Bermuda’s healthcare system is at an important crossroads. As our population ages, chronic illnesses increase, physicians and nurses remain in short supply, and patients experience longer waits for primary care, we must ask an important question: are we using every qualified healthcare professional to the full extent of their education, training and competence?

One solution that deserves serious consideration is the development and integration of the advanced nurse practitioner role within Bermuda’s healthcare system.

This is not about replacing physicians. It is about strengthening the healthcare team, improving access to care and ensuring that Bermudians receive the right care, from the right professional, at the right time.

What is an advanced nurse practitioner?

An ANP is a registered nurse who has undertaken advanced education, clinical training and preparation to develop expert knowledge, complex clinical decision-making skills and an expanded scope of practice.

The International Council of Nurses describes advanced practice nursing as a level of nursing practice involving advanced knowledge and competencies, with the specific scope determined by the country and regulatory framework in which the practitioner works.

Depending on the jurisdiction and legal scope of practice, an ANP may assess patients, take comprehensive histories, perform physical examinations, order and interpret diagnostic investigations, develop treatment plans, manage certain acute and chronic illnesses, prescribe medications, provide health education and monitor patients over time.

Importantly, the ANP is not simply a nurse with more years of experience. Advanced practice requires additional education, demonstrated clinical competence, appropriate credentialing, regulation and accountability.

The role is built upon nursing's holistic approach to patient care while incorporating advanced clinical assessment and decision-making skills.

Why does Bermuda need to consider this role?

Bermuda is not immune to the healthcare workforce challenges being experienced internationally.

Our community is dealing with pressures on emergency services, shortages of doctors and nurses, difficulty accessing timely primary care and an increasing number of older adults living with chronic health conditions.

When a person cannot obtain a timely appointment with a primary-care provider, the Emergency Department can become the place they seek care — even when their condition may be more appropriately managed in a community or primary-care setting.

This places additional pressure on emergency physicians, nurses and other hospital staff.

An appropriately regulated and integrated advanced nurse practitioner workforce could help address some of these pressures.

ANPs could potentially work in primary-care practices, community clinics, long-term-care facilities, specialty services, urgent-care environments and other appropriate settings.

Their role could include managing patients with conditions such as hypertension, diabetes, respiratory illnesses and other chronic diseases, while also identifying when a patient requires physician review, specialist intervention or emergency care.

Learning from other countries

Bermuda does not have to create this model from scratch.

Advanced practice nurses and nurse practitioners have been developed and utilised in numerous healthcare systems around the world, including the United States, Canada, Australia, New Zealand and the United Kingdom, although the educational requirements, titles, prescribing authority and scope of practice vary between jurisdictions.

The Organisation for Economic Co-operation and Development’s 2024 review found that population ageing and increasing chronic disease have stimulated greater interest in using advanced practice nurses to respond to primary-care needs.

In countries where physicians and nurses have successfully shared appropriate clinical responsibilities, increasing the use of advanced practice nurses is viewed as an opportunity to respond to primary-care needs and reduce pressure on doctors and hospitals.

This international experience provides Bermuda with an opportunity to examine what works, what does not, and what safeguards are necessary.

We should not simply copy another country's model. We should develop a Bermuda model that reflects our population, healthcare needs, regulatory environment and available resources.

The potential benefits for Bermuda

There are several potential benefits to developing advanced nurse practitioner services.

1, Improved access to primary care

ANPs could provide additional appointments and healthcare access for individuals who may otherwise face lengthy waits.

For routine assessments, chronic disease management, health promotion and appropriate acute presentations, an ANP could provide timely care within a defined scope of practice.

2, Reduced pressure on emergency services

Not every patient who enters an Emergency Department requires emergency-level intervention.

By strengthening primary and community-based services, Bermuda could divert appropriate patients away from emergency services and allow emergency teams to concentrate on patients with serious and life-threatening conditions.

ANPs can also be valuable members of emergency and urgent-care teams when appropriately educated, credentialed and integrated into the clinical governance structure.

3, Better management of chronic disease

Bermuda has an ageing population and increasing healthcare needs associated with chronic disease.

Advanced nurses can play an important role in monitoring patients, identifying deterioration early, educating patients and families, promoting medication adherence, co-ordinating care and supporting preventative health.

This is particularly important for older adults who have several healthcare needs at the same time.

4, Improved care in long-term-care facilities

There is also an opportunity to consider the ANP role within Bermuda's residential and long-term-care sector.

Residents in nursing and rest homes can experience sudden changes in condition, falls, infections, medication concerns, wounds, dehydration and other health issues.

Having appropriately qualified advanced practitioners available within or connected to long-term-care services could strengthen assessment, early intervention and communication with physicians and hospitals.

The goal should always be to provide the appropriate level of care while avoiding unnecessary transfers when a resident can safely be managed in their care environment.

5, Greater continuity of care

One of the strengths of advanced nursing practice is its emphasis on the whole person.

The International Council of Nurses describes modern nursing as people-centred, evidence-informed and focused on health promotion, disease prevention, safety, continuity of care and collaboration across healthcare settings.

ANPs can help bridge the gap between the hospital, primary care, community services, long-term care and the patient's home.

ANPs are not a replacement for physicians

This point must be clearly understood.

The introduction of advanced nurse practitioners should not be viewed as a strategy to replace doctors.

Physicians possess extensive medical education and expertise, and complex cases will continue to require physician involvement and specialist care.

Instead, ANPs should be viewed as additional highly trained members of an inter-professional healthcare team.

There should be clear referral pathways, defined scopes of practice, appropriate clinical governance, continuing professional development and mechanisms for physician consultation when a patient's condition exceeds the ANP's scope or level of competence.

The question should not be: "Who is better —a doctor or a nurse practitioner?"

The better question is:

"How can doctors, nurses, advanced practitioners and other healthcare professionals work together to provide safer, more accessible and more effective care for Bermuda?"

Bermuda must embrace best practice

Healthcare cannot remain static. Medicine changes. Technology changes. Patient demographics change. Workforce needs change.

Therefore, healthcare systems must also evolve.

The International Council of Nurses has developed international guidance specifically to assist countries in developing policies, frameworks and strategies for advanced practice nursing.

Bermuda should use international evidence and best practices to determine whether and how advanced nurse practitioners can contribute to our healthcare system.

This should include consideration of:

• Educational requirements and accreditation

• Registration and professional regulation

• Defined scope of practice

• Prescribing and diagnostic authority, where appropriate

• Clinical governance

• Continuing education and competency assessment

• Physician collaboration and referral pathways

• Appropriate malpractice and professional liability coverage

• Integration into primary care, emergency services and long-term care

• Data collection and evaluation of patient outcomes

Most importantly, the process must remain patient-centred and evidence-based.

Moving Bermuda forward

Bermuda has an opportunity to be innovative. We frequently speak about healthcare reform, workforce shortages, access to physicians and the growing needs of our ageing population. But reform requires us to look beyond traditional models.

We must ask whether the healthcare professionals we already have are being utilised appropriately. We should also create opportunities for Bermuda's nurses to advance professionally through graduate-level education, specialised training and advanced clinical practice.

Developing an advanced nurse practitioner pathway could create another avenue for experienced Bermudian nurses to remain within the healthcare system, assume greater responsibility and contribute at an advanced level.

At the same time, Bermuda must ensure that advanced practice is never introduced simply because there is a shortage of doctors. Quality, education, competency, regulation and patient safety must come first.

A conversation Bermuda needs to have

The introduction of advanced nurse practitioners should be approached through consultation among nurses, physicians, healthcare administrators, regulators, educators, policymakers and, importantly, the public.

We should examine international models, identify Bermuda's healthcare gaps, establish appropriate educational standards and determine where ANPs could provide the greatest benefit.

A pilot programme could be considered in carefully selected areas such as primary care, chronic disease management, long-term care or urgent-care services. Outcomes could then be measured through patient satisfaction, access to care, hospital utilisation, clinical outcomes and cost-effectiveness.

Bermuda should not be afraid to learn from other countries nor be afraid to develop something uniquely suited to our island.

Healthcare innovation is not about replacing one profession with another. It is about bringing the right people, education, skills and resources together to improve the health of our community.

Bermuda's healthcare needs are changing. Our population is changing. Our workforce is changing.

Our healthcare system must change with it.

The advanced nurse practitioner may not be the answer to every challenge facing Bermuda's healthcare system — but it could be an important part of the answer.

The time has come for Bermuda to have the conversation.

If we are serious about moving healthcare forward, we must be willing to embrace evidence-based practice, expand appropriate healthcare roles, strengthen collaboration and put the needs of our patients at the centre of every decision.

That is not simply healthcare reform. That is investing in the future health of Bermuda.

• Valerie Arorash is a registered nurse and the owner of a home for the elderly