can be mitigated by triangulation Oswald et al 2014 Evident here

can be mitigated by triangulation (Oswald et al, 2014). Evident here, as several methodological approaches were used such as open and closed-ended questionnaires and focus groups; adding vigour and validity. The author attempted reflexivity by demonstrating awareness of bias and endeavouring to limit opinions by acknowledging multiple interpretations of situations (Ferdinand,2018).AnalysisHägglund’s (2010) adopted a qualitative content analysis method, whereas Vethanayagam et al(2016) used Thematic content analysis. Vaismoradi et al (2013) admit that differentiating between these can be complex; explaining that they are both appropriate when low levels of interpretation are needed; as opposed to grounded theory methods. Content analysis can describe phenomenon from the beginning when no previous work has been done (Elo and Kyngas,2008) and seeks themes emerging from dialogue which are coded to enable interpretation to allow retrieval (Pope and Mays, 2009), however, (Vaismoradi et al (2013) warn that themes can emerge merely based on frequency of occurrence. Clarke (2017) advise that themes should not simply be a collection of commonly used words but should seek to find implicit meanings. Whereas, Pope and May(2009) say thematic analysis is the most common, user-friendly form of analysis picking out predictable and non-predictable themes emerging from transcripts or ‘stories’ (Vaismoradi et al,2013). These can be explored in more details if less themes are used (Clarke,2017). Vethanayagam et al(2016), achieved this as they explored 3 key themes in detail. Vethanayam et al’s(2016) Emerging themes were: Finding GPs dismissive, Having to endure it, Embarrassment, normalising UI and ignorance of treatment options and feeling ‘Something has to be done’. Some participants had been diagnosed incidentally during falls or comprehensive geriatric assessments (Vethanayam et al,2016). This is transferrable to practice due to the potential for the LTC service to identify UI by proactive use of caseload management models used in implementing, holistic, personalised care plans (DoH, 2005). Two themes emerged in Hägglund’s (2010) study; Nurses with scheduled appointments reported perceptions of professionalism and improved patient’s well- being and service-engagement. Whereas, those providing unscheduled services reported feeling inadequate. DNs struggled to deliver care alongside other commitments and continence wasn’t prioritised. Time constraints and lack of continence training meant continence care was perceived as burdensome. This study is transferable to practice as time constraints experienced by services appears widespread (Turnball, 2017), echoing why they find continence care unrewarding. Therefore, implementing scheduled visits could help improve outcomes. Validity of Ferdinand’s (2018) study is ambiguous as study methods are not adequately explained. They attempted to examine participants ‘knowledge’ but realistically only examined ‘self-perceptions’ and not actual knowledge. For example, the question ‘How confident are you in…?’ (Ferdinand, 2018) does not add insight into what participant’s know. Participants scored themselves highly; but may have wanted to appear knowledgeable; being continence students. This is social desirability bias, which Farnsworth (2016) says occurs when participants behave to impress researchers. This author suggests this is avoidable when participants don’t meet researchers, but here only the researcher appears to be observing groupwork, collecting data and transcribing discussions.Potential for bias is possible as maximum variation sampling wasn’t used as suggested by CEBM (2019). Ferdinand (2018) used convenience sampling; only providing participants’ professions. Hägglund (2010) and Vethanayagam et al (2016) use considerably more females and no ethnic diversity; narrowing variables which could reduce transferability. Furthermore, Ferdinand (2018) does not reflect the experiences of all community-based nurses. However, Smith (2018) refutes suggestion that qualitative research is unreliable for lack of transferability and stresses that to achieve naturalistic generalizability, researchers need to provide readers with enough evidence to choose if study is relatable. Shenton (2004) agrees that it is the readers responsibility to choose appropriate studies that are transferable to practice. Translation to practice PARiHS (Promoting Action on Research Implementation in Health Services) framework (Kitson et al, 2008) was applied to guide thinking. Using this template, Vethanayagam et al (2016) study was deemed most translatable to practice with 8 points; ranging to Ferdinand (2018) with 3.25. Although arguably, reliability of this tool is questionable. Critics admit that elements of PARIHS (Kitson et al, 2008) are ambiguous and subjective, resulting in different interpretations by different users (Stetler et al, 2011).Revoking recent organisational policy change for continence care to be exclusively provided by continence service (Livewell Southwest, 2019) is unrealistic as this policy has recently been implemented. However, evidence supports arguments for small changes in practice affecting frail patients with co-morbidities under the care of the LTC service. CM’s are advanced practitioners who perform in-depth assessments to develop goals and management plans using pre-determined pathways (DoH, 2005) as such are competent in assessing the impact of bladder and bowel dysfunction on individuals. Vethanayagam et al (2016) demonstrated the importance of professional assessments such as the multifaceted Comprehensive Geriatric Assessment (Wieland and Hirth, 2003) in diagnosing UI when it could previously have remained undiscovered. APPGC (2013) agrees that active questioning is vital to obtain information that patients may be too embarrassed to disclose. This is further compounded by Martin et al’s (2006) who concluded that UI can be correctly diagnosed in primary care from clinical history alone. This can be facilitated in practice opportunistically by CMs whilst completing routine assessments that enable UI to be identified. Whilst Fritel et al (2017) had to conclude interventions improved QOL but not symptoms it is important to recognise that increased autonomy is beneficial and achievable within the CM role.opportunity to facilitate conversations which would be otherwise avoided. According to the PARHiS (2008) framework self-assessment tool the evidence found ranged from useful to more anecdotal evidence which didn’t inform practice that much.More research is needed to show if specialist services are deskilling general nurses as well research to address in more detail, such as UI and its effects on the frail or how continence care can be applied to the role of the CM. Virtual Wards operate using a multidisciplinary team (MDT) approach, to case-find vulnerable people who may otherwise go undetected (Lewis et al, 2017). This platform could be further utilised by CMs and MDT for detecting frail UI sufferers. Vethanayagam et al (2016) highlighted that participants felt GP’s were dismissive about UI. The Virtual Ward approach could help the MDT recognise the debilitating and impactive consequences of UI (Agnew and Booth, 2008). This literature review did not explore the continence provision from the perspectives of CM as intended. Instead evidence only reflected DN perspectives which has different constraints to the LTC service (Drennan, 2014). For example: Hägglund (2010) demonstrated professionalism and competence was enhanced in clinicians given scheduled timed visits to perform assessments. Unlike the DN service the LTC service has opportunities to perform scheduled assessments due to more manageable caseloads (Maybin et al,2016). Whereas the evidence from Hägglund (2010) supports DNs not carrying out continence care due to other constraints and stress that entails. Further research is required to ascertain continence care provision by CMs. More stringent research is needed to ascertain why professionals find continence care burdensome and lack confidence in delivering it. Hägglund (2010) and Ferdinand (2018) found that organisations do not provide adequate training and time for continence care was not prioritised. Terzoni et al (2011) and APPGCC (2013) Agree that organisations should support nurses to build competence in continence care and agree that continence education is ranked as low priority. However, despite presenting logical argument, Ferdinand’s (2018) study appeared largely anecdotal and did not provide sufficient evidence to use to change practice. Study was also poorly transferable as discussed in critical appraisal. Therefore, more robust evidence would be required to evaluate how nurses across all demographics felt about continence competence. Upon reflection it appears the question is too broad to covered comprehensively by limited scope of review. As discussed the evidence varies in validity and relevance to the topic of whether continence care leads to better outcomes depending on if its delivered by Primary care or specialist continence services. Conclusion

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