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.

Deconstructing 'Mono'-Lingualism: considerations of value for 'English' 'language' education in a global setting.

Traditionally, language speakers are categorised as mono-lingual, bilingual, or multilingual. It is traditionally assumed in English language education that the ‘lingual’ is something that can be ‘fixed’ in form, written down to be learnt, and taught. Accordingly, the ‘mono’-lingual will have a ‘fixed’ linguistic form. Such a ‘form’ differs according to a number of criteria or influences including region or ‘type’ of English (for example, World Englishes) but is nevertheless assumed to be a ‘form’. ‘Mono-lingualism’ is defined and believed, traditionally, to be ‘speaking one language’; wherever that language is; or whatever that language may be. In this chapter, grounded in an individual subjective philosophy of language, we question this traditional definition. Viewing language from the philosophical perspectives such as those of Bakhtin and Voloshinov, we argue that the prominence of ‘context’ and ‘consciousness’ in language means that to ‘fix’ the form of a language goes against the very spirit of how it is formed and used. We thus challenge the categorisation of ‘mono’-lingualism; proposing that such a categorisation is actually a category error, or a case ‘in which a property is ascribed to a thing that could not possibly have that property’ (Restivo, 2013, p. 175), in this case the property of ‘mono’. Using this proposition as a starting point, we suggest that more time be devoted to language in its context and as per its genuine use as a vehicle for consciousness. We theorise this can be done through a ‘literacy’ based approach which fronts the context of language use rather than the language itself. We outline how we envision this working for teachers, students and materials developers of English Language Education materials in a global setting. To do this we consider Scotland’s Curriculum for Excellence as an exemplar to promote conscious language use in context.