Nurses are increasingly targeted by pharmaceutical companies around the world and a Wellington academic says that understanding the complexities of marketing should be part of nursing education and healthcare policy in this country.
A recent University of Sydney study found that 14,018 Australian healthcare professionals received more than $62 million in payments and sponsorship from pharmaceutical companies between 2015 and 2018. Nearly 18% of the professionals were nurses.
Lead author of the Australian research, Dr Emily Karanges, from the Charles Perkins Centre and School of Pharmacy, says nurses attended events such as conferences where fees, travel and accommodation were paid by pharmaceutical companies. Other sponsored payments can include fees for speaking at events, participating in advisory boards and consulting.
The publicly available data used by the Australian study is submitted to Medicines Australia by pharmaceutical companies. New Zealand doesn’t have a similar robust compulsory disclosure system regarding drug company gifts and payments, but a 2015 Stuff investigation found that Kiwi health workers had accepted more than $300,000 of drug company-sponsored travel and gifts in the previous year.
In New Zealand, nurse practitioners (300 in 2018) and some registered nurses are qualified to prescribe medicines, which potentially makes them more appealing to drug companies.
Annemarie Jutel, an associate professor of Nursing at Victoria University of Wellington says the role of nurses in choosing and purchasing drugs is under-recognised and that nurses are increasingly targeted by pharmaceutical companies as they become more involved in prescriptions, and as policies restrict pharmaceutical companies’ contact with physicians
“There is still little training for, or awareness of, the ways in which the pharmaceutical industry courts health professionals in general, and nurses in particular. While the branded pen may seem like a very trite object, it still has powerful potential to shift thinking.
“The more contact that nurses have with sales professionals, the more likely they are to believe they are immune to their influence. The biggest risk comes from the self-confidence expressed by nurses who believe they can tell the difference between sales talk and technical talk. Research has shown time and again that this is a problem. Not only is the subject barely treated in health care education, nurses have very scant training in statistics in New Zealand, which makes the analysis of research findings that much more difficult,” Jutel says.
In 2009, Professor Jutel and Professor David Menkes researched how pharmaceutical marketing and sponsorship strategies affected senior registered nurses from Southland and Capital Coast DHBs. They found while most gifts to New Zealand nurses consisted of stationery or free food and beverages, 70% of respondents viewed it as ethically acceptable to receive drug company support to organise or attend a conference, with some arguing it compensated for inadequate funding from DHBs.
Hilary Graham-Smith from the New Zealand Nurses’ Organisation (NZNO) disagrees that nurses are vulnerable to sales talk. The NZNO associate professional services manager says the way nurses practice means they have a deep understanding of what is happening for their patients, which is valuable in improving compliance and supporting health literacy.
NZNO has 20 clinical colleges (eg primary health care, gerontology, gastroenterology) which run conferences and symposiums for their members. “Some of these events receive sponsorship from pharmaceutical and medical device suppliers. Such sponsorship is closely scrutinised and engagement is guided by the NZNO Responsible Income Generation policy and the Medical Technology Association of NZ (MTANZ) Code of Practice which describes ethical practice including not using any inappropriate inducement, or offer any personal benefit or advantage in order to promote or encourage the use of its products,” Graham-Smith says.
She says nurses face ethical issues every day and use drugs based on their efficacy, not on persuasion tactics by drug companies. NZNO provides professional forums on a range of issues including ethical decision making on an ongoing basis and professional nurse advisers provide one to one advice and support for members.
In response to this issue, the Nursing Council pointed to its published code of conduct for nurses which states: 7.10 Declare any personal, financial or commercial interest which could compromise professional judgement.
Nurses perfect targets
Professor Quinn Grundy has written a book on the subject – Infiltrating Healthcare: How marketing works underground to influence nurses. The Canadian academic argues that nurses are the perfect targets as their work is largely invisible and frequently undervalued, yet they wield influence over treatment and purchasing decisions.
“Professor Jutel’s work surveying New Zealand nurses shows that nurses routinely recommend treatments to prescribers, over-the-counter treatments to patients and families, and provide ongoing feedback on treatment choices to prescribers,” she says.
“Because nurses generally do not write prescriptions, there is a pervasive belief that they are not really making decisions. Industry however, recognises the vital role that nurses play in providing patient education and support around taking medications and adhering to courses of treatment and thus, target nurses,” Dr Grundy told Health Central.
Grundy says when nurses accept payments from industry for consulting, speaking, travel or other gifts, there is a conflict of interest. “Their primary obligation — promoting patient and public interests — is compromised by a dual loyalty to the company, whose goals may be at odds with public interest or health.”
In an interview with the Australian Nursing Review, Karanges said the issue of ethical conflicts is complex. Not only are nurses able to influence drug purchases at multiple points of the chain, but they are also a highly trusted source of information about medicines to their patients.
“Nurses can really benefit the pharmaceutical industry and it’s good to have a nurse on the advisory committee giving insights on the medicines patients are using and how they are dealing with them. But there is a danger that these payments would subconsciously or otherwise influence the practice of the nurses receiving them,” she says.
“Our study shows that we need to think about whether our non-doctor professionals are well equipped to evaluate and understand the risks, and to know how to deal with the industry interactions they face on a day to day basis,” Karanges says.
Handling potential conflicts of interest – tips for nurses
Prof Grundy shares some ideas to help nurses deal with potential conflicts of interest. Originally published in American Nurse Today, November 2016 with permission of the author.
• Remember- there’s no such thing as a free lunch.
• Be an independent thinker. Don’t limit your continuing education to industry sponsored programs.
• Read the fine print. Check for industry sponsorship of research articles, teaching materials, and continuing education.
• Do your homework. Seek current best-evidence syntheses from independent sources, don’t rely only on what sales representatives provide.
• Bypass sales reps. Share product feedback with your peers at other hospitals and through professional associations.
• Put it out in the open. Advocate for policies that would require speakers to disclose all funding and creation of processes requiring nurses to disclose receipt of gifts or payment from industry.