Strict regulations on nurses with advanced degrees and training prompt some to move

APRNs — advanced practice registered nurses — help provide access to health care especially in areas where there may be a shortage. Strict regulations in some states prompt many to cross state lines.

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When you need medical care, instead of a doctor, you might see an advanced practice registered nurse, known as an APRN. They are highly trained nurses, often with masters or doctoral degrees, and they're qualified to diagnose illnesses and provide primary care. As healthcare worker shortages continue nationwide, the number of APRNs is expected to grow. But in some places, strict regulations are pushing APRNs to practice in neighboring states, limiting healthcare access, especially in rural communities. Najifa Farhat with member station KBIA reports.

NAJIFA FARHAT, BYLINE: According to the American Association of Nurse Practitioners, there are about 450,000 advanced practice registered nurses across the country. Brandon Forester is one of them.

BRANDON FORESTER: I became a nurse practitioner in 2011, so roughly 15 years ago now.

FARHAT: He's driving to his clinic in Columbus, Kansas. Forester runs Midwest Medcon, a disability evaluation service for veterans. He started the business in southwest Missouri in 2020. Today, the company operates in five states and serves roughly 4,300 veterans each year.

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FARHAT: Inside the clinic, there's a small waiting room.

FORESTER: Usually, a large percent of our exams are orthopedic in nature, so backs, knees, joints, hips, that sort of thing.

FARHAT: He opened the Kansas clinic the same year the state granted APRNs full practice authority, allowing them to work independently. But next door in Missouri, there are restrictions. APRNs must work under collaborative agreements with physicians. Doctors have to be within 75 miles of the clinic and regularly review charts and prescriptions.

FORESTER: Every time we were going to open another clinic, we would not only have to recruit more staff, but then we have to go find another collaborative physician.

FARHAT: Forester says those agreements cost his business about $26,000 in Missouri in 2025 alone. He decided not to add more clinics in Missouri and says states with fewer restrictions are simply easier places to expand.

FORESTER: It removes an enormous barrier between the nurse practitioner and the veteran who's needing the service. I don't have to bring this third party into the relationship that I have to find and convince them to work with us and then pay them.

FARHAT: According to the Missouri State Board of Nursing, the state has about 16,000 APRNs. Roughly half work in hospitals or urban areas, where physician oversight is easier to manage. Jacob Scott is the director of legislative affairs for the Missouri State Medical Association, which represents physicians across the state. He says the restrictions are meant to help ensure quality patient care.

JACOB SCOTT: We believe in a collaborative model where physicians are the one quarterbacking the care, but we certainly see tremendous value in APRNs and everybody in the healthcare team to provide good patient care.

FARHAT: But the nurse practitioner groups argue the restrictions hit rural areas the hardest, where healthcare shortages are already severe. A 2022 Missouri Nursing Workforce Report found about 7% of APRNs leave the state to practice elsewhere. Valerie Fuller, president of the American Association of Nurse Practitioners, says it's common for APRNs to leave states with stricter rules for states with full-practice authority. She says that's how states like New Mexico, Arizona and Nevada saw their APRN workforce grow.

VALERIE FULLER: We know that there are many underserved communities across Missouri, and when you tether people like that, it prevents expansion into those underserved communities.

FARHAT: A bill proposed in Missouri's legislature this year could have paved the way for APRNs to transition to full-practice authority, but the bill was struck down. Fuller says states like Missouri also risk losing future talent as new nurse practitioner graduates prefer states where they can practice independently.

For NPR News, I'm Najifa Farhat in Columbia, Missouri.

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