to provide information to patients/families were included. A detailed taxonomy was developed to define and describe the processes undertaken, and capture them during the trial. The detailed process measure description, together with a range of patient, health service, and economic outcomes were successfully mapped on to the modified CONSORT recommendations for reporting non-pharmacologic trial interventions. Conclusions: the MRC complex intervention framework was an effective guide to developing a novel post-ICU rehabilitation intervention. Combining a clearly defined new healthcare role with a detailed taxonomy of process and activity enabled the intervention to be clearly described for the purpose of trial delivery and reporting. These data will be useful when interpreting the results of the randomised trial, will increase internal and external trial validity, and help others implement the intervention if the intervention proves clinically and cost effective.

Festival Images: brand image and stakeholders' brand relationship types at the Edinburgh Festival Fringe.

The Edinburgh Festival Fringe (The Fringe) is the largest arts festival in the world and it has inspired the creation of similar festivals world-wide. Since its conception in 1947, the Fringe has demonstrated significant growth in visitor numbers; ticket sales; and its economic contribution. Despite this, the sustainable future of Edinburgh’s festivals is debated as Edinburgh, ‘the Festival City’, faces threats from other festival destinations. Festivals position Edinburgh creatively in contrast to the city’s traditionally perceived image as a cultural-historic centre. Despite this, little research has been undertaken into the creative and cultural significance of Edinburgh’s festivals, including the Fringe. This interdisciplinary research grounded in marketing, tourism, and festival and event management; and underpinned by constructivism, presents an understanding of types of brand relationships that exist between the Fringe and its primary stakeholders. This is achieved through defining both the Fringe brand image and its primary stakeholders; and applying these definitions to the development of a typology of Fringe-stakeholders’ brand relationships. The significance of this study is evident within its topic of inquiry and the research methods applied. In the little-considered arena of arts festivals and their stakeholders, this is the first in-depth study into the Fringe as a festival and festival brand. Within this, the definition of a Fringe brand image contributes to understanding the cultural and creative significance of the Fringe. Furthermore, this research contributes a unique understanding of the types of stakeholders that are engaged with the Fringe. The types of brand relationships that exist between these stakeholders and the Fringe are another significant contribution to knowledge and understanding. While specific to the present context, these findings may prove transferable to further festivals or events, and related areas and industries. The contribution made by this research to the methodological developments in festival and event studies is of additional significance. The application of visual research methods, including semiotic analysis and photo-elicitation within phenomenological interviews, has previously been applied in marketing, consumer, and tourism research, but not to the understanding of festival brands and stakeholders’ brand relationship types. Findings of this research illustrate that existing marketing and consumer brand frameworks and stakeholder theories are applicable to festivals. Further, it is possible to define ‘a’ Fringe brand image which is subjective and contradictory. The unique open-access and organic, operational model of the Fringe facilitates its many contributors, and consumers. Fringe stakeholders may be categorised according to their level of engagement with the Fringe (as primary or secondary) and their particular stakeholder role(s), which are varied and multiple. Fringe-stakeholder brand relationship types are overwhelmingly positive; and are based upon interpersonal relationship dimensions (including friendships, marriages, kinships and partnerships). Fringe-stakeholder brand relationship types can be classified therefore as having similar dimensions to those brand relationship types previously described for consumer products and brands.