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

Abstract Aim The purpose of this work was to examine the roles of Registered Nurses (RNs) in primary care (PC) and public health (PH) collaboration. Additionally, we aimed to explore whether the current scope of practice for RNs is adequate to support their roles in PC/PH collaboration. Design A scoping review of current literature relating to the RN’s role in PC/PH collaboration was conducted using the PRISMA 2009 checklist. Methods The review used key terms: primary care, public health, collaboration, nursing and nurse role across six electronic databases; 23 articles that were included in the final review were published over a 7‐year span. Results Four key RN roles relating to PC/PH collaboration were identified: relationship builder, outreach professional, programme facilitator and care coordinator. RNs supported transitions in chronic disease, communicable disease care and maternity care at various healthcare system levels including systemic, organizational, intrapersonal and interpersonal levels.

management is complex (Valaitis et al., 2013). Communicable disease management such as influenza, chronic disease care such as diabetes and asthma, complex maternal/child health care and care delivery to vulnerable populations experiencing health and social inequities are examples of areas of care that would benefit from collaboration between PC and PH. However, health care can be fragmented and discontinuous, making PH/PC collaboration difficult (Hutchison, Levesque, Strumpf, & Coyle, 2011). Collaboration for the purposes of this paper means healthcare professionals assuming complementary roles and working together towards a common goal enhanced patient care (O'Daniel & Rosentein, 2008).
Workforce analysis of who would do this collaborative work falls on physicians and nurses as the largest health professionals in the two systems. Based on their size in numbers, Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Nurse Practitioners (NPs) could play an important role in strengthening collaboration between PC and PH (Valaitis et al., 2013).
Based on their scope of practice, which includes health promotion, collaboration and chronic disease care (Australian Primary Health Care Nurses Association, 2017; British Columbia College of Nursing Professionals, 2018), nurses should be considered in primary healthcare system renewal (Fraher, Spetz, & Naylor, 2015;Smolowitz et al., 2015).
There is a clear need to clarify and optimize the RN's role in PC/ PH collaboration (Bauer & Bodenheimer, 2017;Fraher et al., 2015;Halcomb, Stephens, Bryce, Foley, & Ashley, 2016;Martin-Misener & Bryant-Lukosius, 2014), using their skills in health promotion and disease prevention and collaboration. Yet, the lack of RN role clarification and competency standards in this area (Halcomb et al., 2016; Registered Nurses Association of Ontario, 2012) and structural challenges such as restrictive funding models that inhibit team-based care (Bauer & Bodenheimer, 2017;Hutchinson et al., 2011) impedes the uptake of the RN role in these areas (Martin-Misener & Bryant-Lukosius, 2014).
The purpose of this work was to examine the roles of RN in PC/ PH collaboration in relation to their scope of practice. Specifically, we answer the following questions: (a) What are the roles of RNs in PC/PH collaboration; and (b) is the current scope of practice for RNs adequate to support their roles and activities in PC/PH collaboration? This research focused specifically on RN degree-prepared nurses; other nursing designations such as NPs and LPNs were not included in this review due to RNs' size in numbers and potential impact on the healthcare system and the differing scopes of practice of NPs and LPNs.

| DE S I G N
A scoping review of the RN's role in PC/PH collaboration was conducted. One of the goals of using a scoping review is to further enhance understanding, applicability and refinement of research questions that are broad and complex or have not been studied, for example RNs' role in collaboration between PC and PH in this research (Arksey & O'Malley, 2005;Colquhoun et al., 2014). Using this methodology illuminates the RN's role in PC/PH collaboration and may assist in the development of future research questions.
The PRISMA checklist (see File S1) provided support for reporting findings.

| ME THODS
Drawing on the work of Arksey and O'Malley (2005), Levac, Colquhoun, and O'Brien (2010) and Valaitis et al. (2012), we followed six steps in conducting our research: identifying the research questions; searching for relevant studies; selecting studies; charting the data and collating; summarizing; and reporting the results.

| 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.

| 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.

| E THI C S
In conducting this scoping review, no research ethics committee approval or patient consent was needed and therefore not obtained.
No funding was obtained through this research by the authors or any conflict of interest identified.

| RE SULTS
The combined search strategy yielded a total of 56 papers, and of these, 23 papers met the inclusion criteria ( Figure 1). Twelve papers were removed as there was no clear collaboration between PC and PH. The remaining 44 papers were read in detail, and 21 papers were excluded for no identification of nurse role. Most papers were published from 2012-2014 (see Table 1).
No articles focused entirely on the role of the RN in PC/PH collaborations, and when this role was discussed, it was mentioned briefly. Four main RN roles were identified from the data:   (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; and chronic disease management (Ferrer et al., 2013;Weinstein et al., 2013). 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).

| 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) nationally (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;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), 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).

| CON CLUS ION
There are limitations to this scoping review that require consideration. There was an opportunity of some literature being missed due to database selection, search limitations in language and country and possibly missing some grey literature. There was also a lack of depth in the broadscale nature of the scoping review, and no articles specifically about nurse's roles were obtained, which may have affected the results of the study. The focus of scoping reviews is to provide breadth rather than depth of information; thus, a metaanalysis is generally not conducted (Tricco et al., 2016). However, this method was appropriate for our research given our objectives and the current broad understanding of this topic. Finally, it is possible that there are additional roles for RNs in PC/PH collaboration, as our review included work up to 2016. However, the RN roles

ACK N OWLED G EM ENTS
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

CO N FLI C T O F I NTE R E S T
The authors have no conflict of interest to declare.