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Part II: Building Nursing Capacity in SRH and Abortion Care—Expanding Collective Action

July, 17 2017

Authors: Diana Taylor and Katherine Simmonds

In part two of a historical briefing of nurses working individually and collectively to advance access to evidence-based SRH and abortion care, education, research, and policy,[1] we focus on nurse leaders who have continued and extended the work of the Reproductive Options Education in Nursing (ROE) Consortium (described in Part I, RhN April Blog).

In this blog, we focus on the foundational work of nurses who eventually came together to form RhN[2].

Amy Levi
Monica McLemore
Molly Battistelli
Katherine Simmonds
Joyce Cappiello
Diana Taylor

Foundations: 1960s-90s

In response to high national maternal and infant mortality rates, physician shortages, and lack of attention to sexual health overall, in the 1960s and ‘70s nurses and midwives established birth centers and feminist health centers, received training through Planned Parenthood to provide contraception (including inserting IUDs), treat sexually transmitted infections and promote sexual health, and engaged in policy efforts aimed at improving SRH. In the 1980s, cuts in funding for healthcare, family planning, and abortion services negatively impacted many of these programs and delivery sites, and the clients who received care from them.

In the 1990s, in resistance to cuts in funding and the growing politicization of women’s health and SRH services, new nurse-led initiatives emerged. These included the Advanced Practice Clinician (APC) Initiative; Clinicians for Choice (a project of the National Abortion Federation); the Reproductive Options Education (ROE) Consortium for Nursing (a project of the Abortion Access Project (now Provide); and the first fledgling chapters of Nursing Students for Choice (now Nursing Students for Sexual and Reproductive Health). RhN’s founders were active in establishing and sustaining all of these nursing-focused SRH initiatives. (For more about the history and work of these organizations, see the blog, RhN April Blog on the RhN website).

Foundations: 2000-2015

During the decade and a half that followed, in addition to work with the organizations mentioned above, the future leaders of RhN went to work- individually and collectively- building nursing workforce capacity in SRH/abortion care through education, research, practice and policy initiatives. This work focused on knowledge and practice gaps, including nurses’ role in the SRH workforce, developing competencies, unintended pregnancy prevention, abortion training, and ethics. Though this work was being carried out in different venues and spanned a range of nursing, interdisciplinary and reproductive health, rights, and justice (RH/RH/RJ) organizations, these leaders came to know one another, and began to find ways to collaborate.

Engagement in policy advocacy and activism was also a priority of these scholar-educator-clinicians during these years. Together these future RhN founders served as leaders in a wide variety of nursing, interdisciplinary and reproductive health, rights and justice groups. These included:

  • Advancing New Standards in Reproductive Health (ANSIRH)
  • Abortion Access Project (now Provide)
  • American Academy of Nursing/American Nurses Association, including the Women’s Health Expert Panel SRH Initiative and the Jonas Health Policy Fellowship
  • American College Nurse Midwives (ACNM), including establishing the SRH SIG
  • American Public Health Association (APHA), including in the Population, Reproductive and Sexual Health and Public Health Nursing sections
  • Association for Reproductive Health Professionals (ARHP), including the SRH Workforce Initiative
  • Association of Women’s Health Obstetric and Neonatal Nurses (AWHONN)
  • Center for Reproductive Rights
  • Clinicians for Choice (part of the National Abortion Federation)
  • CoreAlign Fellowship programs
  • IfWhenHow (formerly Law Students for Reproductive Justice)
  • National Organization of Nurse Practitioner Faculties, including formation of the SRH Special Interest Group
  • National Women’s Law Center
  • National Partnership for Women/Families
  • Nursing Students for Sexual and Reproductive Health (formerly Nursing Students for Choice)
  • org (Abortion provider stigma)
  • Sister Song (Reproductive Justice)
  • Society for Family Planning
  • And others on both state and national levels (i.e. the California Choice Coalition, Nurse Practitioners for Women’s Health, etc.)

During these years, the future leaders of RhN also spearheaded a number of research, policy, scholarly and educational endeavors, generating a body of essential evidence, literature, teaching and learning tools, and legislative changes relevant to nurses and SRH care.[3]

A few of these ‘capacity-building’ projects are highlighted here:

Practice roadmap: Unintended Pregnancy Prevention and Management

Between 2009-2011, these scholar-practitioner activists (“practivists”) wrote a number of papers focused on unintended pregnancy as a public health issue.[4] One series, published in the Journal of the Association of Women’s Health, Obstetrics & Neonatal Nurses (JOGNN), established a plan and clinical guidelines for a coordinated system of unintended pregnancy prevention, and delineated the role of the nurse as a leader in this process.[5].

SRH Workforce: Nurses and Abortion and SRH Care

The role of nurses in abortion care—both as vital members of health care teams (RNs, APRNS) and as comprehensive, autonomous providers (NPs, CNMs)–was the focus of scholarly and policy work of many of RhN’s future leaders during these years. Understanding the scope and gaps in the delivery of SRH care by nurses (RNs, NPs, CNMs) was also an area of activity for some. Empirical and policy research generated research publications, policy briefs and collaborations with national workforce experts in nursing[6] and SRH.[7]

Interprofessional SRH Workforce Initiative

RhN leaders Diana Taylor, Joyce Cappiello, and Amy Levi played key roles in a national initiative[8] convened by ARHP (2012-15) to align practice, education and credentialing for primary care and public health professionals in sexual and reproductive health care.[9]  Taylor (ARHP Board member) developed the briefing document[10] for participants that summarized relevant health professional workforce materials. Cappiello and Levi led work groups on educational standards and core competencies in SRH care.

Engaging the nursing and midwifery communities around SRH and Abortion

Efforts to engage nursing and midwifery organizations in nursing capacity building for SRH and abortion care has included development of special SRH sections of the American College of Nurse Midwives and the National Organization of Nurse Practitioner Faculties. RhN leaders have been active in the public health nursing and population/reproductive & sexual health sections of the Am Public Health Assoc. to advance nursing’s role in abortion care.

Led by Diana Taylor in collaboration with the American Academy of Nursing (AAN) and Women’s Health Expert Panel (WHEP) members[11] (includes RhN leaders), the AAN/WHEP established the SRH Initiative (2013-present) with the goal to raise Nursing’s voice for SRH and abortion care policies backed by science and to develop nursing leaders within the American Nurses Association[12] and the Academy.[13]

The foundational work of the AAN-WHEP SRH Initiative (2013-2015) engaged national nursing leaders to respond to threats of political interference with the patient-provider relationship, ethical and evidence-based standards of care, and women’s access to safe, quality SRH care:

SRH/Abortion Education and Training (1998-2014)

  • Early research to explore the extant SRH and abortion content in nursing education programs was carried out in Massachusetts in 1998 by Kathy Simmonds, under the auspices of the Reproductive Options Education Consortium for Nursing (or ROE), part of the reproductive rights organization the Abortion Access Project (now Provide). This survey was used to inform a national study of APRN and physician assistant programs, and develop teaching tools and trainings for nursing faculty.[14]
  • In 2008, Joyce Cappiello took the helm at ROE, furthering this work by conducting a Delphi-study to develop competencies on Unintended Pregnancy Prevention, which were used to develop a set of education modules for nurses. Many of the future RhN leaders engaged in creating these modules, which have been transferred to RhN and are available on the organization’s website.[15]

Policy/Advocacy (2007-2015)

Since 2000, RhN leaders were all engaged with professional and advocacy organizations to raise the voice of nurses for SRH and abortion care (e.g., Clinicians for Choice, the Association of Reproductive Health Professionals, and the Abortion Access Project (now Provide).

From 2007-2014, two ground-breaking initiatives provided the empirical research and policy analysis for creating durable change to improve abortion care access by primary care providers: the Primary Care Initiative (Diana, Molly, ANSIRH team) & the California Health Workforce Pilot Project (Diana, Molly, Amy, ANSIRH team). Major strategies and outcomes of these initiatives that provide the foundation for building nursing capacity in abortion care include:

Policy Analysis/Action/Resources: A consultation team to understand and assist healthcare providers and policy makers to build front-line healthcare provider capacity in SRH/abortion care related to policy/legislation/regulations in selected states (AZ, IL, MT, NM, OR, WA, WV)

  • Policy briefs—APHA resolution (Taylor, Weitz), Scope of practice (Safriet), Training (Taylor)[16]
  • Consultations/Training: Miscarriage Management training (OR, WA, IL); coalition building (examples from WV, WA, NM; defense work (testimony to BRN in OR, AZ)
  • APC Toolkit v1 (2009): A professional toolkit for NPs, CNMs, PAs to become abortion providers
  • Research–Abortion Practice and Training:
    • Safety, Acceptability & Utilization of NP/CNM/PAs as abortion providers
    • Testing a competency-based training program for primary care clinicians in early abortion care
    • Development and testing a taxonomy and reporting framework for abortion-related incidents
  • Policy in Action: creating durable change
    • AB154: legislation authorizing NPs/CNMs/PAs as abortion providers in CA
    • AB980: legislation reducing restrictions for abortion provision in primary care clinics
    • Nursing regulations: abortion training regulations for NPs/CNMs
    • Partnerships: the Women’s Health Alliance, CA Coalition for Reproductive Freedom

Engagement with students and movements advancing Reproductive Health/Rights/Justice (2000-2015)

Building on the long legacy of nurses working in partnership with communities, activists and movements to advance sexual and reproductive health and justice, collectively RhN’s leaders have amassed a wealth of extensive and broad-reaching experience with community-based organizations, student groups and social movements. These are too numerous to list, but a few highlights include:

  • Piloting the first fledgling chapters of Nursing Students for Choice (NSFC) (Simmonds, under the auspices of Abortion Access Project/ROE Consortium). These early efforts were informative to those who went on to form the national organization – now Nursing Students for Sexual and Reproductive Health (NSSRH) – some 10 years later. Since NSSRH’s formation, RhN leaders (Cappiello, Levi, McLemore, Simmonds, Taylor) have served both formally – as Board members – and informally – as mentors, collaborative partners and advisors;
  • RhN members McLemore and Simmonds both participated in CoreAlign fellowships, experiences that strengthened their connections within the RH/RR/RJ-movements, and boosted their knowledge and skills in Design Thinking (DT), which they were able to bring back to the work of RhN;
  • McLemore’s deep involvement – including providing critical administrative and logistic support – in partnership with the Black Women Birthing Justice Collective to grow a program to provide doula support to incarcerated pregnant, birthing and post-partum women in the San Francisco Bay Area;
  • Serving as Board members, project leaders and clinical staff in a number of community-based health care organizations and initiatives, including the Women’s Community Clinic (San Francisco) (Taylor), the Joan G. Lovering Health Center (formerly the Feminist Health Center) (New Hampshire) (Cappiello), and Roca (Chelsea, MA) (Simmonds), to name just a few.

These experiences and relationships have informed RhN’s leaders and their vision of a world in which everyone has access to high quality sexual and reproductive health care, including abortion”. See RhN values and core strategies.

Current work: 2015-present

After many years working to advance SRH and abortion care individually and collaboratively, in 2015 these nursing “thought leaders” and practitioner-activists (“practivists”) came together to plan next steps for increasing the capacity and visibility of nurses as vital providers of SRH and abortion care. During this period, recognition that nurses who are committed to patient-centered sexual and reproductive health care needed a “home” led to the formation of Reproductive Health in Nursing (RhN).

To find more nursing-focused SRH and abortion resources on clinical, educational, policy and research related, visit the RhN website, rhnursing.org.

[1] Sexual and reproductive health (SRH) care is sometimes thought of narrowly as maternal-child, family planning, or women’s health care. However, to produce optimal health outcomes, many experts believe SRH care should include the reproductive health of men and women throughout their lifespan with a special emphasis on adolescents and health equity. Under a definition accepted by the World Health Organization and implemented in a number of national health systems, a minimum package of SRH care accessible to all would include preconception care, contraception, pregnancy and unplanned pregnancy care, women’s health/common gynecology care, genitourinary conditions of men, assessment of specialty gynecology problems including infertility, sexual health promotion, and delivered within a system of public health and primary care services.

[2] Katherine Simmonds (ROE founder and director 1997-2007) and Joyce Cappiello (ROE Director 2008-16) engaged nursing colleagues from organized nursing and public health: the American Nurses Association/Academy of Nursing, NPWH, NONPF (Diana Taylor); the American College of Nurse-Midwives (Amy Levi, Margie Beal, Francine Likis); AWHONN, APHA and reproductive justice groups (Monica McLemore); ANSIRH Primary Care Initiative, APC Working Group, TAWG (Molly Battistelli).[2]

[3] A full list of publications and presentations from these years (2000-2015) and beyond (2015-present) is provided elsewhere; see [Link]

[4] Levi A, Simmonds K, Taylor D (2009). The role of nursing in the management of unintended pregnancy. Nursing Clinics of North America, 44(3), 301-314.

Taylor D, Levi A, Simmonds K. (2010). Reframing unintended pregnancy prevention: a public health model. Contraception; 81(5): 232-239.

[5] Taylor, D. (2011). “Evidence to Inform Policy, Practice and Education for Unintended Pregnancy Prevention and Management.” Journal of Obstetric, Gynecologic, & Neonatal Nursing 40(6): 773-774. (Commentary)

Levi, A. and K. Q. Dau (2011). “Meeting the National Health Goal to Reduce Unintended Pregnancy.” Journal of Obstetric, Gynecologic, & Neonatal Nursing 40(6): 775-781.

Taylor, D. and E. A. James (2011). “An Evidence-Based Guideline for Unintended Pregnancy Prevention.” Journal of Obstetric, Gynecologic, & Neonatal Nursing 40(6): 782-793.

Simmonds, K. and F. E. Likis (2011). “Caring for Women with Unintended Pregnancies.” Journal of Obstetric, Gynecologic, & Neonatal Nursing 40(6): 794-807. (CE article)

Cappiello, J., M. W. Beal, et al. (2011). “Applying Ethical Practice Competencies to the Prevention and Management of Unintended Pregnancy.” Journal of Obstetric, Gynecologic, & Neonatal Nursing 40(6): 808-816.

[6] Collaborations began in 2010 with Dr. Joanne Spetz, Diana Taylor, Monica McLemore and the UCSF ANSIRH team (Molly Battistelli, Pat Anderson) to integrate national nursing workforce metrics with research on nurses working in SRH and abortion care.

[7] Hwang, A, Koyama, A, Taylor, D, Henderson, J, & Miller, S (2005). Advanced practice clinicians’ interest in providing medication abortion: Results of a California survey. Perspectives on Sexual & Reprod Health, 37(2), 92-97.

Auerbach DI., Pearson ML, Taylor D, Battistelli M, Sussell J, Hunter LE, Schnyer C, Schneider EC. Nurse Practitioners and Sexual and Reproductive Health Services: An Analysis of Supply and Demand. Santa Monica, CA: RAND Corporation, 2012.

Battistelli M, Taylor D (2012). Policy brief: NPs and SRH Services. UCSF ANSIRH Blog (RAND report).

McLemore MR, Kools S, Levi AJ. Calculus formation: nurses’ decision-making in abortion-related care. Res Nurs Health. 2015 Jun; 38(3):222-31. PMID: 25820100

McLemore MR, Levi AJ, James EA. Recruitment and retention strategies for expert nurses in abortion care provision. Contraception. 2015 Jun; 91(6):474-9. PMID: 25708505; PMCID: PMC4442037

[8] The work of the Sexual & Reproductive Health (SRH) Workforce Summit—to develop strategies and policy activities that align pre-licensure SRH education, continuing professional development and service delivery for all health care professionals within an integrated competency-based primary health care framework. Nothnagle M, Cappiello J, Taylor D (2013). Sexual and reproductive health workforce project: Overview and recommendations from the SRH workforce summit, January 2013. Contraception, 88(33), 2014-09. http://dx.doi.org/10.1016/j.contraception.2013.05.006

[9] The SRH Workforce Project (2013) publications: Overview and recommendations from the SRH Workforce Summit (Nothnagle, Cappiello, Taylor); SRH Workforce Summit: now is the time to bring sexual and reproductive health to primary care (Cappiello, Nothnagle); The interprofessional sexual and reproductive health care team (Levi et al)

[10] The Sexual and Reproductive Health (SRH) Workforce Project Summit Briefing Document is a summary of national reports and existing models with the purpose to prepare Summit participants for Workgroup and Summit activities. Although the integration of SRH practice and education has lagged behind other specialty and population care advancements, a number of national report recommendations and models in action are relevant as guidelines. [see pdf file]

[11] The Academy WHEP leadership includes: Diana Taylor & Versie Johnson-Mallard (current co-chairs); Ellen Olshansky (current AAN Board member); Judy Berg, Joan Shaver and Nancy Woods (Shaver & Woods are past presidents of the Academy). WHEP members active with SRH Initiative include Kathy Simmonds (AAN-Jonas Policy Scholar), Monica McLemore, Candace Burton, Amy Levi.

[12] The American Nurses Association is the professional organization that represents all nurses in the US regardless of their specialty focus including leading practice scope and standard development in collaboration with specialty partners (e.g., AWHONN).  ANA maintains high levels of activity in influencing policy, as seen in their statements in support of the Affordable Care Act.

[13] The American Academy of Nursing has played a significant role in convening multiple nursing organizations to address emerging issues in health and health care.   Current initiatives, policy briefs and partnerships of the AAN Women’s Health Expert Panel have focused on advancing sexual and reproductive health policy for practice, education, research and advocacy.

[14] Foster, A., Polis, C., Allee, M., Simmonds, K.., & Zurek, M. (2006) Abortion education in nurse practitioner, physician assistant and nurse midwifery programs: A national survey.  Contraception, 73(4):408-414.

Simmonds, K., Foster, A., & Zurek, M. (2009) From the outside in: a unique model for stimulating curricula reform in nursing education. The Journal of Nursing Education, 48(10): 583-587.

Simmonds, K. & Likis, F. (2011) Caring for Women with unintended pregnancies. Journal of Obstetric Gynecologic and Neonatal Nurses, In Focus Series,40, 794-807.

[15] Hewitt, C., & Cappiello, J. (2015). Essential competencies in nursing education for prevention and care related to unintended pregnancy. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 44(1), 69-76.

Link to website modules on www.rhnursing.org

[16] Taylor, D (2010). The role of abortion care education and training in advancing scope of practice for advanced practice clinicians. http://www.ansirh.org/_documents/issue_briefs/ansirh_brief1training.pdf

Safriet, B & Taylor D (2010). Why scope of practice matters for reproductive health. http://www.ansirh.org/_documents/issue_briefs/ansirh_brief3scope.pdf

Taylor D, Maldonado L, Weitz TA et al (2011). Nurse Practitioners, Nurse Midwives & Physician Assistants as Abortion Providers. Submitted to APHA, June 2010; Approved by APHA membership, November 2011.