UCSF

Purpose: The purpose of this multi-sited, ethnographic study was to explore whether and how registered nurses (RNs) interact with medically-related industry in clinical practice.

Background: Recently passed legislation aims to bring transparency to the relationships between physicians and industry in an effort to curb rising costs and threats to patient safety resulting from biased decision-making arising from conflicts of interest. This legislation, however, omits nurses. In this era of healthcare reform, RNs are increasingly influential clinicians and their power is recognized by industry; they may be targeted by marketing and subject to conflicts of interest similar to those addressed for physicians.

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, advanced practice nurses, administrators, and industry representatives. 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.

Results: Through formalized processes, industry representatives had become built into the everyday and often vital functioning of hospitals and these activities were redefined as something other than marketing. Although administrators generally denied that nurses interacted with industry, nurses reported frequent and varied interactions with industry; marketers described their interest in nurses as strategically positioned institution insiders. Due to discourses which constrained the ways that nurses could conceive of and exercise their authority, interacting with industry was empowering. Nurses experienced marketing as benign as they did not identify as “decision makers.” For some participants, interacting with industry triggered the sense that these interactions were potentially problematic and they developed strategies on an individual, ad-hoc basis to attempt to manage them practically and ethically.

Conclusions: Institutions have created a strategic invisibility around nurse-industry interactions, externalized the costs of these interactions to the public and outsourced their management to individual clinicians. Nurses did not relate to the concept of conflict of interest and lacked a social and political climate that validated their ethical dilemmas experienced in the course of interacting with industry. Creating a climate within healthcare that fosters moral perception within the context of industry interactions is necessary to protect the public interest.