1. Kaplan, Louise PhD, ARNP, FNP-BC, FAANP

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Several states, including Connecticut, Minnesota, and New York, removed scope of practice barriers for advanced practice registered nurses (APRNs) in 2014. We celebrate these successes and honor the hard work of the APRNs who contributed to them. It is equally important, however, to share the efforts of APRNs that have met great resistance in their legislative efforts to achieve full practice authority.


This article highlights the Missouri Council on Advanced Practice Registered Nurses of the Missouri Nurses Association (hereafter referred to as the Council) and Kathleen Haycraft, DNP, FNP-BC, PNP-BC, DCNP-BC, FAANP, an active member and leader of the Council's legislative efforts. Missouri's Nurse Practice Act presents APRNs with one of the most restrictive practice environments in the United States. APRNs must have a collaborative agreement with a physician who delegates authority to assess, diagnose, treat, and prescribe. Examples of these restrictive rules include: physicians must be geographically located at a certain distance from the APRN; physicians must be immediately available for consultation; and physicians must be present at least once every 2 weeks when an APRN practices at a site separate from the physician.1


Getting motivated

In her difficult legislative efforts to pursue controlled substance prescribing authority, Dr. Haycraft and her colleagues were met with resistance.2 When legislation passed in 2008, only Schedules III-V controlled substances were included as delegated by a physician; schedule III prescriptions were limited to 120-hour supplies with no refills. It also took until 2011 to finalize rules for controlled substance prescribing. Disappointed and frustrated by the need to make compromise, Dr. Haycraft took a sabbatical from her legislative involvement while she pursued her DNP education. The sabbatical was short lived after she read an article that motivated her to reengage in legislative and political action. She decided to never leave the table-or retire until unrestricted practice authority was achieved.


Strategic approaches

Making the Council more open to allow input from all APRN groups in the state was an initial component of the legislative strategy to achieve unrestricted practice. Dr. Haycraft also convened a group to write a briefing document for APRNs to be better prepared to discuss APRN practice and the negative effect restrictions have on access to care for patients. The Status of Advanced Practice Registered Nurses in Missouri: A White Paper was initially published in January 2012 and revised in January 2014. (


Legislation in 2012

The initial approach to unrestricted practice was a bill modeled after Maryland that only required an APRN to attest to having a physician with whom to collaborate without requiring the physician to sign or be involved in any way. This approach was met with confusion, and the chair of the House of Representatives committee (to whom the bill was referred) refused to allow the bill to receive a vote even though there was enough support to vote it out of committee.


Legislation in 2013

The strategy was revised in 2013 to use "transition to practice" language, much like Maine, which requires nurse practitioners to practice under supervision for at least 24 months.3 This bill was voted out of the House committee and was referred to the Rules Committee whose chair refused to schedule the bill for a vote by the full House. A companion Senate bill received a committee hearing but no vote.


Legislation in 2014

A tri-cameral approach was developed for 2014. Previous efforts had been focused on the Legislature, and while bills were again proposed, engagement with the executive and judicial branches of government also took place. The Executive branch was engaged by having the Governor agree publicly that all barriers to APRN practice should be removed. This, however, was not effective. The Governor's chief policy person is the son of a physician, and the proposal was not fully embraced. In addition, the Democratic governor does not have much influence on the Republican Senate and House of Representatives. The Judicial branch strategy involved letters from the Federal Trade Commission to address restraint of trade issues, which was not helpful, as legislators did not hold federal opinion in high regard.


Senate Bill 659 ( and House Bill 1491 ( are companion bills (the same bill dropped in the House and Senate) that were sponsored by supportive legislators. These bills would have allowed APRNs to assess, diagnose, treat, and prescribe independently. Both bills received a hearing in committee. The Senate committee never voted knowing a physician senator would have filibustered the bill had it moved forward. The House passed the bill out of committee where it died in the Rules Committee when the chair again refused to schedule it for a vote of the full House.


Interestingly, House Bill 1779 ( was signed into law allowing APRNs to determine that a restraint, isolation, or seclusion intervention was indicated for patients in mental health facilities. This bill was drafted by the chair of the Rules Committee who stalled the other APRN bills. The legislator has a state mental health hospital in her district, and this was needed for safety reasons. The APRN groups did not actively lobby this legislation, choosing instead to expend their efforts for unrestricted practice.


Grassroots involvement

Dr. Haycraft spends about 20 days a year at the state Capitol. She has regular contact with key legislators and staff. The Legislature convenes in January, and approximately 150 nurses attend a Legislative Day to kick off the session. The APRN groups' leaders meet four times a year at the Capitol with 30 to 50 people attending. Weekly strategy calls during the legislative session include 10 to 15 representatives of APRN groups. There are monthly calls when the Legislature is not in session. Contact to engage APRNs is made to Missouri's 1,700 members of the American Association of Nurse Practitioners and the Council's 600 members, keeping people informed and to encourage them to lobby a legislator for support of a bill.


Lessons learned for future endeavors

It is essential to have constituents lobby their legislators rather than relying solely on a lobbyist. Having people in leadership positions on committees supportive of the bill can make a crucial difference. Physician legislators support their medical society more than their constituents. Several APRN activists met with members of the St. Louis medical society and found them receptive to the proposed APRN legislation. Meeting with local medical societies is now a part of the strategy for success. There is only one nurse legislator who has been supportive of the Council's efforts. Having additional nurse legislators and electing a few key people who will support APRN legislation is also important.


Legislation in 2015 will likely be a "transition to practice" bill with 1 year of supervision. The final lesson learned is, "Don't give up." We need to keep looking for new ways to crack the wall.




1. Missouri Code of State Regulation. Rules of Departme-nt of Insurance, Financial Institutions and Professional Registration Division 2200-State Board of Nursing Chapter 4-General Rules. 2014. [Context Link]


2. Pennington DM. Continuing barriers to advanced nursing practice: Missouri's quest for controlled substance prescriptive authority. Missouri Nurse. 2007;2:7-15. [Context Link]


3. State of Maine Board of Nursing. Application for Approval of a Supervising Relationship with a Licensed Physician or Nurse Practitioner. [Context Link]