New Bill Proposes Independent Practice for Missouri APRNs

• House Bill 1773 is the state of Missouri’s latest proposal to expand healthcare access by granting eligible APRNs independent practice without a supervising physician.
• APRNs will be eligible for independent practice after 2,000 documented hours of clinical practice under the supervision of a physician.
• Explore the common arguments for and against this bill, as well as the current legislation in other states about independent practice for APRNs.

On February 7th, Missouri concluded public hearings for House Bill 1773, which aims to grant independent practice authority to the state’s APRNs. This bill would allow eligible advanced nurses to practice without the supervision of a physician and grant them the same authority to prescribe medications.

Granting APRNs independent practice is said to aid in the growing health disparities in rural communities, where physicians are less common. Advanced nurses are one of the fastest-growing specialties and can bridge this care gap for patients in Missouri and in other parts of the U.S.

This article will outline the three changes proposed by HB 1773, the pros and cons of independent practice for APRNs, and an overview of the legislation on independent practice across the United States.

MO House Bill 1773

HB 1773 was initially submitted on December 5th, 2023, and has been in hearings since January 3rd, 2024. The last public hearing was held last week on February 7th.

The Association of Missouri Nurse Practitioners (AMNP) has been posting weekly legislative updates for HB 1773 and SB 1058. AMNP has also been calling on APRNs to present testimony during the ongoing hearings for these bills.

There is no hearing scheduled for Missouri HB 1773, but its next steps include two votes on the House and Senate floor before eventually moving to the state governor for signing. This process can take several months.

This bill is broken down into three sections, revising earlier legislation from last year, which repealed the geographic range an APRN and a supervising physician had to practice within. 

Section 1

Section 1, also known as 334.104, dictates the collaborative relationship between physicians and APRNs. One requirement of this partnership with physicians dictates that a disclosure statement must be “prominently displayed” for patients to ensure they know they are being seen by an APRN.

This disclosure statement is to reduce ambiguity for patients who may be seen by advanced nurses, such as a Doctor of Nursing Practice (DNP) who uses the prefix Dr. Last year, the state of California attempted to fine a DNP nurse $20,000 for using her earned prefix of Dr.

The statement will also include the specifics of the APRN’s prescriptive power, such as what class of drugs they can administer to patients.

Section 1 will affirm previous legislation requiring partnered physicians to practice within 200 miles of the APRN. This will allow APRNs and physicians to collaborate via telehealth. 

Section 2

Section 2, also known as 335.016, will allow eligible APRNs to practice in Missouri without partnering with a supervising physician. It defines the types of advanced nurses eligible for independent practice and what the scope of that practice can include.

APRNs must be in good standing with over 2,000 documented hours partnered with a supervising physician to be eligible for independent practice.

Section 3

Section 3, also known as 335.019, describes the predictive power of APRNs practicing independently from a supervising physician. Eligible APRNs will be able to administer any controlled medication available to partnered APRNs within their specialty.

This section also outlines how nurses can gain a certificate of controlled substance prescriptive authority from the Missouri Board of Nursing. The certificate can be acquired by completing an advanced pharmacology course, at least 300 documented hours of experience with a preceptor, and at least 1000 documented hours of practice as an APRN.

Pros and Cons

Proponents of this bill, and APRN independence in general, believe that it can bring accessible healthcare to communities in need. Dr. Michelle Grimes, a family NP, states, “Sometimes when you have a collaborator, you can’t get in to see that doctor for months at a time. When you can’t get in to see a doctor then that leaves that patient going to the ER to seek care, maybe not even receiving care at all.”

The Rural Health Information Hub estimates that 80% of Missouri’s residents lack a primary care provider. The disparity could be helped by the 15,084 actively licensed APRNs in Missouri.

A recent study from October 2023 also found that nurse practitioners matched prescription safety compared to physicians. Controlled medications are just one aspect of independent practice, but an important insight into any potential dangers that could arise.

However, some disagree with this legislation, such as Dr. George Hruza, who thinks these changes are happening too fast. He believes that previous changes (in reference to the mile restriction being lifted) should be “given the chance to work for a few years” before any new changes.

APRN Legislative Update

The conversation around HB 1773 reflects a national discourse on the scope of APRNs. Last month, the 36th Annual APRN Legislative Update was published, detailing legislative regulations for APRNs in each state.

This survey included 86% of all State Boards of Nursing (BONs) and Nurse Practitioner organizations.

According to his survey, 17 states, including the District of Columbia, allow APRNs full independent practice without previous supervision from a physician. 11 states grant full independent practice to APRNs after a period of supervision.

These 11 states have a combination of clinical hour requirements (1,000 to 3,600) and length of practice requirements (18 months to 5 years). Missouri is modeling HB 1773 off of these clinical hour requirements.

Of the remaining states, 16 offer APRNs a restricted/reduced practice without any previous clinical requirements.

That leaves the final 7 states that offer APRNs a reduced/restricted practice after a period of supervision. These requirements are generally stricter than the earlier starts, such as Arizona requiring 6,240 hours of supervised clinical hours before granting a restricted practice.

A full breakdown of full practice versus reduced, and restricted practice can be found here.

The Bottom Line

Overall, legislation across the United States looks optimistic for APRNs gaining full practice authority. With over half of the US granting APRNs full practice authority, more patients will have access to a primary care provider where a physician was not available before.

The experience and responsibilities of independent practice will also push advanced nurses, giving them new insight and perspective they may use as nurse educators or nurse leaders in the future. 

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