Contraception Editorial August 2009

Advancing Scope of Practice for Advanced Practice Clinicians: More Than a Matter of Access

By: Tracy Weitz, Patricia Anderson, Diana Taylor

The declining availability of abortion care has been the topic of many studies, commentaries, conferences and advocacy initiatives over the last 20 years. Among the ideas suggested to ameliorate this problem is increasing the number of physician assistants (PAs), nurse practitioners (NPs), and certified nurse midwives (CNMs) who perform first-trimester abortion.^1-6 While addressing access through this strategy holds great promise, it is not simply a matter of access that calls for more clinicians to participate in abortion care. Rather, as health professionals, we should expect that professional scope of practice determinations are based upon whether the “profession can provide this proposed service in a safe and effective manner”⁷ and not solely on the lack of physicians available to provide the service. It is time to acknowledge that PAs, NPs and CNMs [collectively known as advanced practice clinicians (APCs)] are capable and qualified to provide abortion care services, but that current efforts to provide this care are thwarted by both the politics of health care and the politics of abortion.⁸ Outdated laws, restrictive regulations, lack of clinical training opportunities, professional turf battles and politically-motivated challenges impede APCs abilities to provide abortion care. APCs, physicians, reproductive health and rights advocates and attorneys must join together to promote the provision of abortion by APCs, thereby protecting both women’s access to abortion care and practitioners’ rights to provide essential care for their patients.

APCs have a long history of providing comprehensive reproductive health services within primary care and family planning settings. In 2004, APCs saw six times as many women for publicly-funded family planning services as did physicians.⁹ Noteworthy is that APCs have been providing abortions in some states since 1973 when abortion was nationally legalized in the United States.¹⁰ There is a growing body of evidence that APCs are safe, efficacious providers of abortion, via both medication and aspiration methods. Studies published in 1986, 2004 and 2006, comparing abortions performed by physicians to abortions performed by NPs and PAs found comparable rates of safety and efficacy.^11-13

Despite this evidence, many states have “physician-only” laws which prohibit the performance of abortions by anyone other than licensed physicians. Some of these laws were enacted around the time of Roe v. Wade in 1973 to protect women from unsafe, unlicensed abortion providers. They predate the recognition of APCs role in health care and the development of newer and simpler abortion technologies. These laws were never meant to prohibit the future evolving scope of practice by APCs, but their presence “on the books” is a de facto restrictive legacy. In recent years, abortion rights opponents have used physician-only laws in Arizona, Missouri, North Dakota and Tennessee specifically as a strategy to reduce access to abortion services by limiting who can provide such care.

Usual allies in opposition to abortion restrictions, such as regional offices of the American College of Obstetricians and Gynecologists, fail to aggressively fight these proposed restrictions in part due to their overall support for using the political process to control the scope of practice of other health professionals. Professional nursing and other allied health professionals also fail to engage in challenging these laws, although their motivations stem more from the desire to avoid the messy contested world of abortion politics. Consequently, abortion opponents often find little resistance to their efforts to restrict access to abortion through limiting scope of practice. This editorial seeks to provide health care professionals with the tools for engaging in these debates.

How is scope of practice normally determined for APCs?

Scope of practice can be understood as the activities that an individual health care practitioner is permitted to perform within a specific profession and is uniquely defined by the congruence between law and appropriate practice.¹⁴ The boundaries of scope of practice are determined by clinical competence and skill, knowledge and training, professional and institutional standards and legal-regulatory requirements. Scope of practice evolves and changes over time due to community needs and technology advancements, as well as health professional practice and education standards, institutional policies and state laws or regulations.¹⁵ Advancing scope of practice requires evidence that a new skill or technique will facilitate access to safe and effective health care services and that professional and educational standards and competencies are consistent with a new area of practice.¹⁶ Interpreting abortion to be outside the scope of practice of CNMs, NPs and PAs, regardless of their documented competence, runs directly counter to the normal manner is which scope of practice assessments are made.

In the United States, there are approximately 200,000 licensed CNMs, NPs and PAs who today perform primary health care services once provided only by licensed physicians. APCs specializing in reproductive health have acquired numerous advanced skills that are now considered common practice, such as administering paracervical anesthesia, performing ultrasounds, inserting intrauterine contraception and conducting colposcopy and biopsies [as reflected in the numerous educational programs offered to APCs by the Association of Reproductive Health Professions (ARHP)]. Abortion care is a natural complement to these procedures and practices. Integrating abortion into the care APCs provide holds the potential to foster greater continuity of care, ensure earlier diagnosis and termination of unintended pregnancy and promote women’s health and well-being.

Actions to support including abortion in APC scope of practice

Advancing abortion care within APC scope of practice depends on collaboration among multiple stakeholders. Individual APCs, APC educators and employers, physician allies as well as reproductive health advocates, professional organizations and state regulatory groups must be part of the solution. Professional organizations play a critical part with state licensing boards and legislatures in developing, maintaining and advancing professional practice. The following strategies highlight a few ways for APCs to participate in his/her professional organization and to work with others in bringing the professional voice to scope of practice conversations at the state and national level:¹⁷

• Become involved in your professional organization and take leadership in developing, maintaining, and advancing professional standards and responsibilities. If the professions fail to provide leadership, the licensing boards and legislatures will take the lead.
  • Become active in your national organization’s state chapters and practice committees; they play an important role in the implementation, review and revision of regulatory and credentialing documents.
  • Build relationships with members of your state professional association before there is a scope of practice debate rather than waiting to act until a crisis presents itself.
• Read your state’s professional practice act and know how scope of practice is defined in statutes and regulations.
  • Understand regulatory board functions, as well as the roles of board members, when advocating for change.
  • Check to see if your state regulatory board has developed guidelines for advancing scope of practice and know the procedures.
• Get to know your nursing, medical and/or healing arts boards.
  • Volunteer to help your boards and serve on committees. Develop a better understanding of the issues or limitations that affect both the public and health professional groups.
  • Learn about board processes and the mechanisms used to regulate and advance scope of practice.
  • Attend a board public meeting to observe the process in action and get to know board members and colleagues from around the state.
  • Obtain the minutes from public meetings; in many states they are available online.
• If you are a clinician, develop a professional portfolio that documents abortion care competencies and experience.
  • Describe your professional skills and profile your major accomplishments. All health professionals — whether APCs or physicians — are responsible for compiling essential documents and credentials that authorize them to practice.
• As an educator or trainer, help develop abortion care education and training programs.
  • Serve as a resource to regulatory boards, which look to NP, CNM and PA educators for reproductive health standards and clinical competencies when assessing whether a procedure is within APC scope of practice.
  • Continue your 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.
  • Consider working closely with multi-disciplinary professional organizations that support linkages in education between all members of the health care team, such as the ARHP.
• Educate legislators and policy-makers, testify before legislative committees and draft public statements in support of abortion care as part of the scope of practice for all health professionals who care for women at risk for unintended pregnancy.

Conclusion

APCs as abortion providers can make early abortion care more accessible, but their practice in this arena is not simply a solution to the problem of access but a natural advancement in scope of practice based on professional expertise. APCs, their physician colleagues and reproductive health advocates need to actively engage in the larger debates about scope of practice. Together we can ensure that health policy decisions about who can provide abortions to whom and under what circumstances are determined by evidence and not by the either the politics of abortion or the politics of health care.

Tracy Weitz
Advancing New Standards in Reproductive Health (ANSIRH)
Bixby Center for Global Reproductive Health (Bixby Center)
University of California, San Francisco (UCSF)
Oakland, CA

Patricia Anderson
Primary Care Initiative
ANSIRH, Bixby Center, UCSF
Oakland, CA

Diana Taylor
ANSIRH, Bixby Center, UCSF
Association of Reproductive Health Professionals (ARHP)
Oakland, CA

References

1. National Abortion Federation. Who will provide abortions? Ensuring the availability of qualified practitioners. Washington, DC: National Abortion Federation; 1991.
2. Darney PD. Who will do the abortions?. Womens Health Issues. 1993; 3: 158–161.
3. Grimes DA. Clinicians who provide abortions: the thinning ranks. Obstet Gynecol. 1992; 80: 719–723.
4. Joffe C, Yanow S. Advanced practice clinicians as abortion providers: current developments in the United States. Reprod Health Matters. 2004; 12 (24 Suppl): 198–206.
5. Samora JB, Leslie N. The role of advanced practice clinicians in the availability of abortion services in the United States. J Obstet Gynecol Neonatal Nurs. 2007; 36: 471–476.
6. Kruse B. Advanced practice clinicians and medical abortion: increasing access to care. J Am Med Womens Assoc. 2000; 55 (3 Suppl): 167–168.
7. Changes in Healthcare Professions’ Scope of Practice: Legislative Considerations. https://www.ncsbn.org/ScopeofPractice.pdf [Accessed April 14, 2009]: The Association of Social Work Boards, The Federation of State Boards of Physical Therapy, The Federation of State Medical Boards, The National Association of Boards of Pharmacy, The National Board for Certification in Occupational Therapy, The National Council of State Boards of Nursing, Inc.; 2007.
8. Taylor D, Safriet B, Weitz T. When politics trumps evidence: legislative or regulatory exclusion of abortion from advanced practice clinician scope of practice. J Midwifery Womens Health. 2009; 54: 4–7.
9. Frost JJ, Frohwirth L. Family Planning Annual Report: 2004 Summary Part 1. Report to the Office of Population Affairs, U.S. Department of Health and Human Services. Washington DC: The Alan Guttmacher Institute; 2005.
10. Donovan P. Vermont physician assistants perform abortions, train residents. Fam Plann Perspec. 1992; 24: 225.
11. Freedman MA, Jillson DA, Coffin RR, Novick LF. Comparison of complication rates in first trimester abortions performed by physician assistants and physicians. Am J Publ Health. 1986; 76: 550–554.
12. Goldman MB, Occhiuto JS, Peterson LE, Zapka JG, Palmer RH. Physician assistants as providers of surgically induced abortion services. Am J Publ Health. 2004; 94: 1352–1357.
13. Warriner IK, Meirik O, Hoffman M, et al. Rates of complication in first-trimester manual vacuum aspiration abortion done by doctors and mid-level providers in South Africa and Vietnam: a randomised controlled equivalence trial. Lancet. 2006; 368: 1965–1972.
14. Safriet BJ. Closing the gap between can and may in health-care providers’ scopes of practice: A primer for policymakers. Yale J Regul. 2002; 19: 301–334.
15. Milstead JA. Health policy and politics: a nurse’s guide. 3rd ed. Sudbury, MA: Jones and Bartlett Publishers; 2008.
16. Schuiling KD, Slager J. Scope of practice: freedom within limits. J Midwifery Womens Health. 2000; 45: 465–471.
17. Taylor D, Safriet B, Dempsey G, Kruse B, Jackson C. Providing abortion care: A professional toolkit for nurse-midwives, nurse practitioners and physician assistants. San Francisco: University of California, San Francisco; 2009.

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Used with permission from Elsevier, Inc.