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A 2012 white paper on the status of advanced practice registered nurses (APRNs) in Missouri released in association with the Missouri Nurses Association began by pointing out how advanced nurse clinicians could be the solution to the state’s shortage of healthcare providers. This is a systemic problem that requires a systemic solution, as increasing the number of active APRN licenses also brings attention to the need to increase the number of qualified nurse educators, clinical nurse leaders, informaticists and nurse administrators. The common denominator among all these vital players is a Master of Science in Nursing (MSN).
An MSN provides RNs with an advanced education in health assessment, pharmacology, and pathophysiology, giving them access to a greater level of autonomy and higher pay when compared with ADN and BSN educated clinicians (average salaries for nurses in Missouri provided by the US Department of Labor in 2014):
- RN average salary – $58,040
- Nurse midwife average salary – $86,530
- Nurse practitioner average salary – $89,690
- Nurse anesthetist average salary – $151,330
Active APRN licenses were distributed among the four Board-recognized roles as follows in 2014:
- Nurse practitioners – approximately 6,150
- Nurse anesthetists – approximately 1,764
- Clinical nurse specialists – approximately 375
- Nurse midwives – approximately 119
Missouri State Recognition Requirements for RNs in the Four APRN Roles
The Missouri Division of Professional Registration’s Board of Nursing grants APRN status to qualified RNs by issuing a document of recognition to practice as an APRN. The board recognizes four APRN roles:
- Certified Nurse Practitioner (CNP)
- Certified Registered Nurse Anesthetist (CRNA)
- Clinical Nurse Specialist (CNS)
- Certified Nurse-Midwife (CNM)
Nurse practitioners and clinical nurse specialists further specialize by becoming educated and certified in a specific patient population focus, such as family-individual across the lifespan; adult-gerontology primary or acute care; neonatal; women’s health; or psychiatric-mental health. The following population foci are some of the most popular in Missouri (numbers from the Missouri State Board of Nursing, 2016):
- Family nurse practitioner – 3,418 of these APRNs in Missouri
- Adult nurse practitioner – 1,042
- Pediatric nurse practitioner – 671
- Women’s health nurse practitioner – 340
- Neonatal nurse practitioner – 258
- Clinical nurse specialist in adult health – 162
- Clinical nurse specialist in adult psychiatric/mental health – 92
Applicants must fulfill these conditions to earn APRN status in Missouri:
- Hold a current RN license from Missouri or another compact state
- Earn an MSN degree in a specific APRN area of focus, which must include at least 500 hours of clinical education
- Become nationally certified by a board-recognized organization in a specific APRN role (and population focus for nurse practitioners and clinical nurse specialists)
The national certification organizations recognized by the board are as follows, listed along with the APRN role they certify:
- Nurse-Midwives – American Midwifery Certification Board (AMCB)
- Nurse Anesthetists – National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA)
- Nurse Practitioners and Clinical Nurse Specialists – in addition to the APRN roles these national organizations also certify for specific population foci:
Earning a Master of Science in Nursing (MSN) in Missouri
Online MSN programs provide RNs with the flexibility they need to maintain a busy work schedule while going to school, and often provide additional options for part-time and accelerated scheduling. These schools partner with hospitals and universities throughout Missouri in an effort to maximize local options for the clinical portion of MSN programs. In most cases, students are able to complete clinical sequences at their current place of employment.
Additionally, graduate nursing students can find MSN programs located at schools with campus locations throughout the state in the cities of:
- Warrensburg
- Columbia
- Kansas City
- Springfield
- Saint Louis
- Cape Girardeau
When selecting an MSN program, prospective APRNs should ensure it is accredited by an agency that is recognized by the appropriate national certifying organization:
- Nurse Anesthetist Graduate Programs – the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) is the accrediting agency for nurse anesthetist programs
- Nurse-Midwife Graduate Programs – the Accreditation Commission for Midwifery Education (ACME) is the accrediting agency for nurse-midwife programs
- Nurse Practitioner and Clinical Nurse Specialist Graduate Programs – the Commission on Collegiate Nursing Education (CCNE) and the Accreditation Commission for Education in Nursing (ACEN) are some of the most prominent accrediting agencies for nurse practitioner and clinical nurse specialist programs
Missouri Requirements for MSN Programs that Prepare Advanced Practice Registered Nurses
Students can develop an idea of what to expect in their MSN curriculum by examining the guidelines developed by national nursing education stakeholders:
Nurse-Midwife – the Accreditation Commission for Midwifery Education (ACME) specifies that a nurse-midwifery graduate program curriculum must cover:
- Promotion of family-centered care
- Professional responsibilities of nurse midwives
- Components and fundamentals of midwifery care
- Midwifery management process
- Primary health care of women
- Gynecologic care, perimenopausal, postmenopausal and care for other aging periods
- Management of common health problems
- Childbearing family
- Newborn care
The clinical segment of a program must also cover all of these core-competency areas.
Nurse Practitioners – the National Task Force of Quality Nurse Practitioner Education describes the nurse practitioner curriculum as follows:
- Population core competency objectives must be included in the curriculum
- The curriculum must be continuously updated by current nurse practitioner faculty members
- The didactic and clinical curriculum plan must be consistent with nationally-recognized population-focused competencies
- The curriculum must meet the standards for national certification in a population-focused area of practice
- The curriculum must prepare the prospective nurse practitioner to sit for a national certification exam that corresponds with the NP’s population focus
- Didactic coursework must be reinforced by clinical coursework
Nurse Anesthetist – the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) requires CRNA graduate program curriculum to include the following didactic elements:
- Advanced physiology and pathophysiology
- Advanced healthcare assessment
- Advanced pharmacology
- Ultrasound and radiology
- 135 hours covering pathophysiology, anatomy, and physiology
- 105 hours covering concepts in chemistry and biochemistry, pharmacology of anesthetic agents and adjuvant drugs
- 105 hours covering physics, pain management, equipment, technology, and basic-to-advanced principles of anesthesia practice
- 45 hours covering professional aspects of the practice of nurse anesthesia
- 45 hours covering clinical correlation conferences
- 30 hours covering nurse anesthesia research
Students must also complete 2,000 hours of supervised clinical training and study at least 600 clinical cases.
Clinical Nurse Specialist – the National Association of Clinical Nurse Specialists (NACNS) describes clinical nurse specialist academic requirements as follows:
- The curriculum must be accredited by a nursing education organization that is recognized by the US Department of Education
- It must be clearly aligned to address the care of a specific population, and be aligned with state requirements and nationally-recognized competencies
- The CNS program must be led by a CNS who has at least a master’s degree in the particular area of focus of the CNS program
- Students should have RN licenses throughout their studies
- Clinical courses must give students many opportunities to develop skills in key areas and meet the CNS licensure or certification requirements
- There must be an adequate number of faculty instructors and preceptors to ensure there is direct and indirect supervision during clinical courses
Selecting the Right Program Based on Current Education
Students can select an MSN program that fits their educational background:
- RNs with a Bachelor’s of Science in Nursing (BSN) – Nurses with a BSN can apply directly to traditional terminal MSN programs, which take around two years to complete.
- RNs with an Associate’s degree in nursing (ADN) – RNs with an ADN can apply to RN-to-MSN bridge programs, with accelerated programs capable of being completed in around three years.
- Professionals with a Bachelor’s degree in an area other than nursing – Professionals with a bachelor’s degree in another field can apply to certain specialized MSN programs provided they complete certain prerequisites. These are referred to as direct-entry or entry-level MSN programs, and can be completed in around three years.
Scope of Practice and Missouri State Laws Governing Advanced Practice Registered Nursing
Laws that apply to APRN scope of practice in Missouri can be found in:
- Department of Insurance, Financial Institutions and Professional Registration Division 2200 – State Board of Nursing
- Chapter 335 Nurses of the Missouri Revised Statutes
In general, APRNs are permitted to work within their specific APRN role, population focus, and collaborative practice arrangement, not going beyond their professional training and educational expertise.
The Missouri State Board of Nursing recognizes the scopes of practice provided by the national certification organization for each APRN role (and population focus for NPs and CNSs). These are the guidelines within which all APRNs must practice:
Scope of Practice for Nurse Practitioners – Provided by the American Association of Colleges of Nursing for an adult-gerontology primary care nurse practitioner:
- Manage the status of patient health and illness
- Provide disease prevention services
- Perform physical examinations
- Employ diagnostic and screening activities
- Evaluate outcomes of care
- Provide comfort and emotional trust
- Create an effective learning environment
- Demonstrate evidence-based approaches for care
Scope of Practice for Clinical Nurse Specialists – Provided by the American Association of College of Nursing for adult-gerontology clinical nurse specialists:
- Interact directly with patients, families, and groups of patients to promote health, well-being, and improve the quality of life
- Problem solve via consultation with other medical professionals
- Empower others to influence clinical practice through education, role-modeling, and mentoring
- Develop age-specific clinical standards, policies, and procedures
- Assist patients and their families with navigating the healthcare system
- Provide patient education that is appropriate to age and developmental level
- Analyze research and other evidence to determine potential clinical applications of new knowledge
- Use quality monitoring to enhance and assess patient improvement
Scope of Practice for Nurse Midwives – provided by the American College of Nurse-Midwives:
- Provide a full range of primary health care services for women, from adolescence to post-menopausal
- Services include primary care, gynecological care, preconception care, pregnancy care, and family planning services
- Care also includes that provided during the childbirth and post-partum periods, as well as newborn care
- Provide initial and ongoing comprehensive assessments, diagnosis, and treatments
- Treatments can be offered for all types of this care, including those for male partners with sexually transmitted diseases
- Health promotion, disease prevention, and wellness education
Scope of Practice for Nurse Anesthetists – provided by the American Association of Nurse Anesthetists:
- Performance of a pre-anesthetic assessment and evaluation of the patient
- Development and implementation of an anesthetic plan
- Practices that induce general, regional, local, and sedation
- Selection, application, and insertion of noninvasive and invasive monitoring equipment for the evaluation of a patient’s status
- Continued management of a patient’s anesthesia
- Facilitation of the emergence and recovery of a patient from anesthesia
- Providing post-anesthesia follow-up evaluations and care
APRN Collaborative Practice Arrangement in Missouri
APRNs must establish a collaborative practice arrangement with a supervising physician in Missouri. This does not have to be filed with the board, however, it must be established and kept as a written record. Collaborative practice arrangements can be written arrangements, mutually-agreed upon protocols, or orders for the delivery of healthcare services. These can provide details about:
- APRN’s authority to administer or dispense drugs, including a list of specific controlled substances
- APRN’s authority to provide treatment and healthcare services within a defined scope of practice
- Complete names, addresses, and phone numbers of participating parties
- List of practice locations
- Professional credentials of the collaborating physician and APRN
- How the APRN and physician will engage in collaboration
- How the APRN will maintain geographic proximity to the supervising physician (the geographic proximity requirement can be waived for 28 days at rural health clinics) – generally the APRN must be located within at least 30-50 miles of the collaborating physician
- How the physician will review the APRN’s performance
Physicians may only enter into collaborative practice arrangements with a maximum or three APRNs, except in a hospital setting.
Nurse anesthetists can provide anesthetic drugs under the supervision of an anesthetist, physician, dentist, or podiatrist without specifying the drugs on a collaborative practice agreement.
Except for population-based public health services, collaborating physicians must first be continuously present with an APRN for at least one month before they can work without a physician being continually present.
Prescriptive Authority for APRNs in Missouri
Once RNs receive their document of recognition of APRN status they have the immediate authority to prescribe legend drugs as specified within their collaborative practice arrangement.
Additional steps must be taken to prescribe controlled substances and earn a certificate of controlled substance prescriptive authority:
- Complete an advanced pharmacology course that includes coverage of pharmacokinetics, pharmacodynamics, current and commonly used medications, and drug therapy for the treatment of disease or promotion of health – this type of course is often part of an MSN graduate curriculum
- Apply for a license with the Missouri Bureau of Narcotics and Dangerous Drugs
- Register with the Drug Enforcement Administration (DEA)
The collaborative practice arrangement should specify the class of controlled substance that is authorized for prescription, which can range from Schedule III-V, as well as Schedule II hydrocodone drugs. Nurse anesthetists may not use these drugs for sedation. APRNs may only prescribe a 120-hour supply of Schedule II and III narcotics or hydrocodone.
Implementation of the APRN Consensus Model in Missouri
With the goal of improving the quality of healthcare and expanding access, and to improve APRN mobility so as to allow advanced practitioners to easily move between facilities across state lines, the National Council of State Boards of Nursing (NCSBN) advocates implementation of the APRN Consensus Model. Important aspects of the Consensus Model have already been implemented in Missouri:
- Definition of four APRN roles: nurse practitioner, nurse midwife, clinical nurse specialist, and nurse anesthetist
- Prescriptive authority
Outstanding elements of the NCSBN’s consensus model that have yet to be implemented in Missouri include:
- Full independent practice, including for prescriptive authority
- Separate licensure process to gain APRN status
APRNs and professional organizations in Missouri are in the process of achieving these remaining goals. For example, the Missouri Nurses Association (MONA) lists APRN full Schedule II prescriptive authority and APRN full practice authority as two of its main legislative priorities for 2016.
Continuing Education Requirements for APRNs in Missouri
To maintain their APRN status and renew their document of recognition, nurses must take the following steps:
- Maintain their RN license, which means renewing it biannually by April 30th of odd-numbered years
- Maintain national certification in the APRN role, and population focus if an NP or CNS – this requires completing continuing education and/or enrolling in a maintenance program
- Notify the Missouri State Board of Nursing each time the national certification is renewed, ideally three months before this takes place