Board of Nursing

Nursing & Collaborative Practice

A REGULATORY PERSPECTIVE

In 1993, the Missouri Legislature and Governor provided statutory legitimacy to advanced practice nursing with House Bill 564. The Missouri State Board of Nursing's rule, 20 CSR 2200-4.100 Advanced Practice Nurse, which further defined this statute, 335.016 (2), RSMo, and instituted an advanced practice nurse application process, became effective June 30, 1996, with a modest amendment effective October 30, 1997.

In order to call, title, represent, or designate oneself or practice as an advanced practice registered nurse within a particular clinical nursing specialty area (e.g., family, women's health, medical-surgical, pediatric, etc.) and role (i.e., nurse anesthetist, nurse midwife, nurse practitioner, or clinical nurse specialist), a nurse must be licensed as a registered professional nurse in the State of Missouri and must be granted a 'Document of Recognition' from the Missouri State Board of Nursing. The 'Document of Recognition' is not a separate license. Rather, the 'Document of Recognition' indicates the particular advanced practice nurse title that is to be used by the individual and specifies the legal scope of advanced nursing.

Confirmation of whether a registered professional nurse has current advanced practice registered nurse status can be accomplished by contacting the Missouri State Board of Nursing. Grounds exist for investigation and discipline of registered professional nurses' licenses for titling, designating, or representing themselves or practicing as advanced practice registered nurses in Missouri when advanced practice registered nurse recognition has never been sought or when recognition has lapsed because continued recognition requirements were not met prior to the expiration date on their 'Document of Recognition'.

Collaborative Practice Arrangements

In 1993, pursuant to House Bill 564, the Missouri Legislature and Governor provided statutory authority for physicians and registered professional nurses who were advanced practice registered nurses to engage in written collaborative practice arrangements. Further defining this statute, 334.104.2, RSMo, was the Missouri State Board of Nursing's and State Board of Registration for the Healing Arts' joint rule, 20 CSR 2200-4.200 (Nursing) or 20 CSR 2150-5.100 (Healing Arts) Collaborative Practice, which became law on September 30, 1996, with a modest amendment effective October 30, 1998.

In order to perform advanced practice registered nurse delegated medical acts that would be specified in a written collaborative practice arrangement with a physician, meeting the requirements of the Advanced Practice Registered Nurse Rule and, thereby, securing a 'Document of Recognition' is a necessary precursor. Grounds exist for investigation and discipline of registered professional nurses' and physicians' licenses for engaging in written collaborative practice arrangements wherein the delegations are to the registered professional nurse as an advanced practice registered nurse when the particular nurse is not recognized as an advanced practice registered nurse within any clinical nursing specialty area or role.

Although collaborative practice arrangements are defined in 334.104.2, RSMo as written agreements, jointly agreed upon written protocols, or written standing orders for the delivery of health care services, advanced practice registered nurses often secure written agreements with collaborating physicians.

Within the rule, 20 CSR 2200-4.200 Collaborative Practice, there are several required collaborative practice entries that either the Board of Nursing or Healing Arts would look for in collaborating professionals' written agreements:

• Agreement must establish "guidelines for consultation and referral to collaborating physician or designated health care facility for services or emergency care beyond the education, training, competence, or scope of practice of" advanced practice registered nurse [see (3)(D) of rule]
• Collaborative Practice arrangement must be written agreement, jointly agreed upon protocols, or standing orders "specific to the clinical conditions treated" by collaborating physician and advanced practice registered nurse [see (3)(G) of rule]
• Collaborative Practice arrangement must be signed and dated by both collaborating physician and advanced practice registered nurse before implementation, and signatures must signify "that both are aware of its content and agree to follow" its terms [see (3)(H) of rule]
• "The collaborative practice arrangement and any subsequent notice of termination…" "shall be in writing" and maintained for a minimum of eight years after termination [see (3)(H) of rule]
• The collaborative practice arrangement must identify the process for review and management of abnormal test results [see (4)(D)]
• …collaborating physician, "or other physician designated in the collaborative practice arrangement" [see (2)(B),(3)(J),(4)(A), & (3)(I)9. of rule]

Other pertinent collaborative practice arrangement themes specified in the Collaborative Practice Rule that should be viewed as particularly significant to collaborating professionals with respect to the design, implementation, and defensible documentation of their practice together include:

• Scope or mutual scopes of practice [see (3)(A),(3)(B),(3)(C), & (3)(I)11. of rule]
• One calendar month practice together [see (2)(C) of rule]
• Physician's number of collaborative practice arrangements limitations [see (4)(C) of rule]
• Thirty (non-HPSA) or fifty (HPSA) road mile distance from one another [see (2)(B) of rule]
• Physician availability [see (2)(A),(2)(B), & (4)(A) of rule]
• Other physician designated in the collaborative practice arrangement [see (2)(B), (3)(J),(4)(A), & (3)(I)9. of rule]
• Physician two week review provisions [see (3)(J),(4)(B), & (4)(C) of rule]
• Process and documentation of review on file in collaborative practice setting [see (4)(F) of rule]
• Prescription pad requirements [see (3)(I)7. of rule]
• Controlled substance limitations [see (3)(I)9. of rule]
• Dispensing logs and 72 hour dispensing boundaries [see (3)(I)6.,(3)(I)10. of rule]
• Dispensing of drug samples [see (3)(I)10. of rule]
• No further delegation specifications [see (3)(E) of rule]
• Diagnosis and initiation of treatment for acutely or chronically ill or injured parameters [see (2)(B),(2)(C), & (4)(C) of rule]
• Conditions other than acute self-limited or well-defined problems parameters [see (3)(J) of rule]
• Provision of care to well patients or to those with narrowly circumscribed conditions parameters [see (3)(E) of rule]
• Population-based (public) health services [see (4)(E) & (5) of rule]
• Review and revision of collaborative practice arrangement as needed [see (3)(H) of rule]
• Physician accountability for delegated medical acts [see (3)(I)1. of rule]

It should be kept in mind that the requirements inherent in the above state statutes and rules regarding advanced practice registered nursing and collaborative practice may need to be interfaced with the requirements of other pertinent state or federal statutes and rules. It is imperative that advanced practice registered nurses comprehend their scope of practice and standards of care accountabilities and responsibilities, securing and utilizing all primary source data and documents that have any connection to their practice, its setting, its patients, its avenues of reimbursement, and so forth. The Collaborative Practice Rule states that the Missouri State Board of Nursing has the right and duty to discipline advanced practice registered nurses for "violations of any state or federal statutes, rules, or regulations regardless of the licensee's participation in a collaborative practice arrangement" [see (4)(G) of rule].