Presentation Transcript

1. Advancing Scope of Practice in Reproductive Care

   Joyce Cappiello PhD, FNP Director of the ROE Consortium Provide, Inc.

2. Perhaps a better title…

   When scope of practice intersects with politics and hot button social issues
3. Background There has been a substantial decline in the number of abortion providers in the U.S. The decline of providers slowed between 2000-2005 as more new providers began to offer medication abortion. Advanced practice nurses (APNs) comprise a portion of the new providers offering medication abortion. Current data does not track type of provider.
4. Taxonomy Because an ideal taxonomy has yet to be identified, the professions are listed individually (CNM, NP and PA) rather than use terms such as midlevel, nonphysician or physician extender. The term advanced practice clinicians is in widespread use, however, it does not accurately categorize the physician assistant profession.

5. Professional Organization Position Statements on Abortion Care

   Provide an ethical and legal mandate for APNs to ensure patient access to comprehensive, reproductive health services.
6. Professional Organization Position Statements on Abortion Care American Public Health Association (APHA, 1992) Nurse Practitioners in Women’s Health (NPWH, 1991) American College of Nurse-Midwives (ACNM, 1991) American Association of Physician Assistants (AAPA, 1992).
7. American College of Nurse-Midwives 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 to factual, unbiased information about reproductive choices, in order to make an informed decision; That women with limited means should have access to financial resources for their reproductive choices.” Midwives follow guidelines in Standard VIII of the Standards for the Practice of Midwifery to incorporate new procedures into their practice, including abortion.
8. Nurse Practitioners in Women’s Health (NPWH) Resolution on Nurse Practitioners as Abortion Providers, October 1991 “Whereas, the purpose of the National Association of Nurse Practitioners in Reproductive Health is to ‘assure quality reproductive health services which guarantee reproductive freedom and to protect and promote the delivery of these services by nurse practitioners’; “Let it be resolved that NANPRH believes that nurse practitioners, with appropriate preparation and medical collaboration, are qualified to perform abortions.”
9. American Academy of Physician Assistants (AAPA) Policy Adopted by the AAPA House of Delegates, May 1992: “The AAPA affirms a patient’s right of access to any legal medical treatment or procedure made with the advice and guidance of their health care provider and performed in a licensed hospital or appropriate medical facility. “The AAPA supports the free exchange of information between the patient and provider and opposes any intrusion into the provider/patient relationship through restrictive informed consent laws, biased patient education or information, or restrictive government requirements of medical facilities.” “The AAPA opposes attempts to restrict the availability of reproductive health care.”
10. Professional Medical Association Policy Statements Three physicians’ organizations have adopted position statements to address the shortage of abortion providers: • In 1994 the American College of Obstetricians and Gynecologists (ACOG) “encouraged programs to train physicians and other licensed health care professionals to provide abortion care in collaborative settings” • In 1999 both the American Medical Women’s Association (AMWA) and Physicians for Reproductive Choice and Health (PRCH) endorsed the training of CNM, NP and PA to provide abortion care.
11. American Public Health Association Supports the provision of first trimester surgical and medical abortion by appropriately trained NPs, CNMs, and PAs Supports efforts to overcome legal and regulatory obstacles which limit the participation of NPs, CNMs, and PAs in abortion. (1999, 2011)
12. World Health Organization ‘s Safe Abortion Guide WHO Safe Abortion Guide Safe Abortion: Technical and policy guidance for health systems. Geneva: WHO, 2003. This report provides the latest evidence-based guidance on clinical care. It includes information on how to establish and strengthen services, and outlines a human-rights-based approach to laws and policies on safe, comprehensive abortion care.
13. Specialty organization policy statements National Abortion Federation Association of Reproductive Health Professionals
14. Why are there not more APN providers? The history…
15. Perception of abortion as a difficult procedure. Perception that providing abortions is the exclusive realm of physicians. Variation of legal picture among states.
16. Barriers to APN practice Perception of abortion as a difficult procedure. Is it? Is providing a vacuum aspiration procedure more difficult than comparable skills of endometrial biopsy, IUD insertions, colposcopy with endocervical curettage or miscarriage management? What are comparable types of procedures? Is it significantly different that other procedures performed in the uterus? Is prescribing medication abortion any more challenging than prescribing other prescription medications?
17. Perception that providing abortions is the exclusive realm of physicians. Why does this perception persist? Professional organizations support abortion care. PAs at the Vermont Women’s Health Center (now a Planned Parenthood affiliate) in Burlington, Vt. have provided abortion care since 1973. PA in Montana providing abortions since 1970’s .
18. Studies documenting the safety of abortion care by NPs, PAs, CNMs Warrineret al. (2006) reported findings from randomized, control trials conducted in South Africa and Vietnam (n=2,789 procedures). In both countries, the patient outcomes provided by PAs and midwives were comparable to those of physicians. Goldman et al. (2004) compared outcomes of 1,363 aspiration abortions provided by PAs with those of physicians. They found no differences in complications related to the type of providers. Boymanet al. (2004) examined 1,976 first trimester aspiration abortion procedures. They compared outcomes for 10 physicians with those for 5 NPs and 2 PAs and found no significant differences between physician and APC outcomes: immediate complications were rare (<1%), and delayed complication rates were low (<2%). .
19. Studies, cont. Freedman et al. (1986) found no differences in complication rates between experienced PAs and MDs with respect to overall, immediate, or delayed complications in 2,458 procedures. In California, 11,487 aspiration abortions procedures were analyzed, 1.3% (n = 152) resulted in a complication: 1.8% for NP-, CNM-, and PA-performed aspirations and 0.9% for physician-performed aspirations. Abortion complications were clinically equivalent between newly trained NPs, CNMs, and PAs and physicians, supporting the adoption of policies to allow these providers to perform early aspirations to expand access to abortion care.
20. Regulatory barriers Variation of APN scope of practice varies significantly among states Superimpose specific abortion regulations on this variation. Enacted in 1970’s to presumably protect women from unscrupulous providers. Were not meant to preclude NP practice, the role of APNs was not yet developed. Unfortunately have been used to restrict APC practice. 44 states had physician only laws
21. : New York 1994: NYS New York Civil Liberties Union obtained a Declaratory Ruling from the New York Department of Health. Stated PAs can provide first-trimester abortions in NY under their practice act, despite the state’s physician-only law. Ruling recognized that the intent of the physician-only requirement and the physician assistant legislation are the same — to provide access to safe medical care. 
22. Other Pivotal changes 1996 - NAF Symposium brings together advocates and providers to discuss how to promote the role of NPs, CNMs & PAs. Report: Who will provide abortions: http://www.prochoice.org/pubs_research/publications/downloads/cfc/CNM_NP_PA_org_statements.pdf 2000 – FDA approval of mifepristone widens doors to an alternative early abortion technique.
23. A number of strategies have been employed to advance SoP in abortion care : Legislation Attorney General letters or opinions Local District Attorney letters Professional Board decisions Dept. of Health letters
24. Case Studies Arizona Alaska Oregon New York State
25. Lessons Learned To establish abortion care as within APN SoP: Examine historical evidence Examine professional/clinical evidence Examine education/training Examine evidence of legislative, legal & regulatory environments
26. Know the regulatory process Understand your state practice act and other relevant codes. Develop a working knowledge of your state licensing board. Understand who does what, how and for whom. Understand the politics of health professions (licensing board processes, board members and advisory committees; who to lobby and who not to lobby; how info gets to licensing boards)
27. Use your professional resources Join and engage with your professional organization and other stakeholders. In Arizona, professional nursing groups involved with this effort were extremely competent and articulated their knowledge of the Nurse Practice Act, Board of Nursing procedures and mobilized nurses to focus on abortion as a scope of practice issue. Ironically, most of the APNs in the case study states were not members of their professional organizations.
28. The 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 APRN.
29. Organizations with practice standards, clinical competencies & educational credentialing in women’s health Association of Women’s Health, Obstetrics and Neonatal Nurses (AWHONN) National Organization of Nurse Practitioner Faculties (NONPF) Nurse Practitioners in Women’s Health (NPWH) American College of Nurse-Midwives (ACNM) Association of Physician Assistants in Obstetrics & Gynecology (APAOG)
30. Continued American Nurses’ Association (ANA) (1989) American Association of Physician Assistants (AAPA) (1992), Association of Physician Assistants in Obstetrics and Gynecology (APAOG) (1992).
31. Resources APC toolkit Clinicians for Choice Nursing Students for choice Provide Advancing New Standards in Reproductive Health (ANSIRH) Professional organizations Specialty organizations, eg Association of Reproductive Health Professionals, (ARHP) & National Abortion Federation (NAF)
32. Providing Abortion Care A Professional Toolkit for NPs, CNMs, & PAs The APC Toolkit helps clinicians compile crucial evidence and documentation to support the integration of early abortion care by guiding clinicians in the development of a professional portfolio