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.

Breaking the Rules: writing reflectively for yourself.

The rules which epitomise good writing may on occasions be broken, deliberately and with what the writers judge to be good purpose. This can well occur when students or staff set out to engage effectively with their personal and professional development, through personal reflection on and in experiences. They may do this in what has been called “stream of consciousness” writing, which is deliberately compiled in a manner at variance with the general rules for best practice. The rationale for such an unusual decision, namely to engage in what is frankly disorderly writing, is set out briefly in this chapter. Its characteristics are summarised, in implicit contrast with more conventional styles of writing. Examples are included of claims for the effectiveness of this style when used for developmental purposes by students and staff; and reference is made to the publications of some of those who have endorsed this approach.

An ethnographic interpretation of the work environment within a creative culture in the advertising sector.

Purpose and rationale The purpose of the exploratory research is to provide a deeper understanding of how the work environment enhances or constrains organisational creativity (creativity and innovation) within the context of the advertising sector. The argument for the proposed research is that the contemporary literature is dominated by quantitative research instruments to measure the climate and work environment across many different sectors. The most influential theory within the extant literature is the componential theory of organisational creativity and innovation and is used as an analytical guide (Amabile, 1997; Figure 8) to conduct an ethnographic study within a creative advertising agency based in Scotland. The theory suggests that creative people (skills, expertise and task motivation) are influenced by the work environment in which they operate. This includes challenging work (+), work group supports (+), supervisory encouragement (+), freedom (+), sufficient resources (+), workload pressures (+ or -), organisational encouragement (+) and organisational impediments (-) which is argued enhances (+) or constrains (-) both creativity and innovation. An interpretive research design is conducted to confirm, challenge or extend the componential theory of organisational creativity and innovation (Amabile, 1997; Figure 8) and contribute to knowledge as well as practice. Design/methodology/approach The scholarly activity conducted within the context of the creative industries and advertising sector is in its infancy and research from the alternative paradigm using qualitative methods is limited which may provide new guidelines for this industry sector. As such, an ethnographic case study research design is a suitable methodology to provide a deeper understanding of the subject area and is consistent with a constructivist ontology and an interpretive epistemology. This ontological position is conducive to the researcher’s axiology and values in that meaning is not discovered as an objective truth but socially constructed from multiple realties from social actors. As such, ethnography is the study of people in naturally occurring settings and the creative advertising agency involved in the research is an appropriate purposive sample within an industry that is renowned for its creativity and innovation. Qualitative methods such as participant observation (field notes, meetings, rituals, social events and tracking a client brief), material artefacts (documents, websites, annual reports, emails, scrapbooks and photographic evidence) and focused interviews (informal and formal conversations, six taped and transcribed interviews and use of Survey Monkey) are used to provide a written account of the agency’s work environment. The analytical process of interpreting the ethnographic text is supported by thematic analysis (selective, axial and open coding) through the use of manual analysis and NVivo9 software Findings The findings highlight a complex interaction between the people within the agency and the enhancers and constraints of the work environment in which they operate. This involves the creative work environment (Amabile, 1997; Figure 8) as well as the physical work environment (Cain, 2012; Dul and Ceylan, 2011; Dul et al. 2011) and that of social control and power (Foucault, 1977; Gahan et al. 2007; Knights and Willmott, 2007). As such, the overarching themes to emerge from the data on how the work environment enhances or constrains organisational creativity include creative people (skills, expertise and task motivation), creative process (creative work environment and physical work environment) and creative power (working hours, value of creativity, self-fulfilment and surveillance). Therefore, the findings confirm that creative people interact and are influenced by aspects of the creative work environment outlined by Amabile (1997; Figure 8). However, the results also challenge and extend the theory to include that of the physical work environment and creative power. Originality/value/implications Methodologically, there is no other interpretive research that uses an ethnographic case study approach within the context of the advertising sector to explore and provide a deeper understanding of the subject area. As such, the contribution to knowledge in the form of a new interpretive framework (Figure 16) challenges and extends the existing body of knowledge (Amabile, 1997; Figure 8). Moreover, the contribution to practice includes a flexible set of industry guidelines (Appendix 13) that may be transferrable to other organisational settings.