JEFFERSON CITY — In response to the COVID-19 pandemic, multiple states have given highly trained nurses more leeway to provide care without a doctor’s supervision.
While Missouri has relaxed some of its rules, the state’s nurse practitioners are asking Gov. Mike Parson’s administration to do more, arguing that many of the regulations are unnecessary and even harmful.
“Missouri is the most restrictive state in the nation,” said JoAnn Franklin, who has worked as a nurse practitioner in Missouri since the late 1970s. “A lot of states right now, because of COVID-19, have taken all barriers away.”
Nurse practitioners have at least a master’s degree and go through more training than registered nurses, according to the American Association of Nurse Practitioners. They are a type of advanced practice registered nurse and are certified by a national board.
They provide much of the same primary and specialty care that doctors do.
But in some states — including Missouri — they can only practice with a physician’s oversight. Missouri’s nurse practitioners say this lack of autonomy hurts people’s access to care even in normal times, but especially during emergencies.
Advocates have tried for years to get legislation passed that would expand their authority to practice independently. While the COVID-19 pandemic has caused the state to temporarily loosen the rules, nurse practitioners want the changes to go further — and to stick permanently.
Normally, nurse practitioners and other APRNs in Missouri must collaborate with a physician who is within a 75-mile radius. The physician must also review a certain percentage of their patients’ medical charts.
Both those regulations have been removed until May 15 — with a caveat: physicians still need to review a percentage of charts when nurses prescribe controlled substances. The state also waived a rule that requires an APRN and physician to practice together for the first 30 days of their collaboration.
But these moves haven’t been enough for the state’s nurse practitioners.
The Association of Missouri Nurse Practitioners has sent multiple letters to Parson, asking him to waive the collaboration requirement entirely.
The regulation “is preventing hundreds if not thousands of health care providers from offering care in accordance with their training,” wrote Derek Leffert, the association’s executive director, in an April 1 letter.
When asked whether Missouri was considering this, a spokeswoman for the Board of Nursing said questions about future plans to modify the collaboration requirement should be referred to lawmakers.
Franklin said getting rid of the 75-mile rule doesn’t really help because nurses aren’t likely to find new collaborators on short notice.
“I just don’t see how it improves patient care,” she said. “It’s not going to make a difference.”
Laura Kuensting, the association’s advocacy chair, said even if nurses want to go where they’re most needed, some physicians don’t want them to.
“(The doctors) do not really want to assume responsibility for the APRNs’ actions when they’re not working on behalf of the organization with whom they’re employed,” she said.
“Based on the models we’re seeing for COVID in Missouri, we will need additional personnel to assist at medical facilities, including the alternate care sites that we’re currently making ready,” Sandra Karsten, director of the state’s Department of Public Safety, said at the time.
Kuensting, who is a professor in the University of Missouri-St. Louis’ College of Nursing, said she signed up for the response team. But unless she finds a physician on the team to collaborate with, she can’t diagnose illnesses, treat patients, prescribe medicine or even sign death certificates.
“And I’ve been in practice over 30 years,” Kuensting said.
A long struggle
Twenty-two states, the District of Columbia and two U.S. territories allow nurse practitioners and other APRNs to practice independently from physicians, according to the American Association of Nurse Practitioners.
Among the states that don’t, five have temporarily given nurse practitioners full authority to practice because of COVID-19. About a dozen states, including Missouri, have waived some but not all collaboration requirements. And Missouri’s nurses aren’t the only ones calling for fewer regulations: nurse practitioners in Virginia and California have made similar requests.
Kathleen Haycraft, a regional director with the American Association of Nurse Practitioners, oversees four states, including Missouri. Two of those states — Iowa and Nebraska — let nurse practitioners operate without physician oversight, while the other, Kansas, has much looser rules.
This makes a real difference, Haycraft said.
“Any state with full practice authority has dramatically better outcomes in terms of health care and mortality rates,” she said.
In Missouri, rural areas often lack hospitals and face a shortage of health care workers even in normal times. Fifteen hospitals have closed in the state since 2014, and two-thirds were in rural areas. When that happens, the physicians tend to leave, Haycraft said.
“What you’re left with are nurse practitioners who are perfectly willing to stay and take care of those patients but aren’t able to because they can’t find a physician within that 75-mile radius,” Haycraft said.
Long before the pandemic hit, the state’s nurse practitioners were pushing for more autonomy.
This year, the Association of Missouri Nurse Practitioners backed multiple pieces of proposed legislation that would reduce or remove barriers for APRNs, Kuensting said. While lawmakers plan to return to the Capitol on Monday, it’s not clear whether they will consider anything aside from the state’s budget for the next fiscal year.
Franklin, who is a former president of the association, said before the early 1990s, there weren’t any laws in Missouri restricting their practice. Since then, she’s watched the rules get tighter, even as she advocated for more freedom to practice.
“I’ve been trying to do this for a long, long time,” Franklin said. “It’s just really frustrating that it continues to be so burdensome.”