INTO APC SCOPE OF PRACTICE: EVIDENCE
- Identify the four categories of evidence necessary to establish abortion care as within APC scope of practice.
- Discuss the historical evidence from professional organizations (e.g., position statements on abortion care) supporting APCs as abortion providers.
- Identify specific references to abortion care within the essential documents of APC practice (e.g., practice standards, competencies, and ethical codes).
- Identify evidence of abortion care education and training opportunities for APCs.
- Identify the evidence of legislative, legal and regulatory environments supporting APCs as abortion providers.
- Describe professional and regulatory models for assessing or advancing changes in scope of practice.
- Examine case studies of NPs and PAs who have successfully incorporated abortion care into their practices.
For abortion care to be considered part of APC scope of practice, four categories of evidence must be examined: historical, professional/clinical, education/training, and legal/regulatory environment. The accumulated evidence for abortion care as within APC scope of practice must then be linked with patient safety and health care quality issues. Section IV looks at the evidence category by category as it relates to provision of abortion care by APCs:
- Historical evidence: APC and other professional organizations support CNMs, NPs, and PAs as appropriate providers of abortion care.
- Professional/clinical evidence: The evidence for abortion care as within APC scope of practice lies within the essential documents developed by CNM, NP, and PA organizations—population, specialty, and ethical practice standards as well as clinical and professional competencies. Clinical evidence demonstrating the safety of abortion was cited in Section I.
- Education/training evidence: There is evidence of abortion care education in entry-level APC programs, with clinical training lagging didactic education. However, education and training in abortion care knowledge and skills, including medication and aspiration abortion provision, are offered in a number of postgraduate training programs. Establishing the existence of training opportunities is important evidence but is not sufficient to provide argument that abortion care is a natural extension of APC scope of practice. There is a two-way street between education and training and the regulatory environment in the attempt to prove abortion as within APC scope of practice. On the one hand, the more common education related to abortion care becomes in APC training programs, the stronger the case that can be made for advancing APC scope of practice. On the other hand, positive regulatory and legal decisions related to scope of practice support greater student access to abortion education and training.
- Evidence of Legislative, Legal & Regulatory Environments: Despite the regulatory impediments resulting from vague or outdated practice acts and rules, especially in the politically charged context of abortion care, state Attorney General opinions along with health professional regulatory advisories have been issued in a number of states to clarify APC authority to perform abortions. Licensing boards in two states have established that abortion care is within the scope of practice of appropriately prepared advanced practice nurses, offering a template for other jurisdictions to follow in reconciling their legal authority over APCs’ legal scope of professional practice.
Individual APCs, APC professional organizations, APC educators, and reproductive health care advocates can use this evidence in a number of ways to advance APC practice of abortion. For example, they can:
- develop a professional portfolio that incorporates abortion care competencies and experience (see Figure V.2 in Section V.B)
- submit materials to a state licensing board documenting that abortion care falls within the essential scope of practice elements
- respond to a request from a practice advisory committee of a state regulatory board to document how scope of practice has advanced for abortion care
- support abortion care as part of APC scope of practice if an APC who is already performing abortions is investigated by a state regulatory board
- help APC educators develop abortion care education and training programs
- educate legislators and policy makers, testify before legislative committees, and draft public statements in support of abortion care as part of APC scope of practice
In this section, we describe how these evidentiary categories can be incorporated into the standards and mechanisms used by national APC organizations and state licensing boards to consider whether abortion care (or any new practice) is within professional scope of practice. Finally, we present case studies from Alaska, Arizona, Montana, New York, and Oregon outlining the experiences of advanced practice clinicians who succeeded in incorporating abortion care into their practices.
APC professions and interdisciplinary organizations representing health professionals who provide reproductive health care services codify practice responsibilities through ethical codes of conduct and position statements that set out the role of PAs and advanced practice nursing roles of CNMs, NPs, in upholding patient rights and autonomy and in treating patients with respect and compassion. These documents, copies of which are available directly from the organizations, provide an ethical and legal mandate that APCs ensure patient access to comprehensive reproductive health services including, at a minimum, preconceptual care including contraception counseling, pregnancy options counseling and abortion care (American Academy of Physician Assistants, 2000; American College of Nurse-Midwives, 1997b; American Nurses’ Association, 1989; Association of Reproductive Health Professionals, 2008; Association of Women’s Health, Obstetric and Neonatal Nurses, 1999; National Organization of Nurse Practitioner Faculties, 2002; Nurse Practitioners in Women’s Health, 1991).
All APC professional organizations can be considered pro-choice organizations.
All national APC professional organizations as well as groups including the medical specialty and public health organizations assert the obligation of their professions to assure quality reproductive health services that guarantee reproductive choice and patient autonomy.
Since 1989, the American Nurses Association (ANA) has defined itself as a “pro-choice organization” with the publication of its position on reproductive rights and the role of the nurse:
ANA believes that the health care client has the right to privacy and the right to make decisions about personal health care based on full information and without coercion. It is the obligation of the health care provider to share with the client all relevant information about health choices that are legal and to support that client regardless of the decision the client makes. Abortion is a reproductive alternative that is legal and that the health care provider can objectively discuss when counseling clients. If the state limits the provision of such information to the client, an unethical and clinically inappropriate restraint will be imposed on the provider and the provider-client relationship will be jeopardized. (ANA, 1989, p. 1)
The philosophy of the American College of Nurse-Midwives (ACNM) on abortion has changed
over the years, with the current policy emphasizing women’s autonomy: “Certified nurse-midwives
(CNMs) and certified midwives (CMs) believe that every individual has the right to safe,
satisfying health care with respect for human dignity and cultural variations” (ACNM, 1997b, p.
1). The ACNM has adopted the following positions: that every woman has the right to make reproductive
choices; that every woman has the right to access factual, unbiased information about
reproductive choices, in order to make an informed decision; and that women with limited means
should have access to financial resources for their reproductive choices.
The American Academy of Physician Assistants (AAPA) opposes attempts to restrict the availability of reproductive health care. In 1992, the AAPA House of Delegates affirmed “a patient’s right of access to any legal medical treatment or procedure made with the advice and guidance of the patient’s health care provider and performed in a licensed hospital or appropriate medical facility” (AAPA, 1992). More specifically, the AAPA opposes any intrusion into the provider/patient relationship through restrictive informed consent laws, biased patient education or information, or restrictive government requirements concerning medical facilities. This 1992 policy is reflected in current policy statements: “Patients have a right to access the full range of reproductive health care services, including fertility treatments, contraception, sterilization, and abortion” (AAPA, 2008a, p. 6). The Association of Physician Assistants in Obstetrics and Gynecology (APAOG) supports the 1992 policies of the AAPA regarding reproductive health (APAOG, 1992; NAF, 1997, p.22; NAF, 2009).
APC professional organizations support CNMs, NPs, and PAs as abortion providers.
Not only do many APC professional organizations support reproductive choices for patients, a
number have policy statements supporting APCs as abortion providers.
Nurse Practitioners in Women’s Health (NPWH, formerly the National Association of NPs in Reproductive Health), along with the ACNM, have a tradition of reproductive rights advocacy and promotion of access to women’s health services. They are the only professional nursing organizations to formally support advanced practice nurses as abortion providers.
An NPWH policy resolution passed in 1991 states that NPs in women’s health “assure quality reproductive health services which guarantee reproductive freedom” and that “nurse practitioners, with appropriate preparation and medical collaboration, are qualified to perform abortions” (NANPRH/NPWH, 1991; NAF, 1997, p. 22; NAF, 2009).
In 1991, the ACNM rescinded a 1971 policy prohibiting nurse-midwives from providing abortions, essentially allowing individual CNMs the option of becoming involved in abortion care (Summers, 1992). More recently, the International Confederation of Midwives (ICM) approved a new position statement recognizing the important role of midwives in providing abortion-related services in countries where abortions are legal (F. Likis, personal communication, October 2008).
In 1997, recognizing that PAs had been providing abortion care since 1973, the AAPA clarified its position on the role of PAs in abortion care. The AAPA “believes that PA practice should not be arbitrarily limited by political considerations, but rather should be determined by patient needs, physician delegation, and PAs’ training, experience, skills, and choice” (NAF, 1997, p. 25). The APAOG reaffirmed its support for AAPA policies in 1997.
Public health, physician, and specialty organizations support CNMs, NPs, and PAs as abortion providers.
The American Public Health Association (APHA) in three resolutions15 supports “provision of
first trimester surgical and medical abortion by appropriately trained NPs, CNMs, and PAs”
and urges health professionals and educators to work together to provide training and practice
opportunities for CNMs, NPs, and PAs in abortion care (APHA, 1999; NAF 1997, p. 23).
NAF has long been in support of CNMs, NPs, and PAs as abortion providers. The federation has taken the lead in two national symposia that resulted in position statements and policy direction for promoting CNMs, NPs, and PAs as abortion providers (NAF, 1990; NAF, 1997).
The American College of Obstetricians and Gynecologists (ACOG), in a 1994 statement, “encourages programs to train physicians and other licensed health care professionals to provide abortion care in collaborative settings” to address the shortage of health care providers who perform abortions (NAF, 1997, p. 22).
In 1999, two physician groups, the American Medical Women’s Association (AMWA) and Physicians for Reproductive Choice and Health (PRCH) issued statements supporting the training of all health professionals in abortion care, including CNMs, NPs, and PAs (NAF, 2009).
15 APHA Resolution No. 7626 (1976); APHA Resolution No. 9117 (1991); APHA Resolution No. 9917 (1999).