MODULE TWO:
ADVANCING SCOPE OF PRACTICE TO INCLUDE ABORTION CARE

Module Two explains how professional practice is regulated for CNMs, NPs, and PAs, specifically in a specialty-practice area such as abortion care. We describe the roles of state licensing boards as well as national and state professional organizations in defining, enforcing, and advancing health professional practice—and how their activities apply to abortion care.

As you read Sections III, IV, and V, consider these questions:

  1. What is the relationship between state legislatures and state licensing boards?
  2. What is the role of state licensing boards in defining, enforcing and advancing professional scope of practice?
  3. How do state practice acts and professional standards provide for or create barriers to safe, effective care?
  4. How do CNM/NP/PAs demonstrate and maintain continued clinical and professional competence?
  5. How can you effectively influence the state regulatory agency that governs your practice?
  6. How has your state board addressed politically charged issues regarding scope of practice in the past?
  7. What is the role of, as well as your obligations to, your professional organizations? Does the organization have leaders who you see as mentors or who have experience or interest in the reproductive health field?
  8. Are there provider restrictions to any or all aspects of abortion care in your state?
  9. How might abortion care become normalized into CNM, NP or PA scope of practice? What barriers to this goal do you identify?
  10. Were you trained in abortion care in your APC educational program or your postgraduate training? How might you obtain the training you need to integrate abortion care into your practice?

SECTION III.
APC PRACTICE REGULATION: ROLES OF
LEGISLATURES, LICENSING BOARDS, AND PROFESSIONAL ORGANIZATIONS

OBJECTIVES:

  1. Explain state abortion laws and their relationship to APC scope of practice regulation.
  2. Identify the general credentialing framework for APCs.
  3. Describe authority-based and evidence-based approaches for defining APC scope of practice.
  4. Identify the authority of state legislatures and licensing boards to regulate APC practice.
  5. Discuss the role of the APC professions in defining and advancing scope of practice.

Section III examines who defines APC scope of practice, explaining the roles of state and national professional organizations, state legislatures, and licensing boards, as well as key factors APCs should understand about each of these groups. First, though, we look at state abortion laws and their relationship to APC scope of practice regulation.

A. STATE ABORTION LAWS AND APCS

Abortion laws, many of which were enacted before the statutory recognition of advanced practice clinicians roles and the development of newer and simpler abortion technologies, create confusion for clinicians who want to offer abortion care. After the 1973 Roe v. Wade Supreme Court decision legalizing abortion, many states enacted physician-only laws presumably to protect women from unsafe, untrained, and unlicensed abortion providers. Unfortunately, these laws have become a de facto restrictive legacy to the evolution of APC scope of practice for two reasons: (1) hesitation by some health professionals and reproductive rights organizations to address the issue of women’s access to abortion care from all qualified women’s health care providers, and (2) uncertainty whether these laws apply to demonstrably “safe and competent” providers who are not physicians.

Even in states where APCs have a broad scope of practice including prescriptive authority, they must abide by abortion-specific limitations that prevent them from offering either aspiration or medication abortion services. For example, although in Arizona, PAs have broad physician-delegated authority to diagnose, treat, prescribe, and perform minor surgery, a statute specifically prohibits them from providing abortions (Ariz. Rev. Stat. § 32-2501.11 (2007)). Similarly, in Ohio, PAs’ prescriptive authority specifically excludes abortion-inducing medications (Ohio Rev. Code § 4730.02 (2009)).

However, in a number of states, including those with physician-only laws, APCs with additional training are providing medication and, in some cases, aspiration abortions as a result of Attorney General opinions, regulatory clarifications, and other mechanisms (Joffe & Yanow, 2004; Advancing New Standards in Reproductive Health, 2007). This demonstrates that even in states where abortion is restricted by law to licensed physicians, nonlegislative strategies have provided APCs with opportunities to incorporate abortion services into their practices. (See Section IV.D and IV-E for an overview of these statutory and regulatory examples.)

These state-specific abortion laws must be considered within the context of nursing, midwifery and physician assistant practice acts which also vary from state to state. Although the state regulation of CNM, NP and PA practice will be discussed generally in Section III-C through III-E, it is beyond the scope of the APC Toolkit to provide detailed description of each state’s practice acts regulating advanced practice nursing roles (e.g., NPs and CNMs) and PAs. Fortunately, there are regularly updated reference documents which provide current state-by-state information on CNM, NP and PA practice regulation including state practice acts and legislative changes to scope of practice. See Figure III-1 for a description of these references.

FIGURE III.1

State laws & regulations governing NP, CNM and PA practice:
Where to find information

Since there is no federal law governing the scope of practice, it is necessary to go to each state licensing board to access the specific practice act and rules and regulations for CNMs, NPs and PAs. Fortunately, there are now websites and published documents which summarize and update these state practice laws and regulations along with pertinent government and policy information related to proposed legislation and scope of practice changes for each state and the District of Columbia (DC).

Nurse Practitioners
Since 1988, Linda Pearson, former editor of the Nurse Practitioner Journal, has summarized NP legislation and related health care issues, including a recap and update of each state’s nurse practice act and related rules and regulations. Now the Pearson Report is available in both print and electronic formats with a condensed version of each state/DC report appearing annually in the January/February issue of The American Journal for Nurse Practitioners. The complete version of each state/DC report is available on the NP Communications website (www.webnp.net) which includes specific details on NP scope of practice changes, statewide NP associations and schools, organized opposition to NP legislative or regulatory changes, the number of National Practitioner Data Bank or Healthcare Integrity and Protection Data Bank filings, and the ranking of the state’s NP regulation and consumer choice environment (Pearson, 2009). Dr. Pearson encourages anyone to provide her with updates by emailing her at [email protected]

Nurse-Midwives
The Pearson Report includes some information about the regulation of CNMs. The ACNM also provides information on state laws and regulations specific to CNMs. A handbook that summarizes state laws and regulations affecting CNMs is available online to ACNM members only. Topics include the identity of the regulatory board, scope of practice, prescriptive authority, tort reform, breastfeeding and other statutory provisions governing the practice of midwifery. The ACNM website also provides public access to state/DC summaries of CNM practice regulation and key statistics (http://www.midwife. org/state_legislation.cfm). ACNM annual reports (available online) highlight state advocacy efforts related to CNM practice and regulation. The most recent published report (2007) describes, activities in 17 states, including the passage of legislation in seven states advancing CNM scope of practice (http://www.midwife.org/siteFiles/about/2007_annnual_Report.pdf).

Physician Assistants
The first edition of Physician Assistants: State Laws and Regulations was published by the AAPA in 1982 and now is available online at http://www.aapa.org/gandp/StateLawsandRegulations.htm. This state-by- state compendium provides summaries of more than two dozen key provisions of each state’s statute and regulations complete with legal citations (http://www.aapa.org/gandp/state-law-summaries.html). The states are presented in alphabetical order, with each law followed by its regulations which provide the most complete picture of the requirements and conditions for PA practice. The AAPA website also lists each state PA regulatory agency with addresses, phone numbers, and Web links, available at www. aapa.org/gandp/statereg.html. Also provided is a chart that presents an overview of PA licensure or state certification requirements (http://www.aapa.org/gandp/sumchart.html).