BECOMING CLINICALLY COMPETENT
AND DOCUMENTING COMPETENCY IN
- Identify abortion education and training opportunities for APCs.
- Identify resources to help APCs become clinically competent in the provision of abortion care.
- Provide guidelines for professional portfolio development.
- Offer a template for documenting professional credentials, clinical competency, education, and experience.
A 2003 survey of 14,000 licensed APCs conducted in California determined that 25% desired
training in abortion (Hwang, Koyama, Taylor, Henderson, & Miller, 2005). The reason APCs
cited most frequently for not providing or assisting with abortion procedures was lack of training
opportunities (Hwang et al., 2005). Conducted shortly after the passage of new reproductive
privacy legislation establishing the role of APCs in the provision of nonsurgical (assumed
to mean only medication) abortion, the survey found that approximately one third of APC
respondents believed that aspiration abortion was a surgical procedure outside the practice
of APCs. These results suggest that, regardless of their intention to provide or not provide
abortions, many actively practicing NPs, CNMs, and PAs want training in abortion care or
need education related to new knowledge and technologies for preventing and/or terminating
A few examples show how some programs are helping to advance education and training in reproductive health including abortion care:
The Reproductive Options Education (ROE ) Consortium of the Abortion Access Project promotes the integration of abortion-related content into undergraduate and graduate nursing education by offering training, teaching materials, and support to nursing faculty. ROE launched a two-year pilot program in 2002 to increase the number of nursing students prepared to provide abortion-related care. During the pilot project, 13 nursing education classrooms used ROE curriculum tools to increase the ability of more than 500 students to counsel women with unintended pregnancies and to provide support during an abortion and with postabortion care. In 2005–2006, 135 nursing faculty, students, and practicing clinicians attended ROE Consortium trainings. ROE has developed educational resources including the free, downloadable Caring for the Woman with an Unintended Pregnancy: Teaching Nurses What They Need to Know (AAP, 2001), two guides titled Teaching Reproductive Choice Options: A Resource Guide for Nurse Educators, Practicing Nurses and Nursing Students (Simmonds & Abortion Access Project, 1997) and values clarification tools, case studies, and fact sheets. About 300 nurses, nursing students, and faculty access these tools annually at www.abortionaccess.org.
At the University of California, San Francisco School of Nursing’s Family and Women’s Primary Care Program (NP and CNM students), required coursework includes didacticinformation on primary prevention of unintended pregnancy (contraception, emergency contraception) and secondary prevention of unintended pregnancy (pregnancy options counseling and first trimester abortion methods). Clinical training includes procedural skill training in IUD insertion, ultrasound, and MVA for miscarriage management and abnormal bleeding, along with pain management (such as paracervical blocks) for these procedures. For those students who want more experience, supervised clinical training is arranged.
At the Stonybrook University Physician Assistant Education Program, the reproductive health curriculum includes both required didactic coursework and elective clinical training in abortion and assisted reproductive technology. In addition, as part of the general ethics course taken by all PA students, one class focuses on the history of abortion and infertility treatments in the US as well as the ethical considerations facing women’s health professionals who provide these reproductive health services (Ranieri, 2009).
Some APC faculty has been successful in promoting reproductive rights and health in curriculum and educational policy. For example, the faculty of the Nurse-Midwifery and Women’s Health Nurse Practitioner Program at the University of Illinois at Chicago support the international definition of reproductive health that “All people have the right to decide freely and responsibly the number and spacing of their children, and to have the information, education and means to do so; and the right to make decisions concerning reproduction free of discrimination, coercion and violence” (United Nations, 1995). This definition provides the foundation for educational requirements for students in the program, as their policy on this subject states: “[w]hile individuals may have beliefs that differ, students are required to learn the full range of reproductive options available to women throughout the world and be able to counsel and refer women appropriately” (University of Illinois-Chicago Nurse Midwifery and Women’s Health Nurse Practitioner Program, 2003).
Postgraduate Education and Training for APCs in Abortion Care and Provision
NPs, CNMs, or PAs who did not receive specialty didactic and clinical training in reproductive
health and abortion care in their basic education program must look to postgraduate or
continuing education programs for that training. National professional organizations and a
few academic or residency training groups have developed standards, curricula, and training
guidelines for prelicensure health professional students, medical residents, and women’s health
professionals who want didactic and clinical training in abortion care or procedures or who
wish to advance their practice into abortion care.
It is worth noting, however, that training in abortion care can be very difficult for APCs to access. Many abortion care facilities with established training programs have already committed their training slots to medical residents, students, or their own staff, and APCs may face prejudice from trainers who are not supportive of abortion as part of APC scope of practice or who see APCs as possible competitors. Depending on the APC’s prior experience, training in skills such as ultrasound, pregnancy options counseling, paracervical anesthesia, conscious sedation, medication abortion provision, and endometrial biopsy using MVA may also be necessary, and the training slots for these procedures may be equally competitive.
The following resources offer suggestions for self-study as well as guidelines for training to competency in abortion care. APCs who wish to learn more about acquiring abortion training should contact the Abortion Access Project at [email protected] or the National Abortion Federation at [email protected] to talk about the opportunities and possible challenges.
The Association of Reproductive Health Professionals (ARHP), an interdisciplinary organization that includes advanced practice nurses and PAs has developed educational standards and curricula for health professionals training in reproductive health. ARHP and its organizational partners have developed an innovative web-based curriculum resource called CORE (Curricula Organizer for Reproductive Health Education). CORE is a collection of peer-reviewed, evidence- based teaching materials that allows clinicians and educators to (1) access up-to-date teaching materials on reproductive health topics including abortion care; (2) build their own curricula and other educational presentations; and (3) download activities, case studies, and other handouts for learners. The ARHP website, www.arhp.org, lists a number of publications on abortion care from multiple organizations as well as practice guidelines, clinical reports, interactive tools, and other resources designed for health care providers. In the area of abortion, the ARHP website provides:
- Abortion research from peer-reviewed journals. Available at http://www.arhp.org/topics/abortion/featured-research
- Abortion-related clinical and educational publications and resources, such as training modules in the provision of abortion care from abortion counseling through postabortion care, as well as medication and aspiration abortion procedural training. Available at http://www.arhp.org/topics/abortion/clinical-publications-and-resources
- Online continuing education programs in abortion-related topics, such as webinars on MVA for early pregnancy loss, slide and lecture downloads on abortion from the Guttmacher Institute, and web-based CE offerings from NAF. Available at http://www.arhp.org/topics/abortion/continuing-education
The National Abortion Federation (NAF) is the professional association of abortion providers
in the United States and Canada. NAF sets the standard for quality abortion care in
North America through its evidence-based Clinical Policy Guidelines (CPGs), to which NAF
members are required to adhere as a condition of membership (NAF, 2008). These are the only
such abortion-related guidelines published in the Agency for Healthcare Research and Quality’s
(AHRQ) National Guidelines Clearinghouse (AHRQ, 2008). In these guidelines, NAF fully
supports APCs as qualified abortion providers.
NAF’s Training and Education Program offers accredited continuing medical education for health care professionals through a variety of educational resources, including semiannual conferences, workshops, seminars, and online and electronic self-study modules. NAF’s CME program incorporates a wide range of topics related to the provision of abortion care, including emerging technologies, first and second trimester abortion methods, quality assurance, and pain management. NAF’s CME programming is appropriate not only for physicians, but also for others who are important to the successful provision of abortion care, including APCs, nurses, counselors, clinic administrators, and medical assistants.
NAF was the first organization to train U.S. providers (including many APCs) in early medication abortion and currently sponsors basic and advanced training in medication and aspiration abortion care procedures. NAF has also published a number of educational and practice resources for clinicians interested in becoming abortion providers. Some of these resources include: Clinical Training Curriculum in Abortion Practice (2005a); Principals of Abortion Care: A Curriculum for Physician Assistants and Advanced Practice Nurses (Policar, Pollack, Nicholas, & Dudley, 1999), and the textbook Management of Unintended and Abnormal Pregnancy: Comprehensive Abortion Care (Paul, Lichtenberg, Borgatta, Grimes, Stubblefield, & Creinin, 2009).
NAF curriculum modules are available for download at http://www.prochoice.org/. They include the following titles:
- Early Medical Abortion with Mifepristone and Other Agents: Overview and Protocol Recommendations (NAF, 2002)
- Early Options Educational Slide Program on CD-ROM (NAF, 2005c)
- Early Options: A Provider’s Guide to Medical Abortion (NAF, 2005b)
- Early Options Medical Abortion Education Modules
- The Historical and Social Context of Medical Abortion
- Medical Abortion Regimens
- Expected Side Effects and Management of Complications in Medical Abortion
- Early Surgical Abortion: An Alternative to and Backup for Medical Abortion
- Clinical Training Curriculum in Abortion Practice (NAF, 2005a) (available for download in slide format)
- Ten modules including didactic and clinical skills for medication and aspiration abortion care
- Didactic content: pregnancy verification; estimation of gestational age; counseling and informed consent; selection of appropriate procedure; medical screening for aspiration abortion; pain management and postabortion care and follow-up
- Clinical skills training: medication and aspiration abortion procedure skills and techniques; management of medication and aspiration abortion complications
Planned Parenthood Federation of America’s Consortium of Abortion Providers (CAPS) has
provided onsite didactic and practicum training since 2001 for provision of medication abortion.
This training relies on material that has been reviewed by expert physician and clinician
reviewers and is presented by an APC with extensive experience in provision of medication
abortion. Topics include client selection, client assessment, the medication regimens, the pharmacologic
action of the medicines, timing of medicines, expected course of medication abortion,
side effects and their management, assessment of after-hours emergencies, and assessment
at the follow-up visit.
As a continuing education provider approved by the California Board of Registered Nursing, CAPS provides continuing education credits (CEU) for its abortion training programs. CAPS also provides onsite didactic and hands-on training for administration of conscious sedation and introductory ultrasound training.
For sites starting to offer aspiration abortion as well as medication abortion, CAPS provides training (with CEUs) in this service, with a focus on client selection; contraindications; informed consent; techniques of aspiration abortion; emergency triage; emergency drills; common complications; and client questions, follow-up, and contraception, among other topics. CAPS also provides didactic and hands-on training for performance of moderate-complexity Rh testing of the fetus.
CAPS has also used physician consultants to provide didactic and hands-on training for evaluation of fresh tissue specimens following aspiration abortion and other technical procedures related to aspiration abortion.
In collaboration with Affiliate Risk Management Services (the insurance corporation of Planned Parenthood) and with support from NAF, CAPS created an ACCME-accredited interactive CD, Ultrasound in Abortion Care. The CD provides a series of interactive learning exercises to teach the proper techniques and skills for accurately dating a pregnancy, evaluating the intrauterine position of a pregnancy, screening for ectopic pregnancy, screening for first trimester variants, and assessing the uterine cavity following medication abortion. Many clinical training sites and direct-service facilities as well as residency programs and schools of nurse-midwifery use this CD.
Additional Training and Curricular Resources
A number of educational resources are available as textbooks, CD-ROMs, and web-based materials. Although some academic texts may be available only from the publishers, the following curricula and training programs are available online or directly from the training programs:
- Abortion Training: A Guide to Establishing an Effective Program at Your Facility (Abortion Access Project & University of Massachusetts Medical Center, 1998); available at http://www.abortionaccess.org/component/option,com_docman/task,doc_details/ gid,111/
- Abortion Training in Residency Programs: An Interactive Guide for Medical Students (Medical Students for Choice, (2008); available at http://medicalstudentsforchoice.org/ index.php?page=residency-guide
- Guide for Students Considering Residency in Ob/Gyn or Family Practice (Medical Students for Choice, 2008); available at http://medicalstudentsforchoice.org/index. php?page=ob-gyn-or-family-practice
- Early Abortion Training Workbook (UCSF Advancing New Standards in Reproductive Health, 2007); available at http://www.ansirh.org/training/trainingworkbook.php
- Surgical Abortion Training Curriculum (Gold & Planned Parenthood of New York City, 1996); to order, call PPNYC Clinician Training Initiative at 212-274-7255.
- Ipas Start-up Kit for Integrating Manual Vacuum Aspiration (MVA) and Medication Technologies into Women’s Reproductive Health-Care Services (Ipas, 2008); available at http://www.ipas.org/Publications/asset_upload_file449_3514.pdf
- Vermont Women’s Health Center: Training Program for Abortion and Related Services (Nicholas, 1991)
- Obtaining Abortion Training: A Guide for Informed Decision Making (NAF, 2009); available from the National Abortion Federation at http://www.prochoice.org/education/ resources/postgrad_training.html
- Medication Abortion: A Training Module for Health Professionals (Ibis Reproductive Health, 2003); available at http://www.ibisreproductivehealth.org/pub/downloads/ Medication_Abortion_Training_Module.ppt
The APC Health Workforce Pilot Project: A New Development in Abortion Care Education and Training
As part of a demonstration and evaluation project to prepare APCs to provide early abortion
care, the Health Workforce Pilot Project (HWPP) 17130 is testing a standardized competency based,
provider-neutral early abortion care curriculum and training plan. Following training,
APCs will integrate first trimester pregnancy diagnostic and termination procedures into
existing health services, along with medication and uterine aspiration for treatment of early
pregnancy failure, incomplete abortion, and miscarriage management. The HWPP training plan
consists of didactic education and “hands-on” clinical experience, along with knowledge testing
(online examination) and periodic clinical skills (competency) assessment with the goal of training NPs, CNMs, and PAs to competence in all aspects of early abortion care. The APC curriculum is based on the ANSIRH Workbook in Early Abortion Care (UCSF ANSIRH, 2007).
The HWPP training plan is based on the ARHP-accredited TEACH Project (Training in Early
Abortion for Comprehensive Health Care), which is used to train residents and primary care
physicians nationwide. After evaluation of trainee and patient outcomes, the standardized curriculum
and competency-based training will be submitted for postgraduate specialty continuing
education accreditation (e.g., CEU, CME credits).
A Question for NP, CNM, and PA Educators: What Is Your Role in Advancing Abortion Care for APCs?
- Of the four categories of evidence for situating abortion care within APC scope of practice, education
and training is the essential one. Regulatory boards look to NP, CNM, and PA educators for the
reproductive health standards and clinical competencies when assessing whether a procedure such
as abortion care is within the scope of practice of an APC. Certainly there is an established need for
women’s primary care providers such as CNMs, NPs, and PAs to have the knowledge base and skills
to prevent and manage unintended pregnancies. For example, 70% of patients seen by NPs and PAs
and 90% of CNM patients are at risk for unintended pregnancy (Hwang et al., 2005). Furthermore,
although the Healthy People 2010 initiative set as a national health goal (focused on primary care
providers) reducing unintended pregnancy to 30% (U.S. DHHS, 2000), the rate has remained steady
at 49% since 2000 (Finer & Henshaw, 2006).
- Situate the abortion care curriculum within a broader public health model of unintended pregnancy prevention and management. Currently, all programs teach primary prevention of unintended pregnancy (such as preconception counseling, family planning, and contraception skills including emergency contraception). Secondary prevention of unintended pregnancy focuses on knowledge and skills of pregnancy diagnosis, pregnancy options counseling, and early abortion care such as knowledge and skills for medication and aspiration abortion provision. It is this secondary unintended pregnancy prevention component that needs to be developed and incorporated into APC education and training (Levi, Simmonds, & Taylor, 2009).
- Specify core competencies for unintended pregnancy prevention and management across primary, secondary, and tertiary prevention competencies. For NP faculty, this can mean specification of the women’s health core competencies (NONPF & AACN, 2002). For PA faculty, the APAOG could work with PAEA to develop curriculum in secondary prevention of unintended pregnancy.
- Integrate core competencies into curriculum. Establish clinical opportunities for CNM, NP, and PA students to learn medication and/or aspiration abortion skills.
APC educators have been in the lead in developing reproductive health curriculum and core competencies for women’s health practice. We urge them to continue their dedication to high-quality education by aligning educational curriculum and core competencies in women’s and reproductive health with those for unintended pregnancy prevention, including abortion care. For example:
30 The APC-HWPP Project 171 is being undertaken by the University of California, San Francisco’s Advancing New Standards in Reproductive Health (ANSIRH) Program in collaboration with eight participating health care organizations across California and under the auspices of the California Office of Statewide Health Planning and Development’s (OSHPD) Health Workforce Pilot Program. The California OSHPD HWPP provides a protective mechanism whereby, for the duration of the project, regulations that may restrict CNMs, NPs, and PAs from providing aspiration abortion are temporarily suspended. Data are being collected on APC competency achievement using a standardized curriculum, as well as on patient outcomes for APC and MD comparator abortion procedures. UCSF/ANSIRH’s APC-HWPP staff and faculty are providing oversight and evaluation of the research plan and the project. The project has been approved by the UCSF IRB as well as secondary review boards for each of the partner organizations.