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Practice Matters

Viewpoint: Industry, influence, and nursing

Use your critical-thinking skills to assess industry-funded research. 

Kelly* has worked as a staff nurse in the progressive care unit (PCU) of her facility for 5 years. She recently accepted an administrative position. As part of her new duties, Kelly was assigned to the purchasing committee, which works with the unit’s designated supply chain to order products and equipment.  

Kelly was invited to a dinner by one of her colleagues to talk about product options. The dinner was sponsored by an industry sales representative who sells products to her facility. The sales rep talked about various products and equipment, including upgrades, the cost effectiveness of using their products, and research showing improved patient outcomes and satisfaction. In exchange for providing her email address, Kelly received a small goodie bag filled with a few branded items, such as a badge reel, samples, and pen. The next day, Kelly received an email explaining how to receive free continuing education credits and coupons along with additional information about the company’s products. Although Kelly had never been to an industrysponsored dinner, she had seen sales reps on her unit and at her organizations conferences many times before. Kelly didn’t think that participating in the dinner was unusual or a conflict of interest, or that it would impact her nursing practice.  

A few days after the dinner, sample products arrived in Kelly’s office. The sales rep recommended trialing the products in the PCU and included his contact information to answer any questions Kelly or her staff might have. Kelly showed the samples to the director of the PCU, who seemed optimistic about the products’ success on the unit. The products were dispersed by the unit’s supply coordinator for all the nurses to trial and provide feedback. The products also were mentioned by the charge nurse during shift huddle, where the nurses were encouraged to try them 

When Kelly attended her first purchasing committee meeting for the unit, a nurse colleague who also had attended the industrysponsored dinner suggested purchasing the promoted product. The colleague repeated many of the product benefits spoken about by the sales rep. The committee discussed the product’s usefulness, benefits, and cost effectiveness. They asked for research showing improved patient outcomes and satisfaction, and Kelly’s colleague supplied the industry-sponsored research.  

This is when Kelly began questioning the relationships between nurses and industry. She recognized that nurses are an ideal marketing target because of their purchasing influence. Instead of accepting the sales pitch and information provided by the sales rep, Kelly began a literature review. She found little research that wasn’t sponsored by industry, and independent studies showed no clinically significant improvements in patient outcomes when compared with the product her unit was already using. 

Buying into the marketing would have been easy, but Kelly used her skepticism to find the best product for her patients.  

What should you know about industry and marketing and how it might influence your practice? How can you find unbiased information?  

Industry and nursing

Most of the research and legislative efforts around healthcare industry marketing have focused on the relationship between prescribing physicians and the pharmaceutical industrySpending on prescription drugs accounts for a significant portion of total healthcare expenditure (over 10% in 2015, according to the Centers for Medicaid & Medicare Services’ National Health Expenditures 2017 highlights). However, the healthcare market consists of more than just prescription drugs. As nurses’ roles continue to expand, their decision-making influence grows. They’re influential in product purchasing, patient treatment, and potentially consumer purchasing if they endorse a product. Being aware of the relationship between nurses and industry may help reduce industry influence. (See Let the sunshine in.) 

Let the sunshine in  

To ensure transparency in healthcare professional and industry interactions, the Physician Payments Sunshine Act became U.S. federal law in 2012. The law requires specific entities to report their financial relationships with specific recipients. For example, medical product manufacturers must disclose certain transactions made to physicians or teaching hospitals. The information is managed by the Centers for Medicare and Medicaid Services Open Payment program, which includes a searchable database (cms.gov/OpenPayments/index.html). The program has three reporting categories: 

  • general payments—payments or other transfers of value made that aren’t related research 
  • research payments—payments or other transfers of value made in connection with a research agreement or research protocol 
  • physician ownership—information about the ownership or investment interests that physicians or their immediate family members have in the reporting entities.  

According to the 2018 Open Payments report626,000 physicians received $2 billion in general payments in 2017 (openpaymentsdata.cms.gov/summary) 

Marketing

Marketing is a tool used by companies to gain loyal consumers. In the healthcare industry, pharmaceutical companies and medical product manufacturers use a variety of techniques to attract customers and advertise their products. Unlike in other industries, healthcare professionals, such as nurses, are gatekeepers to the ultimate consumer (the patient), so industry must market through them.  

When asked, most nurses say that they don’t have a relationship with industry and that they aren’t targeted by marketing efforts. However, many nurses encounter marketing every day while providing care. For example, the badge reel that Kelly wears in the PCU has a brand name on it. Not only is it displayed for all the nurses to see when Kelly is using it, but it’s also visible on the badge she wears that patients and the visitors to the hospital see. Does this action unintentionally translate as product endorsement to Kelly’s fellow nurses and patients?  

Many companies use more direct strategies, such as the sponsored dinner Kelly attended and the gifts she received, to influence providers and clinicians’ opinions. These benefits are provided with the intention of influencing the client to think about the company or product positively, using the persuasion technique of reciprocity. 

For a subtler example, consider free manufacturer-sponsored continuing education. In some cases, the sponsoring company obtains nurses’ emails to send reminders. The company can stay in contact with these nurses and gather data about their interests, organizations, locations, and patient populations. This information is then used to further develop marketing strategies. For example, Kelly’s information might be saved and any future products relevant to her patient population will be marketed to her with promotional emails or free samples. 

Influence

Most nurses don’t think they’re influenced by industry marketing. However, studies have shown that marketing does have an impact on healthcare professionals, including physicians and nurses, and this impact could affect decisions and costs. For example, many nurses serve on valuebased purchasing committees that decide which products will be used in the facility. Those decisions aren’t always based on research either at the committee or individual patient level. For instance, nurses who specialize in wound care have increased autonomy to choose medical devices or products that are best suited for a particular wound. However, according to Hodgson and Allen, wound care interventions are poorly trialed and heavily influenced by industry, with 41% of included studies reporting industry funding.  

Influence and persuasion create loyal consumers and encourage nurses to endorse products. Cialdini and colleagues describe six principles of influence and persuasion: reciprocation, commitment, social proof, liking (or rapport), authority, and scarcity. These principles describe how industry uses marketing tools to subconsciously and subtly influence behavior. For example, reciprocation is an obligatory repayment for a positive act or gift. In the case study, Kelly’s colleague endorsed the marketed product at the purchasing committee meeting after attending the dinner and receiving the free gifts. The acceptance of those gifts and the bond made with the sales rep creates brand loyalty and an obligation to support that brand and company. The act of reciprocation is engrained in the human psyche, making it a great marketing tactic; industry gives a little to gain a lotconsumers.  

Influence doesn’t end with nurses; it also can affect patients. Without inquiry, influence can expand to include patients when nurses endorse a product. Many patients ask nurses for recommendations of products that are offered to the public. The subconscious bias resulting from conflicts of interest may lead a nurse to provide the patient free samples or recommendations based on marketing alone. These samples get brand and product awareness to the ultimate consumer.  

Professional responsibility 

It would have been easy for Kelly to accept the marketing and information from the sales rep. However, she had a professional and ethical responsibility to investigate the literature. The American Nurses Association Code of Ethics for Nurses with Interpretive Statements doesn’t specifically address the ethical dilemma that occurs when industry marketing targets nurses. However, it does advise nurses to identify and avoid conflicts of interest whenever possible. Industryfunded gifts, samples, or payments have the potential to lead to a conflict of interest. 

Kelly realized that to provide the most ethical, unbiased care to her patients, she must use her critical-thinking skills when attending industry-sponsored events and be aware of how marketing messages may be embedded in the content. These events are often of value—many contain excellent information—and continuing nursing education guidelines require that content is developed independent of the sponsor. However, nurses should stay aware of potential conflicts and critically appraise the information being presented, as they should with any program, sponsored or not.  

Nurses also have a professional responsibility to investigate literature with a skeptical eye. The best way to do this is to seek unbiased and independent research and obtain research findings from sources other than manufacturers. 

 Think critically

Nurses have a duty to rely on evidence-based research rather than industrysponsored information when considering purchasing or recommending a healthcare product or service. They should seek and critically appraise independent unbiased literature. Nursing schools can incorporate the topic of industry marketing and influence to prepare nurses before they enter the workforce. In addition, more research is needed to identify potential industry-sponsored continuing education influence on practice as well as the effects of nurse endorsement on patient product selection. 

*Names are fictional. 

Lauren Billstrom is a labor and delivery nurse at St. Joseph Medical Center in Tacoma, Washington. 

Selected references

American Nurses Association. Code of Ethics for Nurses with Interpretive Statements2015. nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only 

Centers for Medicare & Medicaid Services. National health expenditures 2017 highlights. cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf  

Centers for Medicare & Medicaid Services. Open payments. May 21, 2019. cms.gov/OpenPayments/index.html 

Cialdini RBInfluence: The Psychology of Persuasion. New York: Harper Business; 2006.  

Grundy Q, Bero LA, Malone R. Interactions between non-physician clinicians and industry: A systematic review. PLoS Med. 2013;10(11):e1001561. 

Grundy Q, Bero LA, Malone RE. Marketing and the most trusted profession: The invisible interactions between registered nurses and industryAnn Intern Med. 2016;164(11):733-9 

Grundy Q. “Whether something cool is good enough”: The role of evidence, sales representatives and nurses expertise in hospital purchasing decisions. Soc Sci Med. 2016;165:82-91. 

Grundy Q. Why marketing to nurses matters. Am Nurse Today. 2016;11(11):28-31.  

Hodgson R, Allen R, Broderick E, et al. Funding source and the quality of reports of chronic wounds trials: 2004 to 2011. Trials. 2014;15:19.  

National Academies of Sciences, Engineering, Medicine. Making Medicines Affordable: A National Imperative. Washington, DC: The National Academies Press; 2017 

Richardson E. The Physicians Payments Sunshine Act. Health AffOctober 2, 2014. healthaffairs.org/do/10.1377/hpb20141002.272302/full 

Sah S, Fugh-Berman A. Physicians under the influence: Social psychology and industry marketing strategies. J Law Med Ethics. 2013;41(3):665-72.  

Terech A. An introduction to marketing and brandingGenerations. 2018;42(1):45-9.  

Tringale KR, Marshall D, Mackey TK, Connor M, Murphy JD, Hattangadi-Gluth JA. Types and distribution of payments from industry to physicians in 2015. JAMA. 2017;317(17):1774-84.  

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