Opinion ID: 1677219
Heading Depth: 1
Heading Rank: 3

Heading: The statutes involved are:

Text: It shall be unlawful for any person not now a registered physician within the meaning of the law to practice medicine or surgery in any of its departments, or to profess to cure and attempt to treat the sick and others afflicted with bodily or mental infirmities, or engage in the practice of midwifery in this state, except as herein provided. Section 334.010. This Chapter does not apply to dentists licensed and lawfully practicing their profession within the provisions of chapter 332, RSMo; to nurses licensed and lawfully practicing their profession within the provisions of chapter 335, RSMo; to optometrists licensed and lawfully practicing their profession within the provisions of chapter 336, RSMo; to pharmacists licensed and lawfully practicing their profession within the provisions of chapter 338, RSMo; to podiatrists licensed and lawfully practicing their profession within the provisions of chapter 330, RSMo; or to chiropractors licensed and lawfully practicing their profession within the provisions of chapter 331, RSMo. Section 334.155, RSMo Supp.1982 (emphasis added). Definitions.As used in sections 335.011 to 335.096, unless the context clearly requires otherwise, the following words and terms shall have the meanings indicated: .... (8) Professional nursing is the performance for compensation of any act which requires substantial specialized education, judgment and skill based on knowledge and application of principles derived from the biological, physical, social and nursing sciences, including, but not limited to: (a) Responsibility for the teaching of health care and the prevention of illness to the patient and his family; or (b) Assessment, nursing diagnosis, nursing care, and counsel of persons who are ill, injured or experiencing alterations in normal health processes; or (c) The administration of medications and treatments as prescribed by a person licensed in this state to prescribe such medications and treatments; or (d) The coordination and assistance in the delivery of a plan of health care with all members of the health team; or (e) The teaching and supervision of other persons in the performance of any of the foregoing; Section 335.016.8(a)-(e). At the time of enactment of the Nursing Practice Act of 1975, the following statutes were repealed: 2. A person practices professional nursing who for compensation or personal profit performs, under the supervision and direction of a practitioner authorized to sign birth and death certificates, any professional services requiring the application of principles of the biological, physical or social sciences and nursing skills in the care of the sick, in the prevention of disease or in the conservation of health. Section 335.010.2, RSMo 1969 (emphasis added). Nothing contained in this chapter shall be construed as conferring any authority on any person to practice medicine or osteopathy or to undertake the treatment or cure of disease. Section 335.190, RSMo 1969. The parties on both sides request that in construing these statutes we define and draw that thin and elusive line that separates the practice of medicine and the practice of professional nursing in modern day delivery of health services. A response to this invitation, in our opinion, would result in an avalanche of both medical and nursing malpractice suits alleging infringement of that line and would hinder rather than help with the delivery of health services to the general public. Our consideration will be limited to the narrow question of whether the acts of these nurses were permissible under § 335.016.8 or were prohibited by Chapter 334. In analyzing this question, we are guided by well-established rules of statutory construction. Fundamentally, we seek to ascertain the intent of the lawmakers and to give effect to that intent. Citizens Bank & Trust Company v. Director of Revenue, 639 S.W.2d 833, 835 (Mo.1982); State v. Kraus, 530 S.W.2d 684, 685 (Mo. banc 1975). A court normally accomplishes this task by attributing to the words used in the statute their plain and ordinary meaning. Bank of Crestwood v. Gravois Bank, 616 S.W.2d 505, 510 (Mo. banc 1981); Kieffer v. Kieffer, 590 S.W.2d 915, 918 (Mo. banc 1979); Beiser v. Parkway School District, 589 S.W.2d 277, 280 (Mo. banc 1979); State ex rel. Conservation Commission v. LePage, 566 S.W.2d 208, 212 (Mo. banc 1978). Legislative intent and the meaning of words used in the statute also can be derived from the general purposes of the legislative enactment. Eminence R-1 School District v. Hodge, 635 S.W.2d 10, 13 (Mo.1982); Bank of Crestwood at 510. Further insight into the legislature's object can be gained by identifying the problems sought to be remedied and the circumstances and conditions existing at the time of enactment. Kieffer at 918; State ex rel. Zoological Park Subdistrict of the City and County of St. Louis v. Jordan, 521 S.W.2d 369, 372 (Mo.1975); Mashak v. Poelker, 367 S.W.2d 625, 626 (Mo. banc 1963). An amended statute, such as § 335.016.8, should be construed on the theory that the legislature intended to accomplish a substantive change in the law. City of Willow Springs v. Missouri State Librarian, 596 S.W.2d 441, 444 (Mo. banc 1980); Kilbane v. Director of the Department of Revenue, 544 S.W.2d 9, 11 (Mo. banc 1976); Gross v. Merchants-Produce Bank, 390 S.W.2d 591, 597 (Mo.App.1965). Finally, all provisions of a statute must be harmonized and every word, clause, sentence, and section thereof must be given some meaning. Staley, 623 S.W.2d at 250. The legislature substantially revised the law affecting the nursing profession with enactment of the Nursing Practice Act of 1975. [5] Perhaps the most significant feature of the Act was the redefinition of the term professional nursing, which appears in § 335.016.8. Even a facile reading of that section reveals a manifest legislative desire to expand the scope of authorized nursing practices. Every witness at trial testified that the new definition of professional nursing is a broader definition than that in the former statute. A comparison with the prior definition vividly demonstrates this fact. Most apparent is the elimination of the requirement that a physician directly supervise nursing functions. Equally significant is the legislature's formulation of an open-ended definition of professional nursing. The earlier statute limited nursing practice to services ... in the care of the sick, in the prevention of disease or in the conservation of health. § 335.010.2, RSMo 1969. The 1975 Act not only describes a much broader spectrum of nursing functions, it qualifies this description with the phrase including, but not limited to. We believe this phrase evidences an intent to avoid statutory constraints on the evolution of new functions for nurses deliverying health services. Under § 335.016.8, a nurse may be permitted to assume responsibilities heretofore not considered to be within the field of professional nursing so long as those responsibilities are consistent with her or his specialized education, judgment and skill based on knowledge and application of principles derived from the biological, physical, social and nursing sciences. § 335.016.8. The acts of the nurses herein clearly fall within this legislative standard. All acts were performed pursuant to standing orders and protocols approved by physicians. Physician prepared standing orders and protocols for nurses and other paramedical personnel were so well established and accepted at the time of the adoption of the statute that the legislature could not have been unaware of the use of such practices. We see nothing in the statute purporting to limit or restrict their continued use. Respondents made no challenge of the nurses' level of training nor the degree of their skill. They challenge only the legal right of the nurses to undertake these acts. We believe the acts of the nurses are precisely the types of acts the legislature contemplated when it granted nurses the right to make assessments and nursing diagnoses. There can be no question that a nurse undertakes only a nursing diagnosis, as opposed to a medical diagnosis, when she or he finds or fails to find symptoms described by physicians in standing orders and protocols for the purpose of administering courses of treatment prescribed by the physician in such orders and protocols. The Court believes that it is significant that while at least forty states [6] have modernized and expanded their nursing practice laws during the past fifteen years neither counsel nor the Court have discovered any case challenging nurses' authority to act as the nurses herein acted. The broadening of the field of practice of the nursing profession authorized by the legislature and here recognized by the Court carries with it the profession's responsibility for continuing high educational standards and the individual nurse's responsibility to conduct herself or himself in a professional manner. The hallmark of the professional is knowing the limits of one's professional knowledge. The nurse, either upon reaching the limit of her or his knowledge or upon reaching the limits prescribed for the nurse by the physician's standing orders and protocols, should refer the patient to the physician. There is no evidence that the assessments and diagnoses made by the nurses in this case exceeded such limits. In preparing this opinion, the Court did considerable research and reading in medical libraries. We find nothing in our construction of the statutes that is incompatible with the history and development of the profession of nursing, the general standards of state and national nursing organizations and associations, the utilization of special nursing services by the Federal and State governments in the delivery of health services, or the utilization of nursing services by schools, factories, homes for the aging and our hospitals. Having found that the nurses' acts were authorized by § 335.016.8, it follows that such acts do not constitute the unlawful practice of medicine for the reason that § 334.155 makes the provisions of Chapter 334 inapplicable to nurses licensed and lawfully practicing their profession within the provisions of Chapter 335 RSMo. This cause is reversed and remanded with instructions to enter judgment consistent with this opinion. HIGGINS, GUNN and DONNELLY, JJ., and MORGAN, Senior Judge, concur. RENDLEN, C.J., concurs in result. BLACKMAR, J., concurs except as to Part II. BILLINGS, J., not sitting.