It was 2023 when the only mental health clinic in the Howell County town of West Plains — one of just two serving a roughly 100-mile radius in southeast Missouri — closed after its sole provider left.
Elizabeth Brake, a psychiatric advanced practice registered nurse, treated patients with anxiety, depression, ADHD, obsessive-compulsive disorder, bipolar disorder and substance use disorders. When she resigned, the clinic shut down.
“There were a lot of people who were upset,” Brake said. “I had patients in tears because they couldn’t see me anymore.”
Brake said she left because Missouri law restricted her day-to-day practice, requiring physician oversight for nearly every clinical decision, including prescribing controlled substances. The clinic operated under a larger business, but without her, it could not remain open.
“If somebody has ADHD and needs a stimulant, the psychiatrist will prescribe but never see the patient,” Brake said. “The nurse practitioner is doing all the follow-ups and just reporting back. In my opinion, that oversight is cumbersome and provides no benefit to patients.”
Brake is one of about 13,000 APRNs in Missouri. According to the American Nurses Association, APRNs are trained to diagnose illnesses, order tests and prescribe medications. Twenty-eight states allow them to practice independently under what is known as full practice authority. Missouri does not.
After leaving West Plains, Brake opened Bliss Psychiatry, with locations in Iowa, Kansas and North Dakota — all states that allow APRNs to practice without physician supervision. She now lives in Willow Springs, Missouri and sees patients via telehealth, but none are Missouri residents.
Under Missouri law APRNs must have a collaborative practice agreement with a physician. Doctors may supervise no more than six APRNs, must be located within 75 miles, review 10% of patient charts and 20% of controlled-substance prescriptions every 14 days, and provide one month of in-person supervision before an APRN can prescribe independently.
Most APRNs do not encounter these barriers because nearly two-thirds work for large hospital systems, primarily in urban areas. Those who run independent practices or work in rural settings often struggle to find physicians willing to collaborate.
KBIA spoke with more than a dozen nurses who either left Missouri or live in the state but work across its borders, where they can practice independently.
Brandon Forester is the owner of Midwest Medcon, which performs medical disability evaluations for veterans. He operates four clinics in southwest Missouri and said expansion in the state proved too costly and cumbersome.
“I made a strategic decision that we’re no longer opening sites in Missouri,” Forester said. “Instead, I looked at states that don’t require collaborating physicians. In one year, we went from three sites to 13.”
Forester now operates in Kansas, Arkansas, Oklahoma and Florida. In 2025, he paid around $26,000 to physicians in his clinics in Missouri to maintain compliance, often without meaningful clinical involvement.
Kansas granted full practice authority in 2022. At one clinic there, Forester said, a nurse practitioner sees about eight patients a day without the same regulatory hurdles.
The 2022 Missouri Nursing Workforce report says around 7% of Missouri nurses work out of state, of whom 5% work in bordering states — a trend advocates say continues to grow.
Association of Missouri Nurse Practitioners Executive Director Derek Leffert said physician shortages, reduced overhead costs and broader scope of practice are pushing nurses out of state. A 2023 survey by the Missouri Nurses Association found some APRNs pay physician collaboration fees as high as $52,000 a year.
“Collaboration already happens naturally in health care,” Leffert said. “Requiring it by law restricts care. People in rural Missouri are waiting four or five months to see a provider.”
Most of Missouri’s neighboring states offer full or transitional practice authority, Leffert said, with Kansas and Illinois drawing the most APRNs.
But hiring APRNs can also mean delays. Terry Thomas, a family nurse practitioner in Hannibal, moved from Nebraska in 2022 but waited four months to begin work while her hospital searched for a supervising physician.
“There’s this misconception that we’re trying to replace doctors,” Thomas said. “That’s not true. Physicians have deeper training, but APRNs can still practice independently within our scope.”
The impact is magnified in rural Missouri, where health care access is already limited. The Missouri Department of Health and Senior Services' Office of Rural Health and Primary Care designates all but seven Missouri counties as having a primary care shortage.
Several bills introduced in the 2026 Missouri legislative session aim to expand practice authority for advanced practice registered nurses by easing or eliminating collaborative practice requirements. One would allow APRNs with at least 2,000 hours of physician collaboration to practice independently and prescribe Schedule II controlled substances, while others would remove geographic restrictions on physician oversight, define eligibility standards, allow prescribing of buprenorphine and reduce documentation requirements for collaborating doctors.
Opposition remains strong. The Missouri Medical Association has opposed the changes, and APRN advocates say passage is unlikely. MMA officials did not respond to a request for comment.
Marcy Marks, an allergy specialist APRN in Columbia, filed a lawsuit in October challenging Missouri’s restrictions.
“This shouldn’t be a fight,” Marks said. “It’s about patients. We can’t get providers into rural areas if these rules stay in place.”
Marks said she fears Missouri’s regulations will continue to drive nurses away and deter future practitioners from moving to the state.
