Media reports abound on the corrupting influence of the pharmaceutical industry on healthcare practice. A voluminous academic literature also addresses industry’s grip on healthcare, with numerous articles in leading medical journals, and books with revealing titles such as Deadly medicine and organized crime: How Big Pharma has corrupted health care, how they deceive us and what to do about it; and most recently a Canadian version, Doctors in denial, Why Big Pharma and the Canadian medical profession are too close for comfort. Most of these focus on how industry money influences physicians and medical researchers. The reasons for the concerns are clear here: physicians prescribe drugs and are the intermediaries between industry and patients consuming their products. Academic physicians often take the lead in clinical trials, provide credibility to academic publications, and function as key opinion leaders and consultants to pharmaceutical industry. They are most directly involved in shaping clinical practice, including through their involvement with clinical practice guidelines. It is therefore not surprising that policy initiatives, such as Sunshine Acts introduced in several states and at the federal level in the USA to promote transparency of industry payments, target the relations between the pharmaceutical industry and physicians.

Yet, considering the profits at stake and the increasing complexity of the organisation of healthcare, it would be naïve to think that other health professionals are shielded from being courted by industry.

This is why Quinn Grundy’s Infiltrating health care: How marketing works underground to influence nurses is such an important and timely contribution to the academic literature. It provides first of all a nuanced and eye-opening picture of the more subtle influence industry is exercising on other healthcare providers than physicians, in this case nurses. It thereby also evokes the need for regulatory and governance approaches that go beyond some of the traditional physician-focused measures.

The focus on nursing may seem somewhat surprising, since it is indeed the health profession that many will associate the least with the commercialisation of healthcare. As Quinn Grundy sets out in her first chapter, nurses are widely seen as “the most trusted profession”. Without concluding that this trust is unwarranted, Grundy sketches in her book a picture of the “routine, yet influential ways that registered nurses interact in their day to day clinical practice with sales representatives” (p 9) of various health product related companies. In fact, at the end of her book, Grundy first issues a broad range of recommendations aimed at strengthening the independence of nurses; and then suggests that the unique nature of the nursing profession, with its close interaction with patients and its understanding of their day-to-day experiences, places nurses precisely in a unique position to be patient advocates and to reduce the negative impact of industry practices.

The book is based on two years of investigation, to some degree as a participant-observer (Grundy is a nurse herself), in several hospitals in the United States. The book reflects Grundy’s observations from clinical encounters, sitting in on hospital purchasing committees, attending conferences and industry-sponsored educational events and lunches, and shadowing industry representatives roaming the hospital wards. These observations are interwoven with an analysis of focus-group meetings; and of detailed interviews with individual nurses in various clinical and administrative positions within four major hospitals in a large urban setting in the United States, and with some working in industry.

An interesting comment early in the book about a key challenge for her research project highlights the overall lack of awareness about nurses’ interactions with industry. Grundy describes how several healthcare administrators appeared reluctant to have her conduct research on industry interactions among nurses in their institution, with the suggestion that these did not really happen. It explains also why governmental regulatory policies fail to address interactions between industry and nurses. Grundy characterises this perception among administrators and policy makers in one of her chapters as reflective of the “‘as-if’ world of nursing practice”; a myth, she argues, which is descriptively wrong (ie there are a broad variety of interactions) and also reflects a wrong appreciation of the situation: as if the impact of interactions between nurses and industry representatives is negligible and of no concern.

The most revealing aspect of the book is how it describes, probably for the first time, in detail the various more and less subtle interactions between nurses and industry, and then each time explores to what extent these specific interactions may impact clinical practice or the broader administration of healthcare. Readers eager to read about the wooing of healthcare providers with cruises in exotic locations, outright bribes, or—as a whistleblower-instigated lawsuit against opioid producer Insys revealed─taking doctors out to strip clubs and shooting ranges*, will be disappointed. The interactions Grundy prescribes are much more ordinary, low key, and by and large absorbed into the day-to-day interactions within a hospital setting. She suggests that this is what makes them also, in a way, more pernicious and harder to control.

The book describes in detail three key types of institutional contexts in which industry and nurses interact: on the ground interactions between nurses and sales people in day-to-day clinical care; interactions in the context of purchasing committee deliberations, and the use of educational contracting services.

With respect to day-to-day interactions with sales people, Grundy shows how, notwithstanding the fact that nurses do not make prescription decisions, sales agents are still keen to build good relations with nurses, simply for the more indirect influence they have on what products are being prescribed or used. They do so more informally, by dropping of pizza-lunches or chatting with nurses about their experiences with specific drugs or medical devices; but also to some extent in more formal arrangements. The institutionalisation of these interactions may surprise some. The reader learns about the development of an entire commercial sector around the profession of “vendors”: an external commercial “credentialing” system involving background checks, health assessments, and training with respect to privacy and patient confidentiality. These credentialised vendors are then allowed to engage in interactions with designated health professionals within hospitals, including nurse educators and clinical nurse specialists. Vendors enter clinical spaces, including operating rooms, and thus appear somehow as part of the healthcare team. They tend to be required to wear clearly identifiable coloured scrubs, or a specific identification badge. But the fact that they are submitted to specific institutional rules also legitimises them and normalises their presence in clinical settings, where they may make recommendations for products, or provide advice about how a new product could be used in response to issues arising in the clinical encounter. This institutional integration, Grundy suggests, explains why nurses often fail to see the marketing component of the vendors’ interactions in these settings.

A more directly identifiable impact of interactions between industry representatives and nurses exists through the impact of marketing on purchasing committees. Purchasing committees handle budgets amounting to millions of dollars. Committee members, including nurses, are often on the receiving end of vendor visits, aimed at introducing new products, or at convincing individual committee members of the unique advantages of a new product they will be discussing at these meetings. Grundy describes how companies often try to bypass the normal purchasing process by introducing samples in clinical settings before committees make their decisions. Sales representatives may try to use nurses as credible “champions” of new products that will be discussed at the meetings. Marketing is thereby often disguised as a way of allowing nurse specialists to become familiar with promising new products to be better informed for discussions at the committee level.

A third way in which industry is increasingly infiltrating the day-to-day healthcare setting is through post-sale training and nursing education. Budget restrictions contribute here to the appeal for hospitals to rely on companies for education about new equipment or new products. Grundy gives us some examples of post-sale training in relation to new hospital equipment, such as beds for specialised care, medical isolation gowns, and a new type of glucometer.

The description of the ways in which sales representatives involved in training create documentary evidence that they are adequately fulfilling their contractual obligations raises questions about the quality of education. We read about industry representatives using free candy to entice nurses to sign a presence sheet of a training session, and nurses simply signing because they need credits of professional education. We also read about sales people using educational events to promote on the side products not yet purchased at the hospital, sometimes creating confusion, as well as pressures on institutions to buy additional products.

Grundy warns us that even if these interactions may generally not be as blatant as some of the aggressive marketing to doctors, the infiltration of sales representatives in the daily healthcare environment of nurses has created in her view a false perception that all these interactions are benign and in the patient interest.

The book explores in a third chapter the more devious courting of nurses under the pretense of being “partners” in the same beneficial endeavour to promote better patient care. Again somewhat in contrast with the examples of how doctors have often received substantial gifts from industry, we read about the building of close relationships through smaller gifts, participation in the departmental holiday party, or in sports events. This then often evolves further into a supporting relationship, whereby the industry representatives show their willingness to go beyond the call of duty to provide support and further training. In some cases, nurses also receive contracts as advisors and key opinion leaders. Grundy suggests that this more subtle courting of physicians in fact plays into a historical undervaluing of nurses, and the perception of nurses as not being as key and influential in the context of healthcare decision making. “This instrumental kind of friendship is a different type of seduction from the way the pharmaceutical industry has wooed physicians with trips to Hawaii and large consulting payments,” she argues, “but seduction it is, validating the importance of nurses’ work in a way they have long been systematically denied.” (p 69)

The book continues on this theme in a fourth chapter, where Grundy elaborates on her earlier mentioned concept of the “‘as-if’ world of nursing practice”. She elaborates in this chapter on the unique way in which relations between industry and nursing may influence healthcare practice. This unique way is directly related, so she argues, with both the external (and misleading) perception that nurses do not have direct impact on healthcare practices, and some of the internalised images that nurses have of their own profession. Grundy gives some concrete examples, including that of a nurse coming back from an industry-sponsored conference with a renal dialysis pump which she manages to integrate in her hospital, working in a way as an intermediary between industry and various people with decision-making powers in the hospital. Another example is how a nurse managed to mobilise support from industry to help overcome an important knowledge gap among nurses about an important technical issue, in the absence of institutional support.

She points to two characteristics of nursing culture that contribute to this more “behind the scenes” influence of nurses. First, nurses have learned to get things done without direct decision-making power; the book refers to this as the “work around” culture of nursing. Nurses, she points out, realise in fact how they do have influence in a less direct way, often informed about their more detailed knowledge of what patients want and what works for them. Second, there is a shared collective frustration of nurses about not being sufficiently recognised for their crucial role. Marketers and industry representatives play into this by making nurses feel respected and rewarded. Grundy suggests that the result of these factors is an increased dependence on industry.

The discussion of all these interactions might give the impression that there simply is a policy void, and that introducing institutional policies would solve the problem. But Grundy emphasises that all hospitals in which she conducted her research did in fact have institutional policies. The existence of policies prohibiting or limiting gifts, restricting drop-in visits, regulating identifying labels for industry representatives, provide a false impression that things are dealt with appropriately. Remember, as pointed out earlier, that institutions often responded to Grundy that there was no need to investigate interactions with industry since policies clearly prohibited this. Nurses, Grundy argues, work in a climate that creates and maintains “invisibility around their interactions with industry, while simultaneously seeking to foster industry interactions in the interest of the hospital”. (p 128)

The picture is, however, not entirely bleak. While Grundy describes the failure of policies, and how nurses tend to justify their interactions as benign and inconsequential, she also gives a voice to some nurses who resist industry influence. But this resistance, she argues, is very idiosyncratic, and really results from nurses following their own gut-feeling about what they deem appropriate and how they can best protect patients’ interests and the interests of the healthcare system. The fragmented nature of these responses, Grundy warns, makes it easier for industry to exploit the cracks in the system.

For that reason, she puts forward in her last chapter that there is a need for reform that should help to create a “moral space” in which the reality of interactions with industry is acknowledged, unease and discomfort is validated, and nurses are empowered against the impact of COIs. As Grundy states: “Addressing the effects of the commercialization of healthcare needs to be a collective endeavor.” (p 132)

Some of her recommendations will sound familiar to those on top of the literature related to conflicts of interest in the medical profession. She appropriately calls for inclusion of industry payments to nurses in Sunshine Acts, but also urges policy makers to go beyond disclosure. More information on payments may indeed elucidate what is going on, but doesn’t solve the problems. She also rightly calls for the need for education of nurses that is at arms-length from industry. As she rightly argues, even if this may appear to save costs in the short term, education and training organised by industry is reflected in the total costs of new products. She further recommends more education on conflicts of interest to improve awareness and to empower nurses in their interactions.

What is particularly interesting about her recommendations is her suggestion that nurses can play a unique role in resisting the commodification of health care. A key reason, she argues, is that their employment structure differs from that of physicians, in that they depend less on direct billing or insurance payments. Nurses further tend to have a unique relation with patients, and have learned to mediate between institutional pressures, demands by physicians, and patient needs. Grundy also points to the fact that nurses tend to be unionised and have thus a collective strength. But when she suggests in this context also that economic interests of nurses will rarely be at risk of new technologies, I wonder whether she is not overstating it. Would, for example, hospitals not jump at automation of certain procedures to reduce labour costs? That nurses have an important advocacy role to play, however, seems hard to deny. Grundy mentions the collective history of nurses as trailblazers of social reform, and of their collective history of standing up to institutional powers.

Some of her more technical recommendations are also of interest, although it would be interesting to see these more developed in future publications. She suggests, for example, that nurses should be instrumental in testing out new products in the healthcare setting, and that institutional structures should be developed to do this independently from industry. This recommendation seems to align with the growing emphasis on the need to look for real-life evidence from the clinical setting.

While some of the observations in the book may be more specific to the US healthcare setting, it seems fair to presume that many of the practices described in the book also occur in other countries. One should hope that Grundy’s book will inspire nurses and healthcare professionals elsewhere to engage in similar studies to explore how nurses and other health professionals have become integrated in the commercialisation of healthcare, and whether local regulatory and professional standards are sufficiently addressing this. Much of what Grundy describes would seem relevant, for sure, for the Canadian healthcare setting. When reading Grundy’s descriptions, I was reminded of how a Canadian geriatrician shared with me in the early 2000s his experience of how a nurse research-coordinator of an industry-funded clinical drug trial had contacted a nurse working with him on a publicly funded grant, with the proposal to transfer some of their research subjects to the industry funded grant. In exchange, the nurse-coordinator of the publicly funded study would have received nice garden furniture. It made me realise how various healthcare professionals are directly involved in the significant commercial interests of industry-sponsored research. Since then, industry interest in medical practice and clinical research have certainly not diminished in Canada, nor likely elsewhere.

Grundy’s book is a valuable read for anyone who wants to have a better understanding of the impact of industry on healthcare practice more generally, of the challenge of professional regulation in an increasingly commercialised healthcare setting, and of how conflicts of interests are dealt with in the context of the nursing profession. Indirectly, readers will also learn more about several components of the current-day practice of nursing in an increasingly commercialised healthcare setting. This revealing book should stimulate further work on the governance of the interactions between industry and healthcare professionals and on unique ethical components of nursing practice, and this also outside the United States.

Note: *See: https://www.motherjones.com/politics/2018/05/insys-subsys-whistleblower-lawsuits/

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