Nurse practitioners: changing the landscape of health care delivery

July 2010

Youth health NPs GILL ALCORN and REBECCA ZONNEVELD report back on the work of nurse-managed health centres in the US.

Late last year we were joint recipients of travel awards from Fulbright New Zealand and The College of Nurses Aotearoa New Zealand. The awards allowed us to attend and present at the National Nursing Centers Consortium’s (NNCC) 8th Annual Conference of Nurse-managed Health Centers held in Philadelphia in November. Following the conference Tine Hansen-Turton, executive director of NNCC and the Convenient Care Association, facilitated an excellent site visit programme to a wide range of nurse-managed health centres serving vulnerable populations within Philadelphia.


Tine Hanson-Turton, Erin Hillman, Diane Shoemaker, Rebecca Zonneveld, Dan Geisler, Gill Alcorn at the Eisenhower Fellowships Office, Philadelphia.

The nurse practitioner role in the United States started more that 40 years ago and over 25,000 NPs are currently employed in the US. International literature has consistently demonstrated that NPs deliver quality health care, and a comparison between NP care and physician care shows that NP care is less expensive and the level of consumer satisfaction is high. NP interventions show a high level of effectiveness in low socio-economic communities where holistic care supports positive health outcomes.

Nurse-managed health centres are community-based, not-for-profit organisations staffed and run by NPs, registered nurses, public health nurses, clinical nurse specialists, health educators, mental health professionals, community outreach workers, and collaborating physicians. Nurse-managed health centres in the US deliver 2.5 million annual client encounters per year to low-income and vulnerable populations. Sites visited included the Homeless Shelter-City Housing Project, the Public Health Management Corporation Health Connection and the Rising Sun Health Center. These centres were examples of health services where NPs are employed as part of multidisciplinary health care teams to serve under-insured and uninsured vulnerable populations.

Eleventh Street Family Health Services of Drexel University is an example of an outstanding nurse-managed health centre where a team of six full-time NPs and four part-time NPs serve as primary health care providers to a population based within surrounding council housing estates. These NPs provide a comprehensive range of care, including: physical examinations, diagnosis and treatment, family planning and mental health care. NPs, social workers, nutritionists, psychologist, physical therapists and dentists work as a multidisciplinary team within this purpose-built health care setting.

A site visit was undertaken of Congreso de Latinos Unido, a not-for-profit Latino organisation situated in a low socio-economic Latino community. Congreso is a comprehensive provider of social, economic, educational, and health services. This multi-agency collaboration promotes service accessibility and seamless referral pathways between services. This site visit was relevant to the New Zealand context as we explore best practice models in relation to ‘integrated family health centres’ and ‘whanau-based interventions’.

The role of NPs in the US has become more visible to the general population since the establishment three years ago of retail health care or NP clinics based in drugstores and chain stores. NPs provide convenient care in retail centres such as Target, Wal-Mart, and drugstore chains such as Walgreens. There are currently 1200 retail NP health clinics across the United States and the Convenient Care Association supports the development of resources, best practice guidelines and standards.

The potential for retail health care to interface with primary health organisations (PHOs), or alternatively to be delivered using a business model, was discussed in relation to the New Zealand context. The potential for NPs and advanced nurses in New Zealand to work in retail settings to undertake health assessment and treatment, health screening, health promotion, and immunisation outreach was evident. Modifying current government funding pathways and developing a commercial business case for the retail NP model has the potential to bring a new dimension to the primary health care landscape as we seek to provide timely, convenient and accessible health care.

The partnership between university nursing departments and the link between NP clinical delivery and NP clinical training was also evident in nurse-managed health centres in the US. NP workforce devlopment and career pathway development in New Zealand require effective clinical training programmes, funded NP candidate training roles, and NP employment contracts reflecting a commitment to ongoing clinical nursing education (CNE).

Funding pathways in primary health care have traditionally been directed through a medical business framework – this historical model requires deconstructing and reconstructing and new funding pathways from government, DHBs and PHOs need to be opened up to allow the NP role in New Zealand to develop. The current shortage of general practitioners here is an opportunity to envision new models of health care delivery to complement traditional primary health care models.

Legislative barriers require urgent review and amendment so NPs can function effectively within this advanced nursing role.

Within the PHO environment the ability of NPs to register clients is urgently required.

The development of nurse-managed health centres has the potential to improve health care access and improve population health.

The partnership between university nursing departments and nurse-managed health centres is a model requiring exploration in the New Zealand context.

NP workforce development needs expansion of NP clinical training programmes.

NP candidate training programmes are required to support NP role development across the health care sector.

The opportunity of conference attendance, site visits and the hospitality provided by Tine Hansen-Turton and her staff enabled us to envision how the NP role can further develop in New Zealand. Incorporating new models of service delivery into the New Zealand health care landscape provides a real opportunity to improve population health. Releasing the capacity of the nursing workforce and the medical workforce and working to forge new models of health care delivery which promote the NP role will improve health care access and improve the health outcomes of New Zealanders.

Gill Alcorn is based at Hutt Valley’s Vibe Youth Health Services and Rebecca Zonneveld at Evolve Youth Health Services in Wellington.

References are available on request from


Gill Alcorn and Rebecca Zonneveld and staff from the Mary Howard Health Center.