## Facts

- A nonprofit agency operated clinics providing family-planning and obstetrics/gynecology services to a largely low-income population in southeast Missouri.
- Registered nurses and physicians employed by the agency delivered care under written standing orders and protocols prepared and signed by agency physicians.
- Under the protocols, nurses took histories, performed physical examinations (including breast and pelvic exams), conducted laboratory tests and blood serology, dispensed certain medications (including contraceptives), and provided counseling.
- The protocols included detailed criteria directing when nurses could proceed, when they must consult a physician, and when they must refer a patient.
- State medical licensing officials asserted the nurses’ activities constituted the unauthorized practice of medicine and that agency physicians were aiding and abetting; orders to show cause were issued.
- The nurses and physicians sought declaratory and injunctive relief, contending the activities were authorized by the statutory definition of “professional nursing” and exempted from the medicine statute.
- The trial court denied relief, concluding the clinic arrangements allowed unauthorized practice of medicine.

## Issues

1. Whether nurses’ clinic activities performed under physician-approved standing orders and protocols constituted the unauthorized practice of medicine under Missouri law.
2. Whether those activities fell within the statutory definition of “professional nursing” and therefore within the nurse exemption from the medical practice statute.

## Decision

- The Supreme Court of Missouri reversed and remanded.
- The court held the challenged activities fell within the statutory scope of professional nursing.
- Because the nurses were lawfully performing professional nursing, their conduct was not the unauthorized practice of medicine, and the physicians were not subject to liability for aiding and abetting on that theory.
- The court declined to adopt rigid, comprehensive definitions demarcating nursing from medicine, resolving the dispute on the statutes and the record before it.

## Legal Principles

- Statutes governing professional scope must be read together: if conduct qualifies as “professional nursing” under the nursing statute, the nurse exemption in the medicine statute removes that conduct from “unauthorized practice of medicine.”
- The 1975 revision expanding the definition of professional nursing, including removal of any across-the-board “direct supervision” requirement and use of nonexclusive statutory language, supports a broader range of lawful nursing functions.
- Written standing orders and physician-signed protocols that structure and limit nursing discretion are relevant safeguards supporting classification of clinic tasks as professional nursing rather than independent medical practice.
- Courts may resolve scope-of-practice conflicts without fixing outer limits for an occupation when the statutes and facts show the challenged conduct fits within the authorized scope.

## Conclusion

The court held that nurses providing specified clinical services under physician-approved protocols were practicing lawful professional nursing and therefore were not engaged in the unauthorized practice of medicine, requiring reversal of the judgment against the clinic’s arrangements.


Sermchief v. Gonzales, 660 S.W.2d 683 (Mo. 1983) (en banc)