The "rules of engagement": Nurses' strategies for managing industry relations
Background: Recently passed legislation that brings transparency to the relationships between physicians and industry adds to a series of policy developments that aim to address conflicts of interest and to curb rising costs and threats to safety resulting from biased decision-making. Many of these policies, however, fail to include or recognize the roles of nurses. With nursing’s growing scope of practice and emphasis on multidisciplinary care models, nurses’ power and influence is increasingly recognized, and they are subject to conflicts of interest similar to those addressed for physicians. Nursing, consistently rated as one of society’s most trusted professions, should be especially concerned with both actual and perceived conflicts of interest as they can threaten public trust.
Methods: An ethnographic approach was used to explore this issue within a purposive sample (n=4) of hospitals selected to represent different types of institutions. Participants (n=72) included staff nurses, nurse managers, Clinical Nurse Specialists, administrators, industry representatives and supply chain professionals. Four data collection strategies were triangulated: targeted observation of nurse-industry interactions; focus groups with RNs; individual interviews with key informants; and documents analysis. Data were analyzed using an interpretive approach in which key themes were inductively derived from the data and described in relation to policy and institutional contexts.
Results: Participants reported “interacting heavily” on a day-to-day basis with industry representatives. Nurses reported developing ad-hoc, personalized strategies for interacting with sales representatives and other forms of marketing on the basis of experience. These “rules of engagement” represented a spectrum of orientations toward industry, ranging from treating sales representatives as essential colleagues to approaching industry interactions with deep mistrust. While some participants had adopted an attitude of vigilance, policing practices in their interactions with industry, others felt strongly bound by a social code that mandated they “not be rude” and strove to maintain friendly collaborations. However, all these strategies were invisible to administrators, who largely maintained that interactions between nurses and vendors did not occur. Although some nurses characterized themselves as patients’ “last line of defense”, their strategies were not always effective in safeguarding patient care or their institutions from industry-promulgated influences that could create bias. Industry representatives were attuned to these personalized strategies and exploited differences among colleagues.
Implications: Due to the absence of inclusive policy and a lack of recognition on part of administrators, nurses were left to navigate interactions with industry on an individual basis. Within institutions, a diverse patchwork of strategies resulted in inconsistent policy implementation, and a lack of clarity around professional and ethical standards. Nurses’ work with industry vendors should be recognized institutionally to ensure ethical, effective collaboration, and nurses should receive formal preparation for this work, including skills for critical appraisal of industry-funded research.