NPs and CNMs are credentialed first as registered nurses and then as advanced practice registered nurses (in the NP or CNM role). To date, five states have recognized the CM credential: NY, NJ, DE, ME, and RI, 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: defined in state laws and regulations.
  • 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.

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.1 In addition, generally applicable (mostly procedural) statutes such as state Administrative Procedure acts and Open Meetings laws and Government-in-the-Sunshine laws also affect the ways in which licensees and boards interact.2 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 FDA3 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. Some states allow health care providers other than physicians to prescribe medications. Health care providers should check their individual state laws.

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).

  1. For links to states’ licensing boards and their practice statutes, rules, procedures, decisions, and opinions, see the Federation of State Medical Boards’ and the National Council of State Boards of Nursing’s websites. Because federal laws affecting abortion services mostly concern eligibility for patient coverage or provider payment and not authority to provide such services, they are not included in this analysis.
  2. Copies of these statutes are available online at the website of each state’s Attorney General or Secretary of State. In addition, almost all states publish “Guides to Understanding” the Open Meetings laws or Administrative Procedures acts. These publications are invaluable aids in mastering the often-confusing procedural niceties of administrative process.
  3. U.S. Food & Drug Administration., Questions and Answers on Mifeprex, 2016.

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