B. ESSENTIAL ELEMENTS OF PROFESSIONAL PRACTICE THAT ESTABLISH APCS AS QUALIFIED PROVIDERS OF ABORTION CARE

The evidence for abortion care as APC scope of practice lies within the essential documents that have been developed by CNM, NP, and PA organizations: ethical clinical practice and professional performance standards as well as clinical and professional competencies. Four organizations have developed role, population, and specialty practice standards, clinical competencies, and educational credentialing for advanced practice nurses in women’s health. They are the Association of Women’s Health, Obstetrics and Neonatal Nurses (AWHONN), the National Organization of Nurse Practitioner Faculties (NONPF), Nurse Practitioners in Women’s Health (NPWH), and the American College of Nurse-Midwives (ACNM). In addition, the Association of PAs in Obstetrics and Gynecology (APAOG) aims to promote clinical and academic excellence for PAs practicing in women’s health. Interdisciplinary (Association of Reproductive Health Professionals [ARHP]) and specialty (NAF) organizations have developed abortionspecific standards and clinical policies that provide the foundation for abortion care, specialty professional practice, and specialty education and training.

Using the general framework of the essential elements of scope of practice delineation, we provide examples from the APC and specialty organizations demonstrating the evidence for abortion care as part of APC scope of practice, standards, competencies, and professional ethical behavior.

Practice Philosophies by Organization

The ANA Social Policy Statement (ANA, 2003), first published in 1980 and currently under revision in 2009, defines professional nursing (including advanced practice nursing) as a multifaceted social contract between nurses and the public. Several sections of the statement are applicable to this discussion. APC provision of abortion expands access to care and is in alignment with the ANA goal that “the lack of accessible, available, and acceptable healthcare services and resources are complex issues that must be addressed to improve the quality of care” (ANA, 2003, p. 3). Clarification of policy issues related to abortion care and its subsequent availability or lack thereof, is part of the professional nurse’s responsibility to address injustice in a systematic manner (ANA, 2008, p. 5). ANA policies can be interpreted to include the incorporation of advanced practices such as abortion care as part of the profession’s growth, as reflected in this statement: “Professional nursing’s scope of practice is dynamic and continually evolving. The scope of practice is characterized by a flexible boundary that is responsive to the changing needs of society and the expanding knowledge base of applicable theoretical scientific domains” (ANA, 2008, p. 9).

The ACNM Philosophy of Midwifery Care states that midwifery practice emphasizes safe, competent clinical management with an emphasis on patient self-determination. Meeting this practice standard requires individual CNMs to examine if the care they are providing is safe and if it is provided at a skilled and competent level; if not, then the care the patient needs or requires is not within the CNM’s scope of practice (ACNM, 2004). The ICM further clarified the ACNM philosophy in 2008, when it approved a new position statement recognizing the important role of midwives in providing abortion care in countries where abortions are legal (B. Lynch, RM, written communication, September 2008).

According to the AAPA, PA scope of practice flows from a medical model of practice that involves the PA, the physician, and the patient. The clinical role of PAs includes primary and specialty medical care in medical and surgical practice settings with direct or indirect physician supervision. In general, PA scope of practice includes any legal medical service (including abortion care) that is delegated to the PA by the supervising physician when the service is within the PA’s skills and is provided with supervision of a physician (AAPA, 2008b).

Practice and Professional Performance Standards by Organization

Clinical/ethical standards and competencies are at the core of all professional practice. For the professional organizations, regulatory boards, and educators to accept abortion as part of APC practice, these essential elements must be aligned and clearly explicated. Licensing boards want to hear that the individual NP, CNM, or PA, along with their representing professional organizations, can articulate the relationship between the core standards (both practice and performance), competencies, and ethical principles and abortion care.

NAF’s evidence-based Clinical Policy Guidelines (CPGs) include standards of practice and education for abortion care “performed by licensed physicians or licensed/ certified/registered midlevel clinicians16 trained in the provision of abortion care, in accordance with state law” (2007, p. 1). The NAF CPGs were developed by consensus, based on rigorous review of the relevant clinical and scientific literature and known patient outcomes. The NAF CPGs are intended to provide a basis for ongoing quality assurance, to be applied rigidly, and to be followed in virtually all cases. The abortion care standards apply to all providers; APCs are evaluated in the same capacity as physicians performing the same procedures.

Since 2003, the ACNM has required that CNMs meet eight minimum practice standards, including the requirement to establish practice guidelines for each specialty area of practice, such as abortion care (Standard V). ACNM Standard VIII outlines policies and procedures for expanding midwifery practice beyond the ACNM core competencies to incorporate new procedures that improve care for women (ACNM, 2003).

AWHON and NPWH, building upon general standards of practice of the AANP, provide standards and competencies related to the population focus (women’s health) as well as the specialty practice of NPs in primary care and reproductive health. AWHONN addresses practice, research, and education standards in women’s health, obstetric, and neonatal nursing specialty practice. AWHONN and NPWH jointly prepared The Women’s Health Nurse Practitioner: Guidelines for Practice and Education (2002) containing the standards for the women’s health NP role. Practice standards for women’s health NPs (WHNPs) apply to assessment; diagnosis; health promotion; disease prevention; provision of clinical management for women having uncomplicated gynecologic problems; and provision of family planning and uncomplicated pregnancy care across the preconception, prenatal, and postpartum periods. Provision of abortion care by WHNPs would need to meet these general standards as well as NAF’s standards for quality abortion care.

The PA profession does not formally specify practice standards beyond medical care standards. For example, ACOG-established practice standards for physicians specializing in obstetrics and gynecology would apply to PAs providing women’s health care. A PA providing abortion care would be required to adhere to the abortion care standards in the NAF CPGs (AAPA, 2008e).

Practice Competencies by Organization

The APC professions and other standardsetting bodies establish standards that articulate expectations for the behaviors that comprise competence. The knowledge, skills, and behaviors necessary for APC practice are specific to current professional standards and the context in which APCs practice.

Professional standards and competencies set acceptable limits for minimum, as well as advanced, scope of practice boundaries. Core competencies for basic APC practice delineate the fundamental knowledge, skills, and behaviors expected of a new practitioner and constitute the requisites for graduates of accredited APC education programs. The following paragraphs highlight competencies related to abortion care for each APC professional organization.

According to ACNM basic midwifery core competencies, the midwife “independently manages primary health screening and health promotion of women from the perimenarcheal through the postmenopausal periods” (ACNM, 2008, p. 4). This includes “clinical interventions and/or referral for unplanned or undesired pregnancies…” (p. 4). Basic midwifery practice also includes procedural competency in techniques for administration of local anesthesia, spontaneous vaginal delivery, third stage management, and performance and repair of episiotomy, repair of lacerations, and management of spontaneous or incomplete abortion (ACNM, 2008). The ICM’s Essential Competencies for Basic Midwifery Practice includes knowledge of factors involved in decisions about unplanned or unwanted pregnancies and care and counseling needs during and after abortion (ICM, 2002). Expansion of these essential competencies to include abortion care by CNMs is planned for 2009 (A. Levi, CNM, personal communication, March 2009) The scope of CNM practice may also be advanced beyond the core competencies to incorporate abortion care skills and procedures that improve care for women and their families by following the guidelines outlined in Standard VIII of the Standards for the Practice of Midwifery (ACNM, 2003).

The foundation for all NP practice, including NPs in women’s health practice, is the Nurse Practitioner Primary Care Competencies in Specialty Areas: Adult, Family, Gerontological, Pediatric, and Women’s Health (National Organization of Nurse Practitioner Faculties [NONPF] & American Association of Colleges of Nursing, 2002). These guidelines are now published by the U.S. Bureau of Health Professions and Division of Nursing and are available online through NONPF. Both NPWH and AWHON collaborated with NONPF to develop these core competencies for NPs providing women’s health care. According to these NP competency guidelines, upon graduation or entry into practice, the NP should demonstrate competence in all of the core competency domains and in the specific competencies relevant to women’s health practice. These competencies do not preclude abortion care provision. For example, under Competency I-C, Plan of Care and Implementation of Treatment, an NP in women’s health is expected to “perform primary care procedures, including but not limited to, pap smears, microscopy, post-coital tests, intrauterine device (IUD) insertion, and endometrial biopsies” (p. 37) and to facilitate “access to reproductive health care services and provide referrals that are provided in an unbiased, timely, and sensitive manner (Competency I-C.15)” (p. 37). A competency under the NP-Patient Relationship domain states that the NP “supports a woman’s right to make her own decisions regarding her health and reproductive choices within the context of her belief system” (p. 37). A Professional-Role competency requires the NP to “recognize the ethical, legal and professional issues inherent in providing care to women throughout the life cycle” (p. 38).

As developed by the AAPA, PA practice competencies provide the basis for professional accountability and credentialing. Professional competencies for PAs include the effective and appropriate application of medical knowledge, interpersonal and communication skills, patient care, professionalism, practice-based learning and improvement, systems-based practice, as well as a commitment to continual learning, professional growth, and the physician-PA team, for the benefit of patients and the larger community being served. These competencies are demonstrated within the scope of practice, whether medical or surgical, for each individual PA as that scope is defined by the supervising physician and appropriate to the practice setting (AAPA, 2005).

More and more, the focus of clinical competencies is on patient needs and conditions rather than the specific health professional. Based on ACOG, ARHP, and NAF abortion care standards and education, a provider-neutral competency assessment was developed to evaluate safe and effective abortion care practice by primary care clinicians. Developed for competency assessment of family medicine residents completing an abortion training elective and subsequently used in training APCs to abortion care competency, the evaluation assesses trainees in six areas of peri-abortion care knowledge and skill (Goodman, Wolfe, & TEACH, 2007; Taylor et al., 2007). Competency is assessed in the following categories: knowledge and skill of medication and aspiration abortion care and provision (e.g., peri-procedural care); patient communication skills; professionalism; interpersonal communication; health care delivery; and practice-based learning and improvement.

Codes of Ethics by Organization

Regardless of personal beliefs, all health professionals, including APCs, are obligated to apply their profession’s national (and in some cases international) ethical codes, standards, and competencies when caring for women experiencing unintended pregnancies and choosing abortion. In general, all APC professions have established ethical codes that mandate professional integrity and the responsibility to respect patient autonomy. Applying these ethical codes to abortion care, a basic competency required of all APCs providing care to women at risk for unintended pregnancy is pregnancy options counseling that is free from bias, nonjudgmental, and nondirective (Simmonds & Likis, 2005; Singer, 2004). In addition, APCs who identify irreconcilable conflicts between their personal beliefs and their professional responsibilities must refer women for comprehensive options counseling in a seamless manner, so that women do not feel judged or are delayed in receiving appropriate services (Likis, 2009).

The ANA’s Code of Ethics for Nurses, first published in 1940 and updated with interpretive statements in 2001, establishes the professional rights, responsibilities, and integrity of basic and advanced practice nursing. This Code is the standard by which ethical conduct is guided and evaluated, and it is not open to negotiation in employment settings, nor is it permissible for individuals, groups of nurses, or interested parties to adapt or change its language (ANA, 2001). It applies to all nursing activities and supersedes specific policies of institutions or employers. For example, in providing abortion care, “the nurse should avoid imposition of the nurse’s own cultural values upon others” (p. 24), and the nurse “establishes relationships and delivers nursing services with respect for human needs and values, and without prejudice” (p. 7). These responsibilities do not suggest that the nurse necessarily agrees with or condones a patient’s choice to terminate a pregnancy but that the nurse respects the patient as a person who has the right of self-determination. The ANA Code provides guidelines for a nurse’s refusal to participate in a particular case on ethical grounds. However, if a nurse becomes involved in such a case, “the nurse is obliged to provide for the client’s safety, to avoid abandonment, and to withdraw only when assured that alternative sources of nursing care are available to the client” (ANA, 1989, pp. 1–2). Although women may make decisions that are different from what nurses wish or believe best, upholding patient autonomy and safety are paramount (Capiello, 2008; Simmonds & Likis, 2005).

The ACNM’s code of ethics for midwives is the guiding principle underlying midwifery practice and articulates the professional moral obligations of practicing midwives (ACNM, 2005). “Midwives have three ethical mandates in achieving the mission of midwifery to promote the health and well-being of women and newborns within their families and communities. The first mandate is directed toward the individual women and their families for whom the midwives provide care, the second mandate is to a broader audience for the ‘public good’ for the benefit of all women and their families, and the third mandate is to the profession of midwifery to assure its integrity and in turn its ability to fulfill the mission of midwifery” (p. 1). “Midwives strive for equality and justice in all aspects of their clinical and professional activity and must respect the rights of all people and their health care choices. They have the responsibility to act without discrimination by avoiding differential and negative treatment of individuals on the basis of their age, gender, race, ethnicity, religion, lifestyle, sexual orientation, socioeconomic status, disability, group membership, or the nature of their health problem” (p. 8).

The AAPA holds as a central tenet patient autonomy in decision making. “Physician assistants are professionally and ethically committed to providing nondiscriminatory care to all patients” (AAPA, 2008a, p. 4). In the area of reproductive decision making, “[p]atients have a right to access the full range of reproductive health care services, including fertility treatments, contraception, sterilization, and abortion” (p. 6). PAs have an ethical obligation to provide balanced and unbiased clinical information about reproductive health care. “While PAs are not expected to ignore their own personal values, scientific or ethical standards, or the law, they should not allow their personal beliefs to restrict patient access to care. A PA has an ethical duty to offer each patient the full range of information on relevant options for their health care. If personal moral, religious, or ethical beliefs prevent a PA from offering the full range of treatments available or care the patient desires, the PA has an ethical duty to refer a patient to another qualified provider” (p. 4).

In addition to the ANA ethical standards, AWHON supports the protection of the individual nurse’s right to choose to participate in abortion or sterilization procedures (AWHONN, 1999). AWHONN practice documents state that any reproductive health care decision is best made by informed women in consultation with their health care providers and supports and promotes women’s right to accurate and complete information and access to reproductive health care services (AWHONN, 1999).

These essential ethical standards uphold an ethical mandate for CNMs, NPs and PAs to ensure patient access to comprehensive reproductive health services, including, at a minimum, access to accurate , timely, and caring pregnancy options counseling.

16 As noted in the APC Toolkit introduction, midlevel clinician is an earlier designator for APC.