The role of registered nurses in primary care and public health collaboration: A scoping review

4.1 Search strategy and study selection

Our database search consisted of: PubMed, CINAHL; Cochrane; PsycInfo; Sociological Abstracts; Web of Science; and Dissertation International. We also scanned reference lists of included articles and conducted Web searches of government, healthcare associations and research networks for key documents and information. Finally, a general Internet search using key terms was used to capture grey literature and/or other information not gained from formal databases. Key terms used in the search included the following: primary care, public health, collaboration, public health nurse, community health nurse, nurse, patient care teams and nurse's roles. A health science librarian at the University of British Columbia supported this scoping review (Appendix S1).

Papers addressed at least one of the following: structures and processes supporting RN’s role in PC/PH collaboration or patient population indicators and outcomes of RN collaboration between PC and PH. Papers were excluded if they addressed PH or PC alone; contained no evidence of collaboration; did not describe the RN’s role in collaboration; or were not published in English (Figure 1). Articles published between January 2009– January 2016 were screened for applicability. These dates were chosen to build on the Canadian scoping review completed by Martin-Misener et al. (2012) and to capture additional international literature around PC/PH RN implementation. Literature published from 2016–present (Pratt et al., 2018; Valaitis, Meagher-Stewart, Martin-Misener, Wong, & MacDonald, 2018; Wong et al., 2017) provides more information on systemic and organizational considerations in PC/PH collaboration; however, they do not specifically address the nurse role.

Papers were from the USA, Canada, Western Europe, Australia, the UK and New Zealand. Commentaries were included if they brought context to the research question. In this scoping review, limited grey literature was retrieved and did not inform this study.

4.2 Analysis

Data were extracted using the concept of “charting the data” as suggested in Arksey and O’Malley (2005). This process is similar to data extraction in a systematic review but involves taking a comprehensive approach to the material and compiling it in a manner that contextualizes the outcomes; this makes it more suitable to readers who will use the findings to inform practice and policy decisions. Data were coded into the following categories: type and/or purpose of collaboration; participants involved in the collaboration; RN’s role in the collaboration; geographic context/situation (urban/rural); health focus such as mental health, maternal or communicable disease; motivators for collaboration; characteristics and attributes of collaboration; and results and indicators of success. We used an interpretive description approach (Thorne, 2016) to analyse the coded data and formulate themes.

Data pertaining to the RN’s role in PC/PH collaboration were also analysed using intrapersonal, interpersonal, organizational and systemic levels identified in the Ecological Framework for Building Successful Collaboration between Primary Care and Public Health (Appendix S2; Valaitis et al., 2013). This framework identifies supporting factors at each level that enhance collaboration between PH and PC sectors. It also provided guidance in the data analysis phase of by allowing us to understand the RN’s role in the context of collaboration and from a lens that identifies collaboration beyond the interpersonal and intrapersonal levels. To ensure credibility and study rigour, data coding and analysis were reviewed by the study team throughout. To examine whether reported RN roles in PC/PH collaboration were in their general scope of practice, we examined these roles against the example of British Columbia's RN scope of practice.

6.1 Relationship builder

At the intrapersonal/interpersonal level, PH RNs played an integral role in team-based primary care and collaboration between PC and PH. Their role as frontline nurses, working with other providers, placed them in key roles to enhance communication through face-to-face interactions (Green et al., 2013; Kelly et al., 2015; Kempe et al., 2014; Monsen et al., 2015; Psaila, Kruske, et al., 2014; Wynn & Moore, 2012). Statements from PC providers about the PH RNs included words such as supportive, sharing, checking in, reminding, visiting and talking (Monsen et al., 2015). For example, a PC provider stated, “it gives us a face and a name so we can call (the public health department) if we have other problems” (Kempe et al., 2014, p. 115). From the PH perspective, it was stated “I think the better they (PC providers) know us and the more they see us as an actual resource, the more comfortable they are when there's really a public health issue that has to be dealt with” (Kempe et al., 2014, p. 115).

At the organizational level, PH RNs built relationships with organizations in and outside the healthcare sector to improve access to care by providing PC in locations where people work, live and play (Kempe et al., 2014) rather than at stationary PC sites. As PH RNs spent time and resources to support PC staff in their practice setting, face-to-face communication between PH and PC was enhanced and described as a “network of communication” by Wynn and Moore (2012), where future initiatives between PC and PH such as chronic disease management and disease surveillance could be supported.

6.2 Care coordinator

At the intra/interpersonal level, the care coordinator role was seen in collaborative clinics and hospital community transition programmes. It was often motivated by the need to increase access to care for vulnerable individuals and families, particularly in maternal/child and chronic disease management health services (Davies, 2012; Ferrer et al., 2013; Psaila, Fowler, Kruske, & Schmied, 2014). Evidence from these studies suggests that PH and PC RN care coordinators improved access to care, streamlined services and increased referrals to community services. RNs integrated care between hospital and community, ran group visits to support chronic disease management and maternal care and addressed the social determinants of health (Ferrer et al., 2013).

At the organizational level, care coordination occurred with PH RNs collaborating with community agencies (Elliott et al., 2014) and working with PC to improve vertical and horizontal continuity of care, specifically in addressing the social determinants of health for complex maternity patients (Davies, 2012; Psaila, Fowler, et al., 2014) and chronic disease management (Ferrer et al., 2013; Weinstein et al., 2013).

6.3 Outreach professional

At the intra/interpersonal level, the literature showed that the PH RN’s role as an “outreach professional” improved patient access to PC, improved prevention and supported a variety of community service and care models. This role is particularly relevant to vulnerable populations. For example, outreach to home settings (only seen in European studies) targeted primary and secondary prevention of chronic disease and obesity. RN activities included assessment and education (Korhonen et al., 2014), monitoring of food intake and body weight and implementation of advice from a dietician (van Avendonk et al.., 2012). RN-led screening achieved meaningful weight loss with brief lifestyle counselling (Korhonen et al., 2014).

At the organizational level, this outreach care was often associated with team-based care models such as the Primary Care Medical Home. This care delivery model provides comprehensive and coordinated patient care by providers such as physicians, nurses, pharmacists and social workers (www.pcmh.ahrq.gov). Public health RNs worked either as consultants or as members of Primary Care Medical Home models and often in association with academic collaborative PC settings (Weinstein et al., 2013). An example of this approach occurred during the H1N1 pandemic in 2010 where family health teams (PC) and PH RNs collaborated in the management of a flu pandemic by creating assessment centres in the community to ensure universal and easy access to care. At these sites, PH RNs liaised with PC sites to provide supplemental staffing for flu immunization clinics and infection control measures such as cough etiquette, education and quarantine, and coordination of clinical care guidelines (Wynn & Moore, 2012).

Beyond traditional healthcare sites, PH RN-led outreach immunization clinics improved access to care and increased vaccination rates by providing immunizations at community-based venues allowing care to be provided in unique locations and unusual times (Kempe et al., 2014; Lebrun et al., 2012). Notably, the largest immunization rate increase was seen among healthy children who do not regularly interface with the PC system. This highlights a unique feature of the RN’s role in communicable disease reduction by immunization outreach to people who face barriers in access or do not regularly access PC (Kempe et al., 2014).

6.4 Programme facilitator

At the organizational level, the PH RN programme facilitator role supported the transfer of PH knowledge to PC in areas such as communicable disease (immunization and pandemic management) (Green et al., 2013; Kempe et al., 2014; Wynn & Moore, 2012) and chronic disease prevention, for example healthy eating strategies (van Avendonk et al., 2012; Levy et al., 2011; Monsen et al., 2015). The RN’s role at this level not only supported interorganizational collaboration, but also enabled future collaboration and increased awareness of population-level needs in PC (Kempe et al., 2014; Levy et al., 2011; Monsen et al., 2015; Wynn & Moore, 2012).

At the system level, the RN’s role supported the use of tools, guides and programmes in PC/PH collaboration. Examples of RNs working at the system level include the following: (a) supporting the use of the Institute for Systems Improvement—Adult Obesity Guideline into the PC setting in Minnesota (Monsen et al., 2015); (b) implementing the Primary Care Nutrition Training Program to targeted underserved PC sites in New York (Levy et al., 2011); (c) liaising with schools and community organizations and PC to implement weight screening and healthy eating with The San Diego Healthy Weight Collaborative (Serpas et al., 2013); and (d) assisting PC obesity guideline translation, including goal setting with PC sites in the use of guidelines and tools, educating PC site staff on motivational interviewing techniques, supplying resources (food models and portion control plates) and facilitating shared best practices in obesity management (Monsen et al., 2015).

6.5 RN scope of practice supported RN’s role identified in the scoping review

The roles identified in this scoping review are in legal regulations in the RN scope of practice (British Columbia College of Nursing Professionals (BCCNP) 2018). However, as new roles emerge in the face of changing healthcare demands, challenges with scope of practice documents maintaining their currency have been noted internationally (Birks, Davis, Smithson, & Cant, 2016; Fealy et al., 2015).

Conclusion. In supporting new roles, regulatory bodies can work with nurse associations and health authorities to advance the concept of individual-level accountability and self-reliance in determining best practice decisions.

These results suggest a growing body of evidence of RNs working to strengthen collaboration across PC and PH sectors. We provide evidence to extend our understanding around the various roles RNs can undertake and the kinds of activities they can perform in their scope of practice. Most of what RNs are undertaking in strengthening collaboration across PC and PH sectors occurs at the inter/intrapersonal and organizational levels. Worldwide, RNs play an ever important role in delivering primary healthcare services (Bauer & Bodenheimer, 2017; Smolowitz et al., 2015), and given the rise of health and social inequities globally (OECD, 2017; WHO, 2008), these roles and activities strengthen the primary healthcare system by increasing health promotion and prevention and access to care (OECD, 2017).

RNs contributed to improved organizational-level collaboration through increased personal connections and information communication pathways (Levy et al., 2011; Psaila, Kruske, et al., 2014; Wynn & Moore, 2012). Past work suggests that building and sustaining relationships can be more important than structural considerations such as colocation (Clancy et al., 2013; Kempe et al., 2014). Termed “boundary spanners” by Fraher et al. (2015), RNs can perform new roles for a new healthcare system with a population health focus. Improved care coordination and transition between the sectors can be supported by these RN roles, highlighting their importance in change management process that occurs with any healthcare reform efforts. As outreach professionals and care coordinators, RNs increased access to PC and PH especially with populations made vulnerable by multiple intersecting determinants of health such as those living on or close to the street and facing homelessness. This role is key to future in the management of disease outbreaks. Programme facilitator roles were particularly important at the organizational and systemic levels. This scoping review reveals the importance of the primary healthcare RN to be used beyond the walls of the office setting to provide care in the community from interpersonal to interorganizational and system levels.

We found less evidence of RN roles in PC and PH at the system level. There are many political, policy, structural and workforce barriers that prevent the expansion of the RN role to collaborative work at the interorganizational and system levels. Societal attitudes, government policy and structural barriers that include the current GP private practice and lack of funding models to support PC nursing (APNA, 2017) and perceived fiscal constraints all constrain RN roles. In PC transformation, RN role development will be under pressure from these complex factors. Without due consideration in role development, as has occurred in Australia and Ireland (Brookes, Daly, Davidson, & Halcomb, 2007; Kelly et al., 2015), RN roles may devolve into roles and activities that focus on “acute care” delivered in the community missing out on important health prevention and promotion activities.

In performing collaborative roles, RNs were more commonly employed by public health than RNs working in PC practice. This could be due to their specific PH RN expertise such as collaboration, community interface/outreach and relationship building and the small number of generalist PC RNs in North American PC settings (Martin-Misener & Bryant-Lukosius, 2014; Valaitis et al., 2013). Structural issues such as the fee-for-service remuneration model and the fact that the PC system is separate from the hospital/PH system also act as barriers to employing more RNs in primary care (Bauer & Bodenheimer, 2017). Further research to support the RN roles includes evaluation of the RN’s basic education preparation specific to these roles.

To ensure that nurses are able to work in these roles, awareness of the RN scope of practice by government and health authorities and PC providers is essential, and as Bauer and Bodenheimer (2017) suggest, reversing overly cautious interpretations of scope of practice regulations. Inclusion of primary healthcare content and clinical practice into pre-licensure training will ensure RNs are well prepared for skills in cross-sector collaboration and primary care (Bodenheimer & Mason, 2017). Ensuring that nursing educators have PC experience could support the establishment of theory and practice into these unique roles and skills into nursing education (Fraher et al., 2015). Opening opportunities for RNs in new models of primary care (Hutchison et al., 2011) and improving RNs in supporting their own role development will also support appropriate nurse's roles in PC (Ashley, Halcomb, Brown, & Peters, 2018).