Licensure and Credentialing
Practice Authority-Licensure, Credentialing, and Scope
NPs and CNMs are credentialed first as registered nurses and then as advanced practice registered nurses (in the NP or CNM role). To date, 9 states and the District of Columbia have recognized the CM credential: DE, HI, ME, MD, NJ, NY, OK, RI, VA, and DC, although the legal and regulatory environment for CMs is changing. You can refer to ACNM documents for most current information. PAs have only one credentialing mechanism.
The credentialing process is based on a set of essential elements that aligns government authority with regulatory and professional responsibilities. These essential elements of professional regulation and credentialing include:
- Scope, standards, competencies, and ethical codes of practice and professional performance: essential documents developed by the professions to provide a basis for education and practice regulation.
- Education: the professional’s formal preparation in graduate degree–granting or postgraduate certificate programs.
- Accreditation: formal review and approval by a recognized agency of educational degree or professional certification programs.
- Legal scope of practice and physician-only laws: not defined by law but rather determined by relevant laws, regulations, and professional organization opinions.
- Licensure: the granting to an individual of authority to practice within a state.
- Certification (or second licensure in some states): formal recognition of the knowledge, skills, and experience the individual demonstrates by meeting the standards the profession identifies.
Who Are the Players?
While there is no uniform federal law that grants a professional license to practice, there are commonalities across states and each of the health professions. Here are the entities that are typically involved in defining scope of practice:
State legislature
Enacts broad laws defining scope of practice, often delegating to the state licensing boards to specify the details.
State licensing boards
Defines and enforces scope of practice, often by reference to national standards. Most licensing boards have processes for determining how to incorporate changes in practice into existing regulations.
Other state boards
Such as those governing office-based surgery or outpatient anesthesia provision, may also establish criteria governing practice by different health professionals.
Professional associations
Professional associations play a critical role in developing national standards. Licensing boards rely on them to assess and define professional practice, standards of practice (including ethical standards), and basic and advanced competencies that are the foundation for safe and effective care.
Educators
State licensing boards also look to professional education and training programs to identify how practice standards and competencies are situated within the curriculum and clinical training.
In all cases, the individual practitioner is accountable to the patient and the profession to practice according to legal/professional ethical standards and to adhere to professional performance criteria established and enforced by the regulatory and professional bodies.
General Legal and Regulatory Requirements
Professional licensees in each state are governed by their respective practice acts and other applicable statutes, as well as by licensing board rules, orders, policies, advisory opinions, and procedures.
As is the case for any other health or medical service a licensed professional might provide, clinicians providing abortion and reproductive services must understand and comply with the legal requirements, both substantive and procedural, set forth in multiple intertwined legal standards, acts, and pronouncements.
That said, the FDA has made clear that qualified health care providers acting within their scope of practice are not precluded from dispensing medication abortion to patients if authorized by state law:
Healthcare providers who prescribe and who meet certain qualifications are authorized to order and dispense Mifeprex.
All health care professionals are legally accountable for actions they take in the course of their practice. This accountability is enforced principally through the legal mechanisms of licensure, state practice acts, and related legislative and regulatory initiatives, all of which explicitly codify the profession’s obligation to act in the best interests of society. Nurse practice acts grant nurses and APRNs the authority to practice—and also grant regulatory boards the authority to sanction those who violate the norms of the profession and act in a manner that threatens public safety. PAs are similarly regulated by state PA practice acts.
NPs, midwives, and PAs, as members of their state professional organizations must continually monitor legislative proposals relevant to their practice regulations and authority. This requires attention to activities related to their particular regulatory board or practice act. It also involves monitoring bills or legislative committee actions in related areas, such as the Pharmacy Act (for prescriptive authority), the Medical Practice Act (for physician supervision or “collaboration” requirements and other constraints), and the Departments of Health or Health Services and the Insurance Commissioner (for conditions of payment for services or requirements for the range of services provided in hospitals or community health clinics).
Understanding Scope of Practice
In an ideal world, statutory definitions of professional practice would be consistent with and build upon a profession’s definition of its practice base, yet be general enough to encompass the dynamic nature of an evolving scope of practice. Such a consistent yet flexible definition would serve society both by enhancing the geographic mobility of providers and by promoting access by all states’ residents to the full range of services nurses, NPs, midwives, and PAs provide. Unfortunately, this consistency does not yet exist, as the wide variation in state practice authority, as well as abortion practice restrictions for NPs, midwives, and PAs shows.
This lack of consistency in statutory definitions is one more reason it is so important for clinicians to understand both their state’s current scope of practice provisions and strategies for advancing their scope to encompass evolving competencies. In this way APCs can work to their full scope of practice without the artificial legal barriers currently imposed by some states.
A quick review of the essential concept of professional scope of practice will help reinforce its relevance to sustaining and promoting the availability of safe reproductive health services, including abortion
Scope of practice has been described as:
In less formal terms, scope of practice addresses the questions of “who can do what for whom in what clinical setting and under what circumstances.” Answers to these questions also determine the ancillary but important issue of who can get paid for providing services.
Whether viewed in sophisticated or common-sense ways, scope of practice underpins the entire framework of our health provider licensing system. That is, state governments acting to protect and promote public health, assess the education, training, and abilities of various provider groups, and then signal to the public through licensure that these providers have been deemed competent and are authorized to provide a relatively defined range of health services in a safe and effective manner.
Understanding scope of practice as the central organizing principle of our regulatory scheme lets us appreciate the history of its political and professional evolution in each state—and its continuing importance for NPs, midwives, and PAs.
The Role of the Professions in Defining Scope of Practice
National NP, midwifery, and PA organizations have developed documents and policies that establish criteria by which professionals are credentialed, criteria which are adopted by state boards and other regulatory bodies to monitor and regulate clinical practice, deem it safe or unsafe, and discipline clinicians. Such documents and policies include:
- philosophies of practice;
- codes of ethics;
- standards of practice;
- competencies for entry into practice and excellence; and
- practice guidelines and policies such as institutional privileging and collaborative practice agreements.
Similarly, accrediting bodies develop mechanisms to accredit educational programs and certifying bodies establish programs for professionals to obtain and maintain certification.
Organizations representing NPs, midwives, and PAs have established a number of essential documents, policies, and mechanisms to assure clinical competence, safety, and quality care.
Academic programs use these standards and competencies as the basis for curriculum development and program accreditation, and to prepare graduates for certification. Most national organizations also have state chapters and practice committees that play an important role in the implementation, review, and revision of regulatory and credentialing documents. Because professional regulation is implemented at the state level through licensing boards and legislative action, members of state practice organizations and committees must provide essential formal and informal expertise to these boards and agencies.
For more information on these professional organizations and their functions, see the Advocacy and Professional & Advocacy Organizations sections within this Toolkit, which provides links to resources from professional organizations, accreditation, and credentialing bodies.
For more information on the history of scope of practice please see the 2018 AP Toolkit here.