Q&A with Myrian Balitian-Dill on the right of nurse practitioners to prescribe medications

24 September 2018: A question and answer interview with Bermuda Hospitals Board nurse practitioner Myrian Balitian-Dill.

BHB Nurse Practitioner Myrian Balitian-Dill

1. When did you become a nurse practitioner (NP)?

I completed my post-Master NP diploma and successfully passed my Board exam in August 2012.  I transitioned into my NP role in BHB in Jan 2013 in Cardiology.

2. How long did it take?

As I already had my Master’s Degree (University of Toronto), it took about 20 months to complete the requirements for the Post Masters Nurse Practitioner Diploma (University of Toronto).

3. Why didn’t you decide to become a physician?

I was already a seasoned nurse and I was helping patients make impactful changes in their lives by teaching them about their disease, counselling them on how to incorporate healthy habits, assisting them with their medications, and helping them manage their disease at home.  My goal was to build on my experience and incorporate more critical and diagnostic thinking into my practice to better assist my patients.  It was not my intent to shift my focus from a nursing perspective to medicine, but rather to advance nursing practice.  As nurses, our focus is to optimize the health/function of our patients through health promotion and disease prevention.

4. Is your degree in a certain specialty?

There are several clinical streams you can choose to be as a Nurse Practitioner—Primary Care, Adult, Pediatric, Anesthesia.  Except for the Anesthetic stream, you can choose a sub-specialty to practice in.  For example, I am an Adult NP with a sub-specialty in cardiology.

5. Are there other NPs in Bermuda?

Yes, and the Nursing Council recently registered two new Bermudian  Nurse Practitioners .6. Do you have any idea how many NPs are on island? Are you the only one at BHB?

I am the only one employed in a nurse practitioner capacity at BHB.  There are five registered with the Bermuda Nursing Council, but I am unaware how many are employed as nurse practitioners.

6. Where is this designation popular?

Nurse Practitioners started in the United States and Canada to address the physician shortage, particularly in rural and outreach areas in the early 20^th Century.  There are now about 248,000 NP’s in the United States and over 5,000 NP’s in Canada.  The role is gaining momentum and popularity globally with many jurisdictions investing and creating advanced practice nursing roles.  Global healthcare needs—such as an aging population, the insurgence of non-communicable diseases, coupled with the positive outcomes associated with NP care, have really propelled NP’s as a solution to our healthcare crisis.

7. In other jurisdictions do NPs prescribe medication?

Yes, but there is still a lot of variability.  In the United States alone, the NP’s prescriptive authority is determined state by state.  Some states allow full prescribing authority—which allows NP to prescribe independently without physician oversight and can include controlled substances, such as narcotics.  In other states, there is no prescriptive privilege at all.

8. You have been an NP for several years, what did you have to do to get this right in Bermuda?

Our legislation in Bermuda permits NP’s to prescribe “under the authority of a medical practitioner”.  This means that NP’s must have a collaborative relationship with an over-seeing physician.  It took several years to articulate the conditions of this collaborative relationship to enact it and allow NP’s to prescribe.   The practice is restrictive but it is a starting point.

9. Can you explain the right to us? Does it have limitations i.e. / can physicians prescribe in instances where you cannot?

NP prescribing in Bermuda is restrictive.  It means I can prescribe from a list that pertains to the management of my patients.  For example, many of my patients suffer from chronic conditions such as diabetes, hypertension and heart disease.  So, the list that I can prescribe from reflects classes of medications that help manage those disease entities.

NP’s who work in other clinical areas will have a list that is reflective of their practice.  As NP practice grows, so will the list—with an inevitable shift to open prescription.  But I am getting ahead of myself.

10. Now that you can prescribe you are essentially on equal footing with physicians?

It is not so much about “equal footing” but rather making the system more efficient.  If the NP can prescribe evidence-based therapy at point of care, why do we need to wait for another practitioner (physician) to prescribe that therapy?

NP’s are registered nurses with an expanded scope of practice which includes diagnosing, ordering and interpreting tests, as well as prescribing and performing certain procedures.  The role has overlapping skillsets with our physician partners.

According to the Institute of Medicine, practitioners should work to their full scope of their training.  It makes the system more efficient and cost-effective. This is the direction we need to go in order to address our healthcare crisis.