As a Bermudian advanced practice registered nurse and midwife who has practised and led nursing and midwifery services internationally, I welcome the Government's review of advanced practice nursing reported in The Royal Gazetteon August 8. But Bermuda needs to be careful about how this discussion is framed. This is not about nurses replacing doctors. It is about whether Bermuda is making appropriate use of qualified health professionals to meet the needs of its population.

Concerns have been raised about differences in the education and clinical preparation of physicians and advanced practice registered nurses. Those differences are real. Physicians undertake substantially more medical education and residency training, particularly in the diagnosis and management of complex disease. But educational hours alone are not a measure of clinical outcomes.

If the argument is that expanded APRN practice or prescribing authority would endanger patients, that assertion should be supported by evidence demonstrating poorer patient outcomes among appropriately educated and regulated APRNs practising within their scope.

International evidence examining nurse practitioners in primary care does not support a blanket conclusion that APRN-delivered care is inherently less safe or of poorer quality for comparable services. Systematic reviews have reported broadly comparable clinical outcomes between nurse practitioners and physicians in a range of primary and ambulatory care settings, with some studies also finding high patient satisfaction and improved access.

That does not mean APRNs and physicians are interchangeable.

They are not. An APRN managing stable hypertension, diabetes, contraception, preventive care or another condition within their education and competence is not claiming the expertise of a cardiologist, endocrinologist, obstetrician or other medical specialist.

Advanced practice requires recognising complexity, knowing the limits of one's competence, and consulting or referring when a patient's condition requires another level of expertise.

That is good clinical practice — not professional weakness.

Bermuda already recognises advanced practice

There is another important point being lost in this debate: Bermuda already regulates advanced practice nursing and APN prescribing.

The Bermuda Nursing and Midwifery Council requires advanced practice nurses seeking prescribing authority to meet defined requirements. Existing regulation addresses assessment, diagnosis, treatment, prescribing, therapeutic monitoring, continuing professional development and collaborative practice.

The question before Bermuda is therefore not whether nurses should suddenly be allowed to diagnose, treat and prescribe. Elements of that framework already exist.

The more useful question is whether our current restrictions remain proportionate to clinical risk and appropriate for Bermuda's healthcare needs. Prescriptive authority should also not be confused with unrestricted practice.

Bermuda can determine which APRNs may prescribe, the education and pharmacology preparation required, which medicines fall within that authority, requirements for continuing competency, when consultation is expected, when referral is mandatory and how prescribing and clinical outcomes are monitored.

Strong regulation and meaningful APRN authority are entirely compatible.

We do not need to look only to the US

Bermuda should also look south. Jamaica has had nurse practitioners for decades. In 2023, the Jamaican Government approved prescriptive authority for Family Nurse Practitioners and Mental Health/Psychiatric Nurse Practitioners under defined conditions.

Importantly, Jamaica did not simply remove regulation. Its approach incorporated education, protocols, referral requirements and circumstances requiring medical assessment.

That is particularly relevant to Bermuda because it demonstrates that the choice is not between physician control and completely unrestricted APRN practice.

There is a considerable and sensible regulatory space between those extremes.

Across the Americas, the Pan American Health Organisation has also encouraged greater development of advanced practice nursing as part of strengthening primary healthcare, supported by postgraduate education, appropriate regulation and clearly defined competencies.

Bermuda should examine these experiences and develop a model appropriate to our own population and health system rather than importing professional disputes from larger jurisdictions.

Patient safety works in both directions

Perhaps most importantly, patient safety must be considered in both directions.

There are potential risks when the scope of any healthcare profession is expanded without adequate education, regulation and oversight. Those risks should be taken seriously. But restrictions also have consequences.

When appropriately qualified clinicians cannot provide care they have been educated and credentialled to deliver, the potential consequences include additional appointments, duplication of services, delays in treatment and underutilisation of available clinical expertise.

Those consequences deserve examination, too.

Bermuda's own health policy has emphasised prevention, earlier intervention, primary and community care, chronic disease management and better management of conditions such as hypertension and diabetes. We also face the healthcare requirements associated with an ageing population.

That makes workforce utilisation more than a professional issue. It is a population-health issue.

If Bermuda needs greater access to primary care, chronic disease management, mental healthcare, women's healthcare and community-based services, we should determine objectively where appropriately prepared APRNs can safely help meet those needs.

Collaboration is not the same as supervision

Healthcare is collaborative by nature. APRNs need physicians. Physicians need nurses, pharmacists, therapists, midwives and other specialists. Every responsible clinician needs mechanisms for consultation and referral when a patient's needs exceed their expertise.

But collaboration should not automatically mean that one regulated profession must administratively supervise another before routine care can be provided.

The question should be whether the clinician is competent to provide that particular care — and whether appropriate safeguards exist when the patient’s needs exceed that competence.

That principle should apply across professions. Bermuda, therefore, has an opportunity to move this discussion beyond professional territory.

Government should undertake a structured review of our population needs, existing APRN workforce and qualifications, gaps in primary and community care, current prescribing restrictions, referral requirements and the evidence regarding patient outcomes.

It should then establish clear national standards for APRN education, credentialling, prescribing, continuing competence, consultation, referral and clinical governance. And importantly, outcomes should be measured.

If expanded APRN practice improves access while maintaining quality and safety, we should know that. If particular areas produce unacceptable risk, regulation should respond accordingly.

Professional assertions — whether they come from medicine, nursing or any other profession — should not determine Bermuda's healthcare policy.

Evidence should. The objective is not APRN autonomy for its own sake. It is certainly not replacing physicians.

It is ensuring that Bermudians can receive the right care, from the right appropriately qualified clinician, at the right time.

For a small island health system with finite human resources, we cannot afford to ask only who has traditionally been permitted to provide care.

We must also ask who is competent to provide it safely — and what our population now needs.

• Pandora Hardtman, DNP, CNM, FACNM, FAAN, is a Bermudian advanced practice registered nurse with clinical and health-system experience in Bermuda, the United States and internationally