Ask a Professor: The NP Practice Environment in Missouri

“It is surprising how many people still do not understand the NP role,” Dr. Carter says. “We must spread the word about what NPs are capable of and how restricted practice hinders patient care. NPs must take advantage of every opportunity to make our collective voices heard.”

Dr. Shelley Carter, Family Nurse Practitioner (FNP) Graduate Program Director at Missouri State University School of Nursing & Clinical Assistant Professor

America needs more expertly trained healthcare professionals. As the retirement of the Baby Boomers raises the average age of the population, medical schools can’t graduate enough physicians at a high enough rate to meet the growing need for their services: a 2020 report from the Association of American Medical Colleges (AAMC) forecasts a shortfall of between 54,100 and 139,000 physicians in both primary care and specialty services by 2033. And for many states, the current shortage is already severe, particularly in rural areas.

Missouri is not immune. The Show-Me State has 324 Health Professional Shortage Areas (HPSAs), which are home to a combined 1.69 million people. According to the Kaiser Family Foundation (KFF), less than 10 percent of the primary care needs are met in these areas. Unless changes are made, the problem will only get worse. 

The good news is that Missouri’s NPs are extensively trained to step in and meet a significant portion of the state’s healthcare needs. The bad news is that antiquated and obtuse regulations at the state level prevent Missouri’s NPs from practicing to the full extent of their education and training. 

Eight of the ten healthiest states in the nation have taken the step of enacting more progressive legislation that empowers NPs to provide the services they’re trained to provide; Missouri could, and should, follow their lead.

Meet the Expert: Shelley Carter DNP, APRN, FNP-C

Dr. Shelley Carter is the family nurse practitioner (FNP) graduate program director at Missouri State University School of Nursing, where she also serves as a clinical assistant professor. She earned her BSN, FNP, and DNP from Missouri State University. 

Dr. Carter’s doctoral research project focused on screening and psychotherapy for depression-chronic Illness comorbidities in a free primary care clinic. Today, in addition to teaching classes on family practice and the applications of advanced human pathophysiology, she maintains research and clinical interests in serving vulnerable populations. 

The Value of NPs in Missouri

“NPs are highly qualified to provide excellent, affordable care to Missouri residents,” Dr. Carter says. “NPs are trained to provide holistic care, meaning they consider the entire patient experience, including a patient’s family situation and access to resources. This style of care is especially important in the rural setting.”

Over a third of Missouri is classified as rural. According to the Missouri Department of Health and Senior Services, the 2.23 million residents of these rural areas have lower income levels, lower education levels, and overall poorer health than residents of urban areas. Poorer health leads to more emergency room visits, lower life expectancies, and higher death rates. 

As grim as the figures are, the state’s NPs could be a critical part of the solution: NPs are statistically much more likely to serve in rural areas than physicians, and, according to a 2019 study in the American Journal of Managed Care, NPs provide the same level of care as physicians for routine patients. 

“Physicians may be hesitant to build practices in rural settings, resulting in underserved individuals in these areas,” Dr. Carter says. “NPs are highly qualified to fill this gap in care.”

The Burdens of Restricted Practice for Nurse Practitioners

According to the American Association of Nurse Practitioners (AANP), Missouri is classified as a restricted practice state, meaning that the state’s NPs face regulatory barriers in practicing to the full extent of their training and education. The majority of the state’s restrictions come through its requirement for NPs to enter into a collaborative agreement with a supervising physician. In essence, it requires an NP to be tethered to a physician who will consult and approve of treatments that the NP is qualified to administer on their own. 

“Being tied to a collaborative agreement means that if the collaborative physician leaves their practice, then the NP must find another collaborator,” Dr. Carter says. “If this process is delayed, then the NP is not able to provide patient care until another agreement is arranged. This leaves patients without care.”

Missouri has some of the most restrictive rules in place for its NPs. A supervising physician must review 10 percent of an NP’s charts and 20 percent of an NP’s charts that include the prescription of controlled substances, every 14 days. 

An NP also needs to document one month of practice with a supervising physician before being allowed to practice in a clinic where a physician is physically present. And a physician cannot collaborate with more than three NPs at one time, which severely limits the force-multiplying benefit that the state’s NPs can provide, especially in rural areas, where physicians are in short supply. 

Missouri is also one of the only states that puts a geographic restriction on its NPs: NPs cannot practice more than 75 miles from their collaborating physician (it was only 50 miles until 2019). This negatively impacts the state’s rural areas, which were already the most underserved. It’s also a major issue during times of crisis: when the Joplin tornado ravaged the state in 2011, Missouri’s NPs were unable to volunteer their support and service outside of their geographically defined area of practice. 

“Many areas in Missouri are rural,” Dr. Carter says. “If an NP cannot find a collaborating physician in a particular rural setting, then people living in that area may not have healthcare readily available. Full practice authority would remove this restriction, and potentially expand care into more rural settings. In order to provide healthcare to the greatest number of people, NPs need to be able to practice to the full scope of their license.”

The Future of NP Practice in Missouri

The answer is full practice authority. Simply defined, full practice authority means granting NPs the ability to practice to the full extent of their training and education, under the exclusive licensure authority of the state board of nursing. Over half the states in the nation have adopted full practice authority laws, and it’s a critical step towards addressing the growing healthcare needs of an aging population. While full practice authority is not a revolutionary idea, it can still have a revolutionary impact.

“A great number of states have granted full practice authority to NPs,” Dr. Carter says. “We must continue to advocate for full practice authority in Missouri in order to increase access to healthcare for all Missouri residents.”

Missouri NPs put forth a full practice authority bill every year, but legislative progress has been slow. House Bill 1816 would’ve removed the geographic restriction in collaborative agreements; other bills have taken aim at dismantling certain aspects of the collaborative agreement requirement. As in other states where progressive legislation has passed, NPs themselves, along with their professional associations, are the leading voice of these advocacy efforts.

Perhaps the most significant step forward has come on the heels of the Covid-19 pandemic: on April 1, 2020, executive orders temporarily waived some of the restrictions on NP practice in Missouri, including the geographic limitation on NP practice. In a time of crisis, Missouri turned to its NPs to step in and fill a critical need; it would be wise to do so before the next crisis hits. Missouri’s NPs are banding together to advocate for full practice authority now, for the benefit of all the state’s residents. 

“It is surprising how many people still do not understand the NP role,” Dr. Carter says. “We must spread the word about what NPs are capable of and how restricted practice hinders patient care. NPs must take advantage of every opportunity to make our collective voices heard.”

Matt Zbrog

Matt Zbrog


Matt Zbrog is a writer and researcher from Southern California, and he believes nurse practitioners (NP) are an indispensable component of America’s current and future healthcare workforce. Since 2018, he’s written extensively about the work and advocacy of NPs, with a particular focus on the rapid growth of specialization programs, residencies, fellowships, and professional organizations. As part of an ongoing series on state practice authority, he’s worked with NP leaders, educators, and advocates from across the country to elevate policy discussions that empower NPs. His articles have featured interviews with the leadership of the American Association of Nurse Practitioners (AANP), the National Association of Pediatric Nurse Practitioners (NAPNAP), and many other professional nursing associations.