Sermchief v. Gonzales
1983 Mo. LEXIS 405, 660 S.W.2d 683 (1983)
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Rule of Law:
The expanded definition of "professional nursing" under Missouri's Nursing Practice Act of 1975 permits licensed nurses to perform diagnostic and treatment procedures, so long as those acts are consistent with their specialized education, judgment, and skill and are performed pursuant to standing orders or protocols created by a licensed physician.
Facts:
- The East Missouri Action Agency (Agency), a non-profit corporation, provided family planning and gynecological services to the public, primarily lower-income patients.
- Nurses Rita Solari and Jan Burgess, licensed professional nurses with post-graduate training in obstetrics and gynecology, were employed by the Agency.
- Licensed physicians employed by the Agency created and signed written standing orders and protocols specifically for the nurses to follow.
- Pursuant to these protocols, the nurses took patient histories, performed breast and pelvic examinations, conducted lab tests, dispensed contraceptives, and provided counseling.
- If a nurse identified a condition described in the protocols that required further evaluation, the patient was referred to an Agency physician.
- There were no allegations that any patient was harmed by the actions of the nurses.
- The Missouri State Board of Registration for the Healing Arts (Board) learned of the nurses' activities.
- The Board threatened to initiate proceedings against the nurses for the unauthorized practice of medicine and against the physicians for aiding and abetting that practice.
Procedural Posture:
- Two nurses and five physicians filed a petition for declaratory judgment and injunction against the Missouri State Board of Registration for the Healing Arts in a Missouri trial court.
- The trial court found in favor of the Board, holding that the nurses' conduct constituted the unauthorized practice of medicine.
- The nurses and physicians, as appellants, made a direct appeal of the trial court's decision to the Supreme Court of Missouri.
- The Board was the appellee in the appeal to the Supreme Court of Missouri.
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Issue:
Do the acts of licensed nurses, including taking histories, conducting pelvic and breast examinations, and dispensing contraceptives pursuant to physician-approved standing orders and protocols, constitute the unauthorized practice of medicine under Missouri law?
Opinions:
Majority - Welliver, J.
No, the acts of the nurses do not constitute the unauthorized practice of medicine because they fall within the expanded scope of professional nursing as defined by the 1975 Nursing Practice Act. The court's reasoning is based on statutory interpretation, focusing on the legislature's intent to broaden the scope of nursing practice. The 1975 Act eliminated the requirement of direct physician supervision and provided an open-ended definition of 'professional nursing,' using the phrase 'including, but not limited to,' to allow for the evolution of the profession. The court reasoned that performing assessments according to physician-approved protocols constitutes a 'nursing diagnosis'—finding or failing to find symptoms described by a physician for the purpose of administering a course of treatment prescribed by that physician—which is distinct from a 'medical diagnosis' and is permissible under the statute. Because the nurses' actions were lawful under the Nursing Practice Act (Chapter 335), they are explicitly exempted from the statute prohibiting the unauthorized practice of medicine (Chapter 334).
Analysis:
This decision legally validates the expanding role of nurses and the use of collaborative practice models. By distinguishing between a permissible 'nursing diagnosis' made pursuant to protocols and an impermissible 'medical diagnosis,' the court provided a legal framework for nurses to perform functions previously reserved for physicians. This precedent is significant for increasing access to healthcare, particularly in underserved areas, by allowing nurses to handle routine care and screening under physician-created guidelines. The ruling protects nurses and their collaborating physicians from charges of unauthorized practice of medicine, thereby encouraging the efficient delivery of healthcare services through standing orders and protocols.
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