Nancy Mosley, a certified pediatric nurse practitioner, left, and Joanne Celenza, physician assistant student, center, explained to LaKeisha Walton follow-up care for a sore throat at the Cape Girardeau County Public Health Center.

Nurse practitioners, registered nurses who have completed advanced education, are making a significant difference in health care.

"Nurse practitioners provide a high quality care that is cost-effective and yields high levels of satisfaction," said Karen Hendrickson, assistant administrator and chief nursing officer at Southeast Missouri Hospital.

Charlotte Craig, director of the Cape Girardeau County Public Health Center, agrees.

"We have two nurse practitioners on staff," said Craig. "This provides us with opportunities to offer health care we wouldn't otherwise have."

Nurse practitioners examine patients, diagnose and treat some illnesses. They refer patients, when necessary, to physicians and other health care professionals under a collaborative agreement.

Nurse practitioners and clinical nurse specialists provide a full range of health-care services, including health assessments, health maintenance, treatment and education.

A large part of the nurse practitioner's practice is centered on teaching patients to take care of themselves as far as exercise, nutrition and healthy lifestyles are concerned.

"Education is important," said Cathy Thornton, who is in her first year as a family nurse practitioner at Southeast Missouri State University.

Hendrickson, who is serving her second term as president of the Missouri State Board of Nursing, said the role of the nurse practitioner has emerged nationally over the past three decades.

To be a nurse practitioner in Missouri, said Hendrickson, "one must have graduated from a nurse practitioner program of study, be a registered nurse who is certified by a national certifying body, be masters' prepared in nursing with a clinical specialty and/or have graduated from a master's level nurse practitioner program."

The nurse practitioner must enter into a collaborative practice agreement with a physician, under new Missouri Bill #674, which permits the Board of Healing Arts and Board of Nursing to jointly make rules regulating collaborative arrangements.

These collaborative arrangements are limited to practice sites located no further than 50 miles away from the advanced practice nurse. Physicians are limited to collaborative agreements with no more than three APNs.

The physician and APN must practice together for at least 30 days prior to practice at a site away from the physicians.

In a dissertation by Hendrickson, presented for a Doctor of Education Degree at the University of Memphis earlier this year, she discussed advanced practice nursing in Missouri, its role and regulatory issues.

There are four kinds of advanced practice, said Hendrickson: certified registered nurse anesthetists; clinical nurse specialists, master's prepared; nurse midwives; and nurse practitioners.

"All four must have collaborative agreements with primary care physicians," said Hendrickson.

The big difference in the advanced practice people and physician assistants is that physician assistants are salaried employees who by law work under the supervision of a physicians. Many physician assistants are registered nurses, but not all. They must, however, be educated in a two-year medical training programs.

Advanced practice nurses increase access to health care for all citizens, said Hendrickson.

"Nurse practitioners do not replace primary care, but with the collaborative agreements with physicians, it offers an opportunity for more people to receive health care," she said.

As many as 30,000 nurse practitioners and clinical nurse specialists practice independently with collaborative agreements with physicians.

Many others work in physician offices and other health care settings.

The concept originated more than 30 years ago at the University of Colorado.

The role was created in response to an increased awareness of the inaccessibility of health care in the nation for poverty stricken, uninsured, and rural populations, coupled with the nationwide physician manpower shortage.

Nurse practitioners now deliver most of the care to more than 5 million low income women and men.

The majority -- 32 percent -- of advanced practice nurses in Missouri are engaged in family practice. Sixteen percent are involved in pediatrics, 13 percent in adult health and the remainder in geriatrics, mental/psychiatry and others.

Health organizations report an improved workload and increased patient satisfaction. The collaborative practice provides a practice configuration that is attractive to primary care physicians. .

The utilization of nurse practitioners is vital to the Cape Girardeau County Health Department.

Nurse practitioners provide an opportunity for the department to see more clients.

"We have visited with over 1,000 children over the past three months," said Craig. "We're averaging between 15 and 20 new children each month."

At that pace, the health department will record more than 4,000 visits within a year.

Thornton's new job at Southeast Missouri State University, is a full-time position in the Department of Nursing. Her duties will be split between the university's Center for Health and Counseling and the Department of Nursing, College of Health and Human Services.

"I've been a nurse practitioner three years," said Thornton. "There are 8,000 potential patients on campus, and I really enjoy this age group."

Thornton helped launch a nursing center in Moberly, Mo. for the University of Missouri-Columbia last year. In addition to serving as a family nurse practitioner at Moberly, Thornton also served as an instructor of clinical nursing at UM-Columbia. She has worked as a nurse practitioner provider in a rural health clinic at Dexter.

Various studies, said Thornton, indicate that 80 to 90 percent of the problems addressed by a primary care physician can be taken care of by family nurse practitioner.

However, nurse practitioners cannot prescribe controlled substance -- morphine, demorel, codeine -- as defined by the FDA. They can prescribe antibiotics.