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.

Development of process control methodology for tracking the quality and safety of pain, agitation and sedation management in critical care units

Objective: To develop sedation, pain, and agitation quality measures using process control methodology and evaluate their properties in clinical practice. Design: A Sedation Quality Assessment Tool was developed and validated to capture data for 12-hour periods of nursing care. Domains included pain/discomfort and sedation-agitation behaviors; sedative, analgesic, and neuromuscular blocking drug administration; ventilation status; and conditions potentially justifying deep sedation. Predefined sedation-related adverse events were recorded daily. Using an iterative process, algorithms were developed to describe the proportion of care periods with poor limb relaxation, poor ventilator synchronization, unnecessary deep sedation, agitation, and an overall optimum sedation metric. Proportion charts described processes over time (2 monthly intervals) for each ICU. The numbers of patients treated between sedation-related adverse events were described with G charts. Automated algorithms generated charts for 12 months of sequential data. Mean values for each process were calculated, and variation within and between ICUs explored qualitatively. Setting: Eight Scottish ICUs over a 12-month period. Patients: Mechanically ventilated patients. Interventions: None. Measurements and Main Results: The Sedation Quality Assessment Tool agitation-sedation domains correlated with the Richmond Sedation Agitation Scale score (Spearman [rho] = 0.75) and were reliable in clinician-clinician (weighted kappa; [kappa] = 0.66) and clinician-researcher ([kappa] = 0.82) comparisons. The limb movement domain had fair correlation with Behavioral Pain Scale ([rho] = 0.24) and was reliable in clinician-clinician ([kappa] = 0.58) and clinician-researcher ([kappa] = 0.45) comparisons. Ventilator synchronization correlated with Behavioral Pain Scale ([rho] = 0.54), and reliability in clinician-clinician ([kappa] = 0.29) and clinician-researcher ([kappa] = 0.42) comparisons was fair-moderate. Eight hundred twenty-five patients were enrolled (range, 59-235 across ICUs), providing 12,385 care periods for evaluation (range 655-3,481 across ICUs). The mean proportion of care periods with each quality metric varied between ICUs: excessive sedation 12-38%; agitation 4-17%; poor relaxation 13-21%; poor ventilator synchronization 8-17%; and overall optimum sedation 45-70%. Mean adverse event intervals ranged from 1.5 to 10.3 patients treated. The quality measures appeared relatively stable during the observation period. Conclusions: Process control methodology can be used to simultaneously monitor multiple aspects of pain-sedation-agitation management within ICUs. Variation within and between ICUs could be used as triggers to explore practice variation, improve quality, and monitor this over time