Maggie Williams
email: maggie.williams@ghnt.nhs.uk

Lorna Green

BSc (Hons) a. Lorna Green RN. BSc Maggie Williams Rgn

Hons Karen

Exploring the Needs and Expectations of Women Presenting for Hysterosalpingogram Examination Following a Period of Sub Fertility: -A Qualitative Study

Exploring the Needs and Expectations of Women Presenting for Hysterosalpingogram Examination Following a Period of Sub Fertility: -A Qualitative Study

findings are that if anxiety relating to treatment at this early stage can be managed effectively it could minimise the possible physical and emotional trauma to the woman as her sub fertility journey continues, thus at the same time preventing future anxiety related illness.

Introduction

HSG provides an assessment of both Fallopian tube and uterine causes of infertility [START_REF] Thurmond | Imaging of female infertility[END_REF]. It is performed in a Radiology department under the direction of a team led by a doctor or suitably trained nurse or radiographer. Additionally there is a nurse to look after the patient and a radiographer in the team. In recent years HSG has been undertaken by nurses or radiographers who are in a position to influence the quality of the patient experience. The nurse practicing at this advanced level can use that position to improve communication leading to an enhanced patient experience and a seamless episode of care.

Despite advances in the treatment of sub fertility, semen analysis, hormone determination and HSG are still seen as leading diagnostic investigations before any fertility treatment is decided upon. [START_REF] Smith | Diagnosis and Management of Female Infertility[END_REF]. At present women are seen in Gynaecology Out Patients' Clinic and at this appointment are referred for some or all of the above investigations. At the same time written and verbal information is given by nursing and medical staff. How well women cope following this initial out patient appointment can depend upon their ability to absorb this information. Variables can exist that include the experience of the referring clinician, whether the attending nurse has specialist knowledge and any previous patient experience within healthcare.

For some years now nurses have increasingly been taking the lead role in HSG and contributing to the increasing numbers performed, more than doubling at Gateshead Health NHSF Trust between 2003-09. Review of the online information surrounding HSG for many hospitals shows the patient is told that the procedure is quite likely to be carried out by a nurse. This is the case in Gateshead Health NHSF Trust and is a natural progression of the advanced nursing role and is seen as appropriate in most quarters. Regardless who performs the procedure the clinical question about continuity of care is; 'do we address patient anxiety and do we provide a seamless episode of care from the out patient appointment to the completion of the HSG?'

A previous medical study, by Tyrell et al in 1993, sixteen years ago, asked about emotional issues for the women surrounding the HSG examination. One aim of this study is to see if time has changed any of those issues. Nurses working as independent practitioners performing HSG examinations can support their work by contributing to the body of qualitative knowledge in this way.

Literature Review

A review of the literature showed that very little work had been undertaken looking at the issues of HSG since 1993 when patient's perceptions were examined by Tyrell.

All of the studies focused around the emotions of patients or their satisfaction level with the total package of infertility treatment including IVF. [START_REF] Souter | Patient Satisfaction with the Management of Infertility[END_REF]) (Oddens, Tonkelaar & Niewenhuyse.1999). Oddens study found that infertility as a 'life event' was seen as severe. Given that HSG is part of the sub fertility investigations we wanted to consider the severity of this event to the women during the specific time covering HSG examination. It was previously discovered that at the time of HSG anxiety levels associated with this examination were high.

(Tyrell 1993) Sub fertility is shown to be a cause of grief as well as stress from the start of the process. In all walks of life the literature shows that stress occurs during life events even if the individual does not recognise it at the time, possibly giving an indication for the future episodes of anxiety, as described by [START_REF] Shevrin | Events -Related Markers of Unconscious Processes[END_REF] Van Den Hout (1995) [START_REF] Kemp-Wheeler | Anxiety Responses to Subliminal Experience of Mild Stress[END_REF]. Long before IVF is considered there are many questions that need to be answered. [START_REF] Smith | Diagnosis and Management of Female Infertility[END_REF] Some couples will progress to be offered IVF treatment. Cassidy & Sinttrvani (2008) recommended stress reduction interventions for these couples. Ramezanzedeh et al (2004) looked at a group of 370 women infertile for between 1 and 20 years. Results showed that 40% of women had depression and 86% had anxiety. Depression was most common after 4 to 6 years of infertility and severe depression in years 7 -9 years. The study concluded that attention should be given to women's psychological health and 'treating them properly' was a great advantage to their mental health. When looking at the psychological and emotional effects of sub fertility [START_REF] Hamdieh | The effect of Provision of Information Regarding Infertility Treatment Strategies on Anxiety Levels of Infertile Couples[END_REF] showed a correlation between information giving and reduced anxiety. Following a session of face to face information giving along with a provision of written information at follow up, there was a 'significant' reduction of anxiety. This duel strategy is supported by [START_REF] Timmins | Exploring the Concept of Information Need[END_REF]. Information giving was seen as vital by Timmins who showed that written information is not sufficient for a full understanding of an invasive procedure. It showed a women's natural coping mechanism is to seek out information in response to a specific problem. Written information alone is not enough. Successful information giving requires the input of nursing and medical staff personally to support written and other material. Malin, Hemminki, Raikkonen, Sihvo& Perela (2001) report that the most positive treatment experience was 'respectful, empathetic and personal care from the doctor'. A higher percentage of dissatisfaction with treatment was found in this study group than in the general population. The most common cause for dissatisfaction was found to be negative treatment experiences. The authors state that this dissatisfaction could reflect the relatively young healthy women's assertive attitude towards infertility care services and the vulnerability and intimacy associated with childlessness. These women's only reason to be in healthcare is the inability to become pregnant. Anxiety reducing strategies at the time of procedure have been researched by radiographers and showed that music can reduce anxiety during a HSG. (Agwu and Okoya 2007). In this study patients were asked to bring music of their choice. In the experimental group of women, music reduced the physiological and cognitive responses of anxiety. It was found that the blood pressure and pulse rate of women in the control group was higher than that of women in the group listening to music. Women's willingness to return for repeat procedures was also more positive in the experimental group. The specific radiology literature in most parts goes no further than describing an HSG [START_REF] Jones | Imaging for Nurses[END_REF] or the merits of HSG as compared with other forms of imaging. [START_REF] Fatum | Investigation of the Infertile Couple[END_REF] As regards the psychosocial impact of sub fertility, Covington and Hammer Burns, (2000) show sub fertility to be a taboo subject, not easily discussed. Sub fertility is an experience that alters an individual's identity and sense of self. This is caused by feelings of deficiency, hopelessness and shame. In society it is seen as a failing to fulfil personal and societal roles. [START_REF] Unruh | The Psychology of female infertility: Toward a new perspective[END_REF] As part of the 'medicalization of infertility' [START_REF] Newton | Motives for Parenthood and response to Failed in vitro Fertilization: Implications for Counselling[END_REF] healthy, yet childless, women become patients and undergo HSG. Due to the increasing number of women having to submit to this process, it was decided to investigate as a follow up to the 1993 Tyrell study what is uppermost in the minds of women attending for an HSG and if their anxiety level has increased or decreased since that study. These previous papers help to focus the work of this study questioning; do the documented problems with anxiety and anxiety related illness still occur? How early in the infertility pathway are these symptoms present? Can they be addressed at an earlier stage in women's care, and how?

Aims of the study

To understand the specific needs of this group of women at this point in their care.

To add to the knowledge within the field of sub fertility treatment. Discover the underlying issues and anxieties that women have at the start of sub fertility investigations Raise awareness of the need for research by nurses in areas where they are practicing at an advanced level.

Research Design and Method

This exploratory study used a qualitative methodology to examine if women had sufficient information prior to HSG examination to meet their needs at this time.

Grounded theory methodology was appropriate given the sensitive nature of the topic. [START_REF] Glazer | L The discovery of Grounded Theory: Strategies for qualitative research[END_REF]. This research approach allows information to develop inductively and for common themes to emerge as the data is collected and analysed. Data was collected through semi-structured interviews. A set of 12 core questions were devised that would allow the use of semi structured interviews. The questions guided the researchers to gain information in the following areas. Firstly the background to the woman's sub fertility history, secondly the expectations of the women and finally the importance of HSG, and the availability of both health service support and informal friend and family support. Each interview was analysed and common themes emerged and were identified. Interview data was coded and analysed until data saturation had been achieved. When each interview had taken place and been analysed, it was then assessed as to whether any new information had been obtained. After eight interviews it became clear that there were no new themes.

To consolidate an additional two interviews were conducted. At the end of ten interviews it was evident that the data collection could stop. Now it was certain that no new theme would emerge the researchers could argue that data saturation had been achieved. [START_REF] Ashworth | Qualitative research in psychology[END_REF]

Sampling and recruitment

The study was carried out within the Radiology Department at Gateshead Health NHSF Trust. Referrals for HSG were received from Trust Consultants. All referrals were screened by the senior nurse to assess suitability for inclusion in the study. Prospective candidates were required to have a diagnosis of sub fertility. All women identified as meeting the criteria were sent an information pack explaining the proposed research. The information pack contained a patient information sheet and consent forms.

Within seven days the prospective candidate was contacted via telephone. If further information was required this was then given. Recruitment proved more difficult than expected. The participants in the study were women between the ages of 27 and 39 years. The status of women in the target group is otherwise young and healthy. They all had employment and busy lives. During the day it was difficult to reach them by phone in a situation in which private conversation could take place. On occasions it proved impossible to make contact with the patient in the short space of time before they presented for HSG.

When a woman agreed to an interview it had to be at a time and a place convenient to the women. This required evening and weekend interviews. Most women looked for a time when the partner was not present. No partners were present at any of the interviews. For the purpose of this study only the women were approached. 16 women were contacted to take part and 10 women were eventually interviewed. Although two women did not go on to have HSG because they fell pregnant naturally, at the time of interview these two women had no knowledge that they would not need to progress to HSG. It did not become apparent that they were pregnant until they failed to menstruate. Therefore these two interviews were valid and were not excluded from the sample. Women declined for a number of reasons. These included the number of hours they were working, not thinking 'it was for them' and other family issues resulting in little free time. The lack of research in this area may suggest that others have also found this group of patients difficult to engage. It is therefore a challenge to the health service to look at ways of resolving this. Overall the women who were contacted were extremely positive about the research, commenting that although this research would not benefit them personally, it would "benefit women in the future".

Data collection

When women agreed to take part, arrangements were made for a researcher to visit them at their home or suitable location. Allowing the women to choose a location for the interview was found to be the favourable strategy as women tended to relax in their chosen environment. 9 interviews were conducted in the home and one interview was conducted within the hospital. Interviews lasted for approximately 60 to 90 minutes.

For continuity all interviews were carried out by the same researcher. The interviews were tape recorded and transcribed as soon after interview as possible. Brief memo notes were also taken during the interview and immediately after each interview to contextualise circumstances that may prove important when data analysis took place.

At the end of each interview the women were given a card with contact details of the researcher. Women were told that they could contact the team with any additional information they wished to give or if they needed to discuss any issue. Kelle and Seldel (1995) states the codes act as collective pointers to the themes. The analysis of the data, as described above led to the emergence of four themes. They all link to the core category of anxiety.

Theme Emergence Theme 1. HSG is seen as an important examination and a defining moment .At this time attention was focused away from conception and transferred to anxiety surrounding the HSG procedure.

The prominent theme that emerged with all candidates was that HSG is an important examination. All of the women rated the importance of HSG between 8 and 10. 10 on the scale rated as the most important. The women described HSG as a defining examination. Most saw HSG as important and something that had to be ".gone through" in order to ".find out what is wrong." Women felt that without knowing the results of an HSG then no progress could be made to eventual conception. (See table 3)

Most of the participants felt the HSG was the thing that was uppermost in their minds. Fear and anxiety associated with the process of the HSG shifted their focus away from the reason for the examination being required, the desire to become pregnant. All understood that in order to be able to progress to further treatment this procedure had to be endured not matter how unpleasant. When discovering the detail of the procedure one woman stated that she 'was horrified'.

Theme 2. A delay in gaining an appointment. We live in an 'I want it now society.'

For some of the women in the sample it took an average of two cycles to actually get an appointment for their HSG. Because of the nature of the examination normal rules for waiting lists do not apply. It is important that prior to the procedure the patient is not unknowingly pregnant. Each examination needed to be carried out after menstruation has stopped but before day 10 of the menstrual cycle.

If an appointment could not be given during this window, women had to wait until their next cycle. Women who had been waiting for up to two years for answers to their sub fertility before referral for HSG found this very frustrating (table 3). The women in the study had waited for up to 4 years. Some of the women stated that if 1. HSG is seen as an important examination and a defining moment. At this time attention was focused away from conception and transferred to anxiety surrounding the HSG procedure. 2. A delay in gaining an appointment. We live in an 'I want it now society.' 3. Sub fertility was not a subject to be discussed openly. A taboo subject to be kept private. 4. Written information leaflets do not meet all of the needs of the women and information is often gained from family and close friends rather than healthcare workers. they were given an explanation as to why they could not get an appointment this would have made the waiting easier. One woman stated her unresolved frustrations were '.getting an appointment-it's just the NHS' Theme 3. Sub fertility was not a subject any wanted to discuss openly -a taboo subject.

This research has established that women still see sub fertility as a subject that is kept private. In their book 'Infertility Counselling', Covington and Hammer-Burns (2000) state that '…in all cultures involuntary childlessness is recognized as a crisis that has the potential to threaten the stability of individuals, relationships, and communities' It would seem that from listening to the women they experience a loss of well-being and self-confidence as a result of the loss of privacy and control of their own body (table 3).

Also they experience the anticipatory grief of the possibility of being left without a child. (Saunders 1989). Studies have shown that infertile women have feelings of defectiveness and worthlessness as well as shame and guilt. (Unrch and McGrath 1985) In our society where cancer, aids and heart disease are talked about openly, sub fertility which takes many persons by surprise has been left behind as a taboo subject for discussion.

Theme 4. Written information leaflets do not meet all the needs of the women and information is gained from family and close friends rather than healthcare workers

It soon became clear that information giving was coming to the fore as a prominent theme. Most of the women stated that they 'think they know what is going to happen.' On probing, all women had additional questions and issues that were playing on their minds as HSG drew close (table 3). Much anxiety was generated from reading the information leaflet.

The women found that when they later took time to read the information leaflet that was given to them at the Out Patient visit, instead of reassuring them it raised their anxiety and gave them new questions.

One point from the leaflet states that there will be slight bleeding for some time after the procedure. It was verbalised well in this statement. '. The thought of slight bleeding afterwards? I wanted to know well, why? What has happened that is causing the bleeding a little bit afterwards? Because I thought you don't want someone to do something to you that is going to make you bleed.'

One conclusion from the Tyrell (1993) paper was for all women to be supplied with written information before presenting for HSG. It was found that most of the current participants had received written information about HSG. .

It was evident that written information was often not read. Sometimes it was read but misunderstood. At the commencement of an interview the women were asked to get the packs that had been sent to them. Only a minority of participants could find the A delay in gaining an appointment. We live in an 'I want it now society.' 'At the beginning of my cycle I rang and I was told that no appointments were available. I think that this was the worst bit for me because I was so excited about the fact they were doing something' 'The first time I phoned up they could not do anything because they had not got the request, then when I had my period they had no appointments, so I thought to myself will this happen again on my next period?' Sub fertility was not a subject any wanted to discuss openly -a taboo subject.

'I do not want to be the source of other peoples gossip' 'I had horrible thoughts about other people who were pregnant, like you get people saying to you 'oh well children are not everything' but shut up because unless you have been through it you don't know what it is like, it's painful' Written information leaflets do not meet all the needs of the women and information is gained from family and close friends rather than healthcare workers

'There is nowhere at all you can turn. If I did not have my friend who has been through all these procedures.... and my partner who has been supportive and loving' 'I wondered what will the environment be like and who will be there?

Discussion

All of the women wanted to tell their own particular story. Some of the women had pent up feelings which were described as 'why me' or is this 'some kind of punishment'. This was sometimes the first opportunity that they had to voice their anxiety. Anxiety was present as each of the themes emerged. Anxiety around the procedure, the situation that the women found themselves in and anxiety about the outcomes.

At interview it was found that the women had many misplaced worries. Some worried about privacy and dignity while others worried about the possible injection. Most did not understand the concept of the X-Ray equipment or how many staff would be required to facilitate the procedure.

As the interviews progressed it was clear that although they were asked at the Out Patient appointment if they had any questions it was difficult to verbalise specific worries at that time. They had not had the opportunity to reflect upon what had been explained to them or the time to read and digest the written information. After reading the information they found that they had new anxieties, this time around the HSG procedure itself.

It became evident that there were gaps in understanding. These gaps in understanding are the areas that previous studies have highlighted can lead to subliminal experiences of stress [START_REF] Kemp-Wheeler | Anxiety Responses to Subliminal Experience of Mild Stress[END_REF] [START_REF] Van Den | Responding to Subliminal Threat Cues is Related to Trait Anxiety and Emotional Vulnerability[END_REF] If the women are not fully aware of the anxiety that is being experienced this may be a contributing factor to the episodes of depression already described..(Ramezanzedeh 2004) [START_REF] Shevrin | Events -Related Markers of Unconscious Processes[END_REF] pointed out that '..aversive conditioning could be established unconsciously'. The implications are that anxieties can unconsciously act as a forerunner to depression. This can be directly related to the stress and anxiety felt prior to HSG and subsequent sub fertility treatments. Some women suffer a high degree of anxiety that can result in the episodes of depression identified by year 4 of sub fertility. (Ramezanzedeh 2004) An understanding of this process leads this research to point to anxiety reduction as a priority. Anxiety is present at all stages of the patient journey A review of the information leaflet showed that the written information consists of a set of statements. These statements are because nurses consistently aim to provide not only information, but to improve client knowledge that they assume will improve outcomes. [START_REF] Nikolette | Information needs and coping styles of primary family caregivers of women following breast cancer surgery[END_REF] Timmins acknowledged that the need for information is all about coping with events. Each event is unique to an individual, so the information that each individual needs has to be unique to them also. No generic leaflet can cater for all. Although written and other sources of information such as electronic data are likely to be useful the researchers found that a verbal explanation from an informed source was superior. Written information needs the support, guidance and direction of a trained professional in order for it to be beneficial [START_REF] Timmins | Exploring the Concept of Information Need[END_REF].

Each woman had access to the support services, whose details were provided on the information sheet, sent with the research pack. None of the women had contacted either of the organisations. None thought that unless they were desperate they would consider phoning an anonymous help line. This gives a wider scope to the study as the NHS sees it as very necessary that patients be given written information. Many millions of pounds have been spent putting information on websites, printing and sending out leaflets etc; but is this information reducing or raising anxiety in the population? Back In 1993 during the Tyrrell study it was noted by their participants that although written information would be useful it should not replace the explanation and discussion given by the clinician.

It is important that healthcare staff remember that no matter how 'simple' the procedure, the significant meaning to the patient cannot be underestimated. Staff within the radiology department would feel that this service was a good one, particularly considering that the days available within each menstrual cycle may include a weekend when no appointments are available.

During this period of waiting most found that they gained their emotional support from partners, friends and family. In only one case was formal support offered in the form of conversation at the GP surgery. There was little NHS support offered to the women who were interviewed.

Conclusion

This research has demonstrated that at the time of the HSG, women's focus changes from conception, to anxiety about the HSG procedure itself, an invasive 'medical' procedure. Although anxious the participants saw the HSG as a very important examination in their fertility treatment. The opportunity to address women's anxiety at this early stage may help to provide women with an avenue of support and coping mechanisms for their future fertility treatments.

HSG should be seen as an important step in the whole treatment of sub fertility and not just as a diagnostic procedure.

Communication between patients and professionals about waiting times and the women's expectations were also identified and provides Radiology Departments with a challenge to meet this need given the small window of opportunity to appoint these patients.

The effective use of NHS resources at an early stage to address the anxiety needs could save women from emotional distress at the time of HSG and as their treatment progresses. Anxiety reduction at an early stage may save the NHS from the financial burden of treating depression as sub fertility treatment progresses.

Previous literature and data from this study demonstrated that the use of written information needs to be supported by a verbal contact with a member of staff, which can be done via a number of methods such as pre assessment either face to face or telephone.

Despite the modernisation agenda which has undoubtedly bought vast improvements to healthcare, women's needs are often the simplest ones. It is demonstrated here that to allow women the opportunity to discuss the process of sub fertility investigations at an early stage can lead to a reduction in anxiety. Women's feelings are that sub fertility is not spoken about out with the immediate family or friends and sometimes not even with them. The Advanced Practitioner with responsibility for HSG can be the link to provide a seamless service that educates and promotes changes in practice, to ensure that sub fertility is not a taboo subject HSG examinations are increasing in number annually, but the process of the procedure will not change dramatically. What can change for women is the situations and environment surrounding HSG. This study aims to facilitate this change.

Implications for practice

Simply stated when a woman is asked at a Gynaecological Out Patient visit "do you have any questions" she will not have had an opportunity to read an HSG leaflet. She will not know what her specific need for information will become. Practice should reflect:- • Women need access to healthcare professionals to discuss HSG at the earliest opportunity. • Recognition that written information meets only part of the information needs of women. • Sub fertility investigations are rated highly important amongst women. Service providers need to address a possible miss match in perception. • Effort should be made to meet demand for HSG during first menstrual cycle following referral. • Ways should be found to reduce patient anxiety prior to HSG in order to reduce possible later mental health issues.

  submitted to the Research and Development Committee of Gateshead Health NHS Foundation Trust and the local Research Ethics Committee for validation of ethical standards.

  stated they had put it away after the initially reading the information. Only a minority had studied the literature.

Table 2 Interview

 2 Coding started soon after the first interview was completed. As data analysis progressed coding allowed the sorting of data into manageable segments. Constant comparison of established codes with incoming data allowed for the development of new code categories or consolidation of existing categories.Axial coding is the process of relating codes to each other.[START_REF] Strauss | Basics of Qualitative Research[END_REF]

	F o r
	P
	e
	e r
	R
	e
	v i e
	w
	O n l
	y

Questions

1. How did you feel when you found you were to have a HSG examination? 2. Describe to me your expectations from this examination? 3. Do you feel that you know what will happen during the examination? 4. Describe to me what you think will happen after the examination? 5. Describe to me how importantly you would rate the importance of HSG? 6. What is the factor that is uppermost in your mind prior to the examination? 7. How are you dealing with this? 8. Do you have any unresolved frustrations in relation to your experiences so far? 9. Tell me about the formal help you received at this time. I.e. GP, hospital? 10. Tell me about the informal support you are receiving. I.e. family and friends? 11. Tell me about the background to you sub-fertility? 12. How do you feel about being involved in this research? 4. Data analysis p.195). While coding the data, behaviours and specific acts were looked for. Axial coding soon led to a core category. This core category of anxiety soon emerged. It acted as a link entwining each category.

Table 3 Women's Responses

 3

	Theme	Comment 1	Comment 2
	HSG is seen as an	'I really want everything	''My worry is the fear of
	important examination	to be fine and lovely, but	the unknown'
	and a defining moment.	in a way I would be
	At this time attention was	disappointed in the sense
	focused away from	of what is wrong with me...
	conception and	are my tubes fine?' there is
	transferred to anxiety	nothing wrong then what
	surrounding the HSG	is wrong?'
	procedure.

  • Advanced Nurse Practitioners can use the role to enhance education and communication between all specialities involved in the sub fertility field.

	F o r F o r
	P P
	e e
	e r e r
	R R
	e e
	v i e v i e
	w w
	O n l O n l
	y y

Funding and Acknowledgements

Funding was received from Gateshead Health E, R&D Committee. The Authors would like to thank Gateshead Health NHS Foundation Trust for their belief in this study and the support from the Research and Development Committee.

Author Contributions

Maggie Williams, Lorna Green and Karen Roberts all contributed to the concept and design, data analysis, the writing of the article. Karen Roberts critically reviewed the article Lorna Green conducted data collection and transcribing of data.


Kathryn Julie Davis
email: kathryn.davis.1@city.ac.uk

Devinder Kumar

Martyn Wake

Davis Kj

Wake Mc

Pelvic floor dysfunction: A scoping study exploring current service provision in the UK, interprofessional collaboration and future management priorities

Keywords: Female, pelvic floor dysfunction, services, interdisciplinary care, collaboration

come

PFD comprises symptoms ranging from bothersome to debilitating that are challenging to patients and healthcare professionals in primary and secondary care and have substantial NHS healthcare cost implications. PFD is a multi-disciplinary issue that concerns a wide range of healthcare practitioners. Traditionally, its management has followed a clinically compartmentalised and fragmented approach that potentially is failing to address multicompartmental symptomatology and resulting in an incomplete resolution of the problem.

What's new

This study has highlighted gaps and inconsistencies in current service provision for women with PFD. There is under utilization of primary care resources and variable access and availability to specialist care. Management pathways are further compromised by circuitous routes of referral, treatment and diagnostic delays, duplication of effort and inappropriate referrals to specialist services. New ways of working with improved Interdisciplinary service provision have the potential to improve outcomes of care.

Background

Pelvic floor dysfunction( PFD) presents an increasing clinical challenge and financial burden to the National Health Service. Against a background of rising public expectations, technological advances, increasing prevalence of predisposing factors such as obesity, diabetes and, an ageing population it is predicted that future demand for PFD-related healthcare will rise by 50% over the next 30 years, potentially stretching current service capacity [START_REF] Luber | The demographics of pelvic floor disorders: Current observations and future projections[END_REF]. PFD comprises symptoms that are associated with anatomical and functional disturbances of the lower urinary tract and micturition, lower gastrointestinal tract and defaecation and/ or sexual function [START_REF] Delancey | The Hidden Epidemic of Pelvic Floor Dysfunction: achievable goals for improved prevention and treatment[END_REF][START_REF] Morgan | Symptoms of Anal Incontinence and Difficult Defecation Among Women with Prolapse and a Matched Control Cohort[END_REF] . These range from being bothersome to debilitating and are challenging to patients and healthcare professionals in primary and secondary care.

Although PFD is common among women of all ages, the risk of developing symptoms rises steadily in middle and older age affecting an estimated 40% of women aged between 65-70 years increasing to 50% in those over 80 [START_REF] Nygaard | Prevalence of symptomatic pelvic floor disorders in US women[END_REF]. It is estimated that than one in ten older women will undergo surgery for PFD with as many as 30% of these requiring further surgery for symptom recurrence [START_REF] Olsen | Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence[END_REF]. Traditionally management of PFD has followed a clinically compartmentalized and often fragmented approach that may, due to variable access and availability to integrated services, be failing to address multi-compartmental symptomatology and resulting in an incomplete resolution of problems. This study presents the findings of preliminary study undertaken to investigate current service provision for women seeking treatment for PFD in the UK. Data gathered from a range of healthcare practitioners working in different specialty areas and mapped against relevant policy and documentary evidence is used to enhance a scoping literature review. The professional groups studied include nurses, doctors and physiotherapists with a specific interest in women's health.

Aims and Objectives

The primary aim of this scoping study is to investigate and synthesize evidence on current service provision in the UK. The secondary aim was to highlight priority areas for change to inform future service improvement and research. The following objectives were refined to aid the identification and interpretation of evidence;

• Identify the range, nature and extent of services This phased approach was deemed appropriate in the light of the complexity of the topic area and limited existing research evidence. The main strengths of a scoping study lie in its ability to extract the essence of a diverse body of evidence and give meaning and significance to a topic that is both developmental and intellectually creative. The concepts of interdisciplinary and inter-professional collaboration provided an interpretative analytical framework for this study [START_REF] D'amour | The conceptual basis for interprofessional collaboration: core concepts and theoretical frameworks[END_REF]. The underlying principles of sharing, partnership, power, interdependency, and process were used to guide data extraction, appraisal and synthesis.

•

The primary research questions posed were; What type of service provision is available to women seeking treatment for pelvic floor disorders and what level of inter-professional collaboration exists?

(1) Scoping literature review strategy Our approach followed established methods for a scoping literature review [START_REF] Arksey | Scoping Studies: Towards a Methodological Framework[END_REF][START_REF] Crd | Systematic Reviews: CRD's Guidance for undertaking reviews in healthcare[END_REF] . The review process comprised: establishment of the analytical framework, definition of key concepts and search terms, identification of key data sources, charting of the evidence, expert consultation and a summary analysis of the findings. Eight electronic bibliographic databases were searched including Cochrane Database of Systematic Reviews. These searches were supplemented by the pursuit of grey literature retrieved through secondary references, hand searching non-index linked publications and, advice from experts in the field. A systematic search strategy was used based on keywords comprising explicit single and combined terms relating to the topic (for example pelvic floor and pelvic floor dysfunction/disorders, incontinence and continence as free text and related indexed terms) and, the target population (women). A second layer of keywords such as multidisciplinary, interdisciplinary, integrated service and inter-professional collaboration were then used to refine the search.

To ensure comparability and applicability of research findings, we focused our review on publications specific to services for women with pelvic floor disorders. Additional limitations were employed to include only material that was published in the English language and reported on service provision from 1990 to 2009 to ensure current relevance. Policy documents, reports and position statements relevant to the management of women with PFD in the UK were also sought using the following databases; -Department of Health National The following final free text question, asked to each of the professional groups, canvassed opinions and recommendations on service improvements; "In order to provide optimal services for women with pelvic floor disorders, particularly to women with co-existing symptoms relating to pelvic organ prolapse, bowel, bladder and sexual function, what service developments/improvements do you think are required?" It is not uncommon to use more than one method of purposive sampling techniques and in this phase three specific types were used;

• critical case sampling to elicit participants who exemplified key characteristics of PFD service provision, for example those who had published/lectured on PFD

• snowball sampling to determine other suitable participants; and

• maximum variation sampling that sought a range of participants from different disciplines to ensure that our data was reflective of a diversity of experiences.

Each respondent received a copy of the study information so that they could decide in advance whether they wished to participate. A prepaid-reply envelope was provided to those returning completed questionnaires by surface mail. Consent was accepted if the (3) Data Synthesis An interpretative analysis of the survey, documentary and literature data was undertaken by the PI and then discussed among the researchers. Summary descriptive statistics and manifest content analyses were the primary tools used for categorising and identifying emerging themes. The findings are synthesized and presented in the form of a narrative summary. The literature and documentary evidence was managed in a word program with quantitative survey data managed and analysed using SPSS TM version 11 (SPSS inc, Chicago,Il USA).

Ethical consideration

The UK National Research Ethics Service declared this study a service evaluation that did not require further ethical review by local Ethics Committees.

Results

Only 36 papers of over 2000 publications potentially focused on aspects of service provision and were selected for further review. Twenty one were considered eligible for inclusion [9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,29,30] . Five (published across 7 publications) provided a holistic functional perspective of the evaluation and management of PFD and potential benefits of collaborative, multidisciplinary approaches in relation to both outpatient and surgical service delivery [START_REF] Davis | Pelvic Floor Dysfunction: a conceptual framework for collaborative patient-centred care[END_REF][START_REF] Davis | Pelvic Floor Dysfunction: The need for a multidisciplinary approach[END_REF][START_REF] Gurland | Challenges in Developing a Multidisciplinary Pelvic Floor Centre[END_REF][START_REF] Kapoor | Management of complex pelvic floor disorders in a multidisciplinary pelvic floor clinic[END_REF][START_REF] Mirnezami | Multidisciplinary team meetings for pelvic floor disorders[END_REF][START_REF] Nager | Management of pelvic floor dysfunction[END_REF][START_REF] Heidi | Combined Approach Helps Ease Pelvic Floor Dysfunction[END_REF]. The remainder focused on service provision in terms of just one aspect of PFD (urinary incontinence [START_REF] Albers-Heitner | The effects of involving a nurse practitioner in primary care for adult patients with urinary incontinence: the PromoCon study (Promoting Continence)[END_REF][START_REF] Du Moulin | The role of the nurse in community continence care: a systematic review[END_REF][START_REF] Du Moulin | Effects of introducing a specialized nurse in the care of community-dwelling women suffering from urinary incontinence: a randomized controlled trial[END_REF][START_REF] Hagen | A United Kingdom-wide survey of physiotherapy practice in the treatment of pelvic organ prolapse[END_REF][START_REF] Jha | Integrated care pathways: the way forward for continence services?[END_REF][START_REF] Milne | An exploratory study of continence care services worldwide[END_REF][START_REF] Monz | A description of health care provision and access to treatment for women with urinary incontinence in Europe -a five-country comparison[END_REF][START_REF] Moore | Randomised controlled trial of nurse continence advisor therapy compared with standard urogynaecology regimen for conservative incontinence treatment: efficacy, costs and two year follow up[END_REF][START_REF] Potter | National audit of continence care for older people: management of faecal incontinence[END_REF][START_REF] Thomas | Improving continence services: a case study in policy influence[END_REF][START_REF] Wagg | Continence care for older people in England and Wales: data from a national audit[END_REF][START_REF] Wagg | National audit of continence care for older people: management of urinary incontinence[END_REF][START_REF] Wells | Integrated continence services and the female Bangladeshi population[END_REF][START_REF] Williams | Clinical and cost-effectiveness of a new nurse-led continence service: a randomised controlled trial[END_REF] or pelvic organ prolapse [START_REF] Hagen | A United Kingdom-wide survey of physiotherapy practice in the treatment of pelvic organ prolapse[END_REF] . These papers tended to focus on the heterogeneity of access, appropriateness and treatment provision, service inconsistency and fragmentation, the importance of multidisciplinary team work and the need for greater service integration. Unlike other countries such as the United States of America [START_REF] Bean-Mayberry | Federally funded comprehensive women's health centers: leading innovation in women's healthcare delivery[END_REF] and Australia [START_REF]Developing a Women's Health Policy for Australia-Setting the Scene[END_REF] who have developed National Women's Health policies to ensure that the planning and delivery of health services best meets the needs and improves health and well being of women in their respective populations, no national overarching strategy for women's health and PFD in particular, was identified for the UK. Although numerous sources providing a wide range of commissioning guidance's, treatment pathways and protocols for specific aspects of PFD, were identified (Table 1).

The frontline survey highlighted a number of issues associated with the provision and delivery of pelvic floor services. However, in the absence of a national association or database of practitioners with a special interest in PFD and the decision to use a variety of sampling techniques, final response rates were unable to be calculated. The two most difficult professional groups to access, despite positive liaison with representatives of their respective professional forums, were the GP's and nurse specialists. In light of a very small national GP response (26) the steering committee agreed that the focus of further efforts to gather the views of GP's should be placed on establishing a representative cohort. This involved recruiting GP's from 56 practices in one large, urban Primary Care Trust. GP's from 19(32%) of these practices responded.

Following reflective discussion between the researchers analysis of the survey data focused on three key dimensions (i) demographics and professional characteristics of practitioners (ii) management of PFD and models of healthcare delivery and, (iii) priority areas for improvement.

(i) Demographics and professional characteristics

We recruited 243 practitioners including 95(39%) specialist physiotherapists, 63(26%) medical consultants, 45(19%) general practitioners (with a cohort of 19 from one PCT) and, 40(16%) specialist nurses, from a variety of clinical subspecialties (Table 2). They were geographically spread across the ten Strategic Health Authorities in England with a small number responding from services based in Scotland (10), Wales (6), Northern (8) and Southern Ireland (6) and, the Channel islands(1) (Figure 1). Eighteen (45%) of the nurses worked exclusively within primary care with the exception of 2 general practice-based, nurse practitioners, the remainder were continence nurse advisors, 16(40%) within secondary care( 5 colorectal, the remainder in urogynaecology) and 6(15%) worked across primary and secondary care( providing continence care). Of the 95 physiotherapists, 22 (23.1%) worked in primary care (6 worked The management of PFD varied widely across the disciplines and between practitioners.

Medical consultations were greatly restricted by time compared to specialist nurses and physiotherapists who were able to arrange longer appointments (45-60 minutes) and generally involved additional symptom severity and quality of life assessment measures and pelvic examination. Of the GP's only 2 recommended a second appointment for further assessment, examination and discussion. Four referred directly either to a hospital consultant, women's health physiotherapist or continence nurse advisor rather than manage symptoms themselves. The initial treatment strategies described by the group collectively, were broadly similar. First line management comprised lifestyle interventions, diet and fluid manipulation, bowel and bladder retraining, evacuation techniques, pelvic floor muscle exercises, vaginal pessaries and pharmaceutical therapies prescribed as required. Generally the guidelines for Urinary Incontinence(UI) [START_REF]CG40 Urinary incontinence: The management of urinary incontinence in women[END_REF], Faecal Incontinence(FI) [START_REF]CG49 Faecal incontinence: the management of faecal incontinence in adults[END_REF] Pelvic Organ Prolapse [START_REF] Dh | 18 week Commissioning Pathways -Female incontinence, prolapse[END_REF] were followed however, when asked about the use and usefulness of guidelines in clinical practice, the practitioners views were not universal. Only 3 GP's and 12 consultants perceived clinical guidelines as very useful while 23 GP's and 38 consultants found them moderately useful. The remainder either had not read any guidelines or did not find them useful. For nurses and physiotherapists, clinical guidelines and treatment protocols provided the framework for their practices. models Four distinct models of healthcare delivery were identified; single practitioner-led, multidisciplinary within-specialty, across-specialty and cross boundary (Figure 2). Nearly 50% (including the GP's) managed PFD as single practitioners. The majority of the remainder followed a within-specialty model and used a combination of different service approaches. Only 33 practitioners worked in across-specialty services and just 2 (working in continence) provided cross boundary services between primary and secondary care. Within these three models many practiced formalized triage systems developed to facilitate direct referral pathways to single specialist-led, combined and/or joint multidisciplinary outpatient clinics and diagnostic services. There was one example of a consultant-led outreach clinic in primary care and four secondary/tertiary centres provided dedicated PFD outpatient services.

Attendance at regular multidisciplinary team(MDT)-style meetings tended to be confined to practitioners within individual clinical subspecialties in secondary care. The attendance by nurses was less than half 16(40%) and only just over half among physiotherapists 49(51.5%). The main reason given for non-attendance was 'no meetings', limited time to attend and logistical difficulties. Complex cases were discussed by 43(65%) consultants at infrequent, ad hoc meetings. With the exception of one consultant surgeon who managed all pelvic floor problems as a single specialist surgeon, the majority of consultants preferred a single specialty approach referring patients requiring further surgery for other pelvic

(iii) priority areas for improvement

One hundred and ninety nine (81.8%) practitioners provided views on how services could be improved. Of the 44 that declined to offer an opinion, over half were medical staff; comprising 15/45 (33.3%) GP's, 16/63 (25.3%) consultants (11 colorectal, 2 urology, 3 urogynaecology), 8/95 (8.4%) of the physiotherapists and 5/40 (11.1%) nurses. Using a qualitative methodological approach to the analysis of this data, five overlapping themes identified as priority areas for improvement, were identified; 1) Access and availability to specialist services 2) Team working and collaboration 3) Funding and investment

4) PFD education, training and research 5) Public and professional awareness

There was consensus that access and availability to specialist care was being potentially compromised due to the low priority and lack of a coherent strategy to PFD. While the perspectives of this theme differed slightly between professional groups, it was generally agreed that circuitous routes of referral, duplication of effort and treatment delays presented particular obstacles to optimal service provision. For example, when symptoms failed to respond to treatment, few specialist nurses and physiotherapists, particularly in primary care, had direct referral access to consultants or specialist diagnostic investigations. Local arrangements commonly required patients be referred back to their GP's for further assessment in order to secure an onward referral. In secondary care similar frustrations were also described in relation to direct referral access to allied health specialties. From the GP's perspective, defined referral pathways to continence advisors, WHP's and hospital services were variable. While for some, local arrangements were good for others access was reported as more difficult for several reasons including; lack of direct referral arrangements to specialist investigations or 'one/two stop' specialist PFD clinics and, uncertainty about the availability or location of local specialist nurse or physiotherapy services.

Improving inter-professional collaboration was a key issue and supported by numerous recommendations. These included making better use of existing resources to improve communication and coordination between different service fragments, development of a national database, patient-held documentation and, wider involvement of specialist nurse/physiotherapists working in advanced roles to facilitate services and improve earlier access to treatment. Practitioners generally concurred that services needed to shift with the development of more primary care-directed service models that would not only encourage a more synchronous and seamless service approach but, would also have the advantage of freeing up limited specialist secondary/tertiary care resources for patients with more complex problems.

There was universal agreement that greater funding and investment in staff, equipment and training was required if services were to improve and new ways of working were to be developed. Numerous recommendations to achieve standardized approaches to care were made in relation to improving opportunities for inter-professional education and training within and across primary and secondary care settings although specific educational needs tended to differ across the groups.

The need to raise professional and public awareness of PFD as a significant women's health problem was also highlighted and a number of proposals were made that would potentially enhance current services including the provision of more primary care-based and school based educational sessions to promote healthy pelvic floor practices, ante and post natal drop in clinics, self help support groups, better advertising of services and the development of local health service websites, information leaflets and posters.

Discussion

This study suggests that a combination of external (macro) and internal (meso) organizational and, personal (micro) factors are contributing to a fragmented, highly variable and poorly integrated approach to PFD service delivery in the UK. At a 'macro' level, the strategic policy approach to women's health care in the UK differs significantly from that of other countries [START_REF] Bean-Mayberry | Federally funded comprehensive women's health centers: leading innovation in women's healthcare delivery[END_REF][START_REF]Developing a Women's Health Policy for Australia-Setting the Scene[END_REF][START_REF] Goodman | A qualitative evaluation of the National Centers of Excellence in Women's Health Program[END_REF] where through synchronized approaches to cross referral and team working, models such as the Calgary Pelvic Floor Disorders Clinic (currently being evaluated in Canada) [START_REF] Ross | Evaluation of the Pelvic Floor Clinic[END_REF] and the Maimonides Centre for Pelvic Floor Dysfunction in the USA [START_REF] Heidi | Combined Approach Helps Ease Pelvic Floor Dysfunction[END_REF] have developed. It could be argued that although the majority of women's health services in the UK are well provided through local services, from the views expressed by the respondents in this study, there is a suggestion that the tendency to subsume or 'piggyback' women's health issues within other areas of health policy could result in the multiple causes and consequences of PFD being inadequately addressed. This may also explain some of the service inconsistencies we identified and support evidence that outcomes in relation to the management of multi-compartmental pelvic floor symptoms are suboptimal [START_REF] Delancey | The Hidden Epidemic of Pelvic Floor Dysfunction: achievable goals for improved prevention and treatment[END_REF][START_REF] Davila | Concept of the Pelvic Floor as a Unit in. Pelvic Floor Dysfunction: A Multidisciplinary Approach[END_REF]. Another factor to consider at the macro level relates to targets. These have become an essential element in the UK Government's plans for modernizing the NHS (DH [START_REF] Dh | The NHS Plan; A plan for investment, a plan for reform[END_REF] and despite efforts to move away from a target-driven to a "high quality" service (DH 2008) [START_REF] Dh | High quality care for all: NHS Next Stage Review final reportDepartment of Health. The Stationery Office (TSO)[END_REF] initiatives like the 18 week commissioning pathways remain important service indicators [START_REF] Dh | 18 week Commissioning Pathways -Female incontinence, prolapse[END_REF]. We contend that although such initiatives have gone a long way to improving patient healthcare they are not without their critics particularly when managing the time consuming and often complex problems associated with PFD that require a plural rather than singular approach. Our findings indicate that in patients with mulitple symptoms the efficacy of treatment can be limited if a single specialty service position is consistently endorsed.

At the 'meso' level we found that the majority of practitioners describe broadly similar approaches to care with a high level of autonomy in the provision of services. However, as patients often enter and re-enter the system via many routes and consult with many different practitioners along the treatment pathway, there is potential for patients to be exposed to duplication and delay in treatment (Figure 3). Although there is evidence supporting the clinical and cost effectiveness of more specialist nurse and physiotherapist practitioner involvement [START_REF] Albers-Heitner | The effects of involving a nurse practitioner in primary care for adult patients with urinary incontinence: the PromoCon study (Promoting Continence)[END_REF][START_REF] Du Moulin | Effects of introducing a specialized nurse in the care of community-dwelling women suffering from urinary incontinence: a randomized controlled trial[END_REF][START_REF] Williams | Clinical and cost-effectiveness of a new nurse-led continence service: a randomised controlled trial[END_REF] confirmation of inter-professional collaboration is limited. We suggest that this may provide an explanation for the predominance of the partitioned, 'within specialty' model approach identified in this study that, alongside the lack of a standardized approach to managing PFD as a single clinical entity, inhibits service innovation and the development based on locally available expertise of robust, effective integrated services. Another factor to consider at this level relates to the use of and adherence to clinical guidelines. Our findings concur with previous studies [START_REF] Albers-Heitner | Adherence to professional guidelines for patients with urinary incontinence by general practitioners: a cross-sectional study Journal of Evaluation in Clinical Practice[END_REF] where adherence by practitioners to guidelines developed for the identification and management of bowel, bladder or sexual function, may be only partial.

The major reasons highlighted in our study include; insufficient time, lack of available resources especially staffing numbers limited or no access to specialist 'one-stop MDT services'. The recommendations made by practitioners for new service configurations that include more specialist services being made available within primary care, would appear to offer a solution to this problem. In addition it would facilitate greater opportunities for interdisciplinary professional development and support recent recommendations made by The Department of Health [START_REF] Dh | Set 4: Specialised Services for Women's Health -1.3 The assessment and treatment of complex urinary and faecal incontinence and genital prolapse in women The Stationary Office[END_REF] . We propose that by creating a more synchronized, collaborative, inter-professional approach between GP's, primary care-located triage hubs and specialist centers, the potential benefits already apparent in other specialties [START_REF] Mackay | Characteristics of evolving models of care for arthritis: a key informant study[END_REF] will become evident. suffer complex groups of problems which if not routinely enquired about may be underappreciated and lead to inadequate treatment [START_REF] Delancey | The Hidden Epidemic of Pelvic Floor Dysfunction: achievable goals for improved prevention and treatment[END_REF][START_REF] Morgan | Symptoms of Anal Incontinence and Difficult Defecation Among Women with Prolapse and a Matched Control Cohort[END_REF][START_REF] Nygaard | Prevalence of symptomatic pelvic floor disorders in US women[END_REF]. In addition, the propensity for duplication of effort for assessment and conservative therapies as patients bounce around the system, are further indications that optimal care is being compromised. Our findings suggest that differences in professional attitudes, experiences and knowledge alongside a lack of government directive and financial investment in PFD in the UK has contributed to a degree of professional territorialism and may account for the 'therapeutic nihilism' reported in some studies [START_REF] Teunissen | Urinary incontinence in the elderly: attitudes and experiences of general practitioners. A focus group study[END_REF] . Recommendations from practitioners for more 'protected consultation time', 'ring fenced' clinical arrangements, more inter-professional educational opportunities in addition to improved specialist staffing levels were identified as key areas for improvement.

Conclusion

The assessment and management of PFD is time consuming and involves the input of a wide variety of healthcare professionals. This study has highlighted areas which will be of interest to practitioners, providers and commissioners involved in the future planning and delivery of women's health services. Although our survey data cannot be interpreted as representative of the wider views of each professional group because they are based on a self-selected, purposive sample with unknown response rates, we contend that this study affords an opportunity to gain valuable insight into the current views and recommendations of key frontline practitioners working across the different subspecialties. Given the impact of PFD on the health and wellbeing of women and the eminently treatable nature of symptoms regardless of age, early access to specialist health care is important. Raising awareness of optimal service provision for the prevention and management of PFD should be a health policy priority. This study provides for the first time, baseline evidence that exposes a number of barriers hindering the development of specialist integrated services. Our analysis reveals that availability and access to formalized interdisciplinary PFD care in the UK is highly variable. We hypothesize that new service configurations will facilitate greater service collaboration and break down traditional professional boundaries across primary and secondary care and ensure more effective and efficient use of resources. Improving interdisciplinary education and training would also strengthen relationships and change practitioner's views on the benefits of combined management approaches. This will not only lead to improved understanding of the complexity of female PFD but also expose more patients to the range of therapeutic benefits available including pelvic floor health promotion initiatives helping to prevent pelvic floor complications developing later in life, contributing to healthier ageing and well being and improving women's participation in health decision making and health management.

Summary of key documentation & evidence based practice guidelines identified to support best practice in the assessement and management of PFD

4 Text

 4 Revised and reduced in length

( 1 )( 2 )

 12 Determine models of service provision and levels of interdisciplinary practice • Ascertain the experiences, views and needs of frontline service practitioners in relation to current and future PFD service provision Concurrent scoping literature review and analysis of relevant research, documentary and policy evidence Consultation with frontline practitioners (3) Overarching synthesis

  Institute for Health and Clinical Excellence(NICE) (government agencies) the Health Care Commission (healthcare agencies), Royal Colleges and professional bodies and, charitable associations such as The International Continence Society.(2) ConsultationTo elicit the expert views held by UK healthcare practitioners already engaged at the frontline of practice and enhance the findings of the scoping literature review, a questionnaire survey was conducted among a purposive sample of health care professionals. These were initially sought through contact with the UK membership of a wide range of groups and associations including; The International Continence Society, Association of Coloproctology of Great Britain and Ireland, UK Royal College of Nursing's Continence, Stoma and Gastroenterology and Nurse Practitioner Forums, Women's Health Chartered Physiotherapists(ACWHP), Royal College of General Practitioner Academic faculty groups in addition to local meetings and seminars. The questionnaire was piloted among a convenience sample of eight specialist practitioners. Following minor revision the final versions were made available for completion. The questionnaires comprised a series of open and closed questions that sought information about individual professional roles and practices, range of symptoms assessed, management and treatment strategies employed, pathways of referral within and across specialties, use of existing national guidelines/protocols and treatment outcome measures.

  and returned. Two follow up reminders were made to non respondents at 4 and 8 week intervals.

  in dedicated continence services with 1 in private practice), 48(50.5%) in secondary care, 25(26.3%) provided services across primary and secondary care. All declared a specialist interest in women's health physiotherapy with 13 having full membership of the clinical interest group the Association of Chartered Physiotherapists in Women's Health(ACPWH). Three provided extended-scope practitioner services. The medical consultants worked in District General, Secondary and Tertiary Hospitals. The proportion of time estimated to be devoted to PFD was 60-100% by urogynaecologists, ≤ 20% by the urologists and colorectal surgeons and less than 1% of the GP's practice.(ii) management of PFD and models of healthcare delivery management

  to surgical colleagues as appropriate. Only 23(36.5%) of the surgeons participated in combined operative procedures.

Finally, at the

  practitioner 'micro' level, several factors emerged that emphasized links between the pressures on consultation/treatment time and poor resourcing, inadequate knowledge and lack of understanding of the expertise of colleagues and efficacy of treatments. Previous research has shown that patients presenting with PFD are likely to

  Figures IJCP 2010

  Figure 1 Respondents by Geographical Location

Figure 2 Models

 2 Figure 2 Models of healthcare delivery

Figure 3 Current

 3 Figure 3Current service pathways for investigation & management of PFD

Table 1

 1

24 of 24 International Journal of Clinical Practice International Journal of Clinical Practice

					Page
	Primary care
	WH
	Physiotherapy
				2ndary care
				WH Physiotherapy/
				CNS
				Urology/Urogynae
		Secondary Care		Operative
			OPD		Intervention
	General
	Pracice	Consultant Specialists
	GP/NP	• •	Urogynae Urology	Specialist Investigations	Drug therapy
		•	Colorectal
		•	Gastro		OPD
					Follow up
				2ndary care
				CNS
	CNS Continence			Colorectal/Gastro
	Advisory Service

Acknowledgements

This study was conducted as part of a Postdoctoral Research Fellowship funded by The Burdett Trust for Nursing. The authors would like to thank the ACWPH, CSP, ICS, Associations of Coloproctology of Great Britain and Ireland, UK Royal College of Nursing -Continence, Stoma & Gastroenterology and, Nurse Practitioners forums, UK Royal College of General Practitioners Academic Faculty Groups for access to their membership lists. We would also like to thank Mrs Teresa Lunnis and Mrs Becky Ashton for the piloting of the surveys and their support in facilitating access to specialist physiotherapists and nurses, Mr Jan Poloniecki for his statistical advice and, all of the practitioners who took the time to participate in this study.

Authors Contribution

All authors have approved the final draft for submission and had access to the study data. Specific contributions were made in the following areas: Kathy Davis was responsible for the conception and design, data collection, analysis and interpretation of this scoping study. In addition, she was responsible for the preparation, drafting and critical revision of the manuscript. Devinder Kumar participated on the data interpretation, preparation and critical revision of the manuscript for important intellectual content and contributed to statistical analysis of the data. Martyn Wake assisted in the design of the study, facilitating the acquisition of data from general practitioners and critical review of the final drafts of the manuscript.

Author Documentation Content

DH NHS National Institute of Clinical Excellence (NICE)

Commissioning guidances CG40 UI (2006) [START_REF]CG40 Urinary incontinence: The management of urinary incontinence in women[END_REF] • Urinary continence service for the conservative management of urinary incontinence in women; [START_REF]CG49 Faecal incontinence: the management of faecal incontinence in adults[END_REF] • Faecal continence service for the management of faecal incontinence in adults; • Commissioning a faecal continence service for the management of faecal incontinence in adults; and • Help using the faecal service commissioning tool

The Management of Faecal Incontinence in Adults NICE CG55 (Sept 2007) [START_REF] Nice | CG55 Intapartum Care: management and delivery of care to women in labour National Collaborating Centre for Women's and Children's Health[END_REF] Intrapartum Care: management and delivery of care to women in labour

Various relating to a range of pelvic floor related procedures such as insertion of slings, mesh, bulking agents or nerve stimulation devices for prolapse or incontinence. [START_REF]SIGN No.79 UI Management of Urinary Incontinence in Primary Care: A national clinical guideline[END_REF] Management of Urinary Incontinence in Primary Care: A national clinical guideline.

Department of Health

Chartered Society of Physiotherapists (CSP) & Association of Chartered Physiotherapists in Women's Health (ACPWH)

Professional body Clinical guidelines(2001) [START_REF] Laycock | Clinical Guidelines for the Physiotherapy Management of Females aged 16-65 with Stress Urinary Incontinence[END_REF] Audit and information

CSP Clinical Guidelines For The Physiotherapy Management Of Females Aged 16-65 With Stress Urinary Incontinence

CSP SUI audit pack and urinary incontinence assessment ACPWH Pelvic Floor And Vaginal Assessment-Guidance For Post-Graduate Physiotherapists and Physiotherapy Tutors UK Royal College of Obstetricians and Gynaecologists(RCOG)

Green-top Guidelines No. 29 (2002) No. 35 (2007)

The Management of Third-And Fourth-Degree Perineal Tears Surgical Treatment of Urodynamic Stress Incontinence

Royal College of Physicians, London Healthcare Commission Audit reports (1995, 1998, 2005-2006) [START_REF] Wagg | Continence care for older people in England and Wales: data from a national audit[END_REF][START_REF] Wagg | National audit of continence care for older people: management of urinary incontinence[END_REF] Incontinence: causes, management and provision of services Promoting continence. [START_REF] Chatoor | Organizing a Clinical Service for Patients with Pelvic Floor Disorders[END_REF] Overviews for FI, Constipation, Obstetric trauma follow-up and, pelvic organ prolapse

International Urogynaecological Association and ICS

Joint report on the Terminology for female PFD [START_REF] Haylen | GN An International Urogynaecological Association(IUGA)/International Continence Society(ICS) Joint Report on the Terminology for Female pelvic Floor Dysfunction[END_REF] A consensus based terminology report comprising over 250 definitions to aid diagnosis and assessment of female PFD