Pharmaceutical influences – Nurse prescribers: eyes wide open [cite this article?]

Jill Davies, Programme Leader Extended/Supplementary Prescribing Course, The University of Sheffield

Steve Hemingway, Lecturer in Mental Health Nursing, The University of Sheffield
 

Published: 30/12/2004

SUMMARY

The role of the Pharmaceutical Industry within healthcare has been a debate amongst our medical colleagues for the past decade. However, with the growing number of nurses who are now qualified to prescribe, this controversial aspect of professional practice is becoming an area of interest to nurses. This article reviews some of the literature on prescribing and the pharmaceutical Industry, in an attempt to raise nurses awareness. Nurses have skills that are central to their education of assessment and evaluation. It argues that nurses are well placed to utilise these skills to identify the influences of the Pharmaceutical Industry. The role of the Pharmaceutical Industry in professional development is debated, suggesting that nurses have the skills to analyse the potential impact of this form of education. Concepts of Ethics are discussed in relation to prescribing, patient care and professional education and practice.

KEYWORDS

The role of the pharmaceutical industry within health care continues to be a controversial and complex debate. Historically this has been an arena of the medical profession. However, with the growing numbers of nurses now able to prescribe, it has become an area of professional practice that the nurse needs to assess and evaluate to inform and guide professional ethical practice. The evidence suggests that nurse prescribers are now targeted by the pharmaceutical industry, actively sought after through office visits and via invitations to dinners and special events [1]. Hemingway [2], although presenting the perception from a mental health standpoint, supports this view, and suggests that although pharmaceutical industry is one avenue for nurses to gain up-to-date information about new drugs, there are other sources, such as the National Institute of Clinical Excellence (NICE), local trust guidelines, peer-reviewed journals and pharmacists. Concluding that the pharmaceutical industry is a powerful influence within nurse prescribing, and care should be taken when assessing their potential involvement in education and subsequent client care.

Conversely, this is not a simple issue, where practice and theory unite successfully, but an issue that has been a conversation amongst our medical colleagues for over a decade.

Medical and nursing literature reports that pharmaceutical companies influence prescribing, and although there is limited evidence of prescribing habits of nurse prescribers, Stokamer [3] states that there is growing evidence that nurses are also being influenced in much the same way.

While and Biggs [4], when discussing factors that influence prescribing, identified in a study of 123 prescribing health visitors and district nurses that 50% stated that they were influenced by information from pharmaceutical companies.

The pharmaceutical industry is an intoxicating force within prescribing, and deciding which medicines to prescribe can be inconceivably difficult.

It is well documented that huge sums of money are spent on drug promotions (National Prescribing Centre [5]). Their products are promoted in numerous ways targeting diverse audience of prescribers, including visits, sponsorship and gifts, seminars and educational meeting, to name just a few.

Shaughnessy and Slawson [6] present this interesting visual concept of pharmaceutical representatives as follows: ‘they are like stealth bombers of medicine: they swoop in, change practice, better than any journal article or formal educator, and disappear again’. Suggesting that pharmaceutical representatives are communication experts, with their main aim to prescribe their drug, seemingly, supporting this with medical evidence.

In April 2000, the then, Secretary of State, Alan Milburn, announced £10 million from 2001 to 2004 to support training programmes to extend nurse prescribing. Conversely, funding for the continued professional development needs of these nurses appears conspicuous in its absence. The need for nurses to develop their practice, experience and pharmacology knowledge is well documented in the literature [7,8]. Therefore, it could be suggested that the expertise and knowledge of the pharmaceutical industry could suitability fill this gap in nurses’ professional development by means of educational events, review papers and literature. This opportunity has been quickly grasped by the pharmaceutical industry; as far back as 1997, Leifer [9] observed that the lack of courses for nurse prescribers made them vulnerable to the drug companies. Signifying that drug companies were targeting nurses with courses which explained how to use their products. The Royal College of Nursing advised that nurses had to consider carefully whether there were ethical dilemmas when accessing educational courses that were sponsored by the pharmaceutical industry. However, some years later, the role of the pharmaceutical industry is still prominent in nurse education. Hall et al. [10] found that while nurse prescribers commonly used journals as well as the British National Formulary as sources of information, they also obtained information from pharmaceutical representatives.

Moyniham [11] identifies that, most doctors deny influence, when discussing educational events sponsored by the pharmaceutical industry. However, adds that evidence suggests that these events highlight and present their own drug in a positive light, and how can judgement not be tainted. It is also argued that medical journals rely on sponsorship from drug companies by the way of advertisement, despite the obvious conflict of interest.

Lipley [12] makes a claim that research suggests that three-quarters of nurses would change their practice for a ‘glossy leaflet or sandwich’, interesting to note that the source of this research is a ‘confidential’ pharmaceutical company document. However, it is still worthwhile to remember the powerful effect of this industry, and perhaps nurses need to reflect and evaluate this.

Stokamer [3] argues that Pharmaceutical companies work within the law to promote their product, suggesting that, although medicines save lives they cost enormous amounts of money to research and development, and often come at a high price. Arguing that the money spent in advertising with professionals could be better spent elsewhere on patient care.

The Association of British Pharmaceutical Industry (ABPI) has a Code of Practice, which they work to, that stipulates their marketing activities; this prohibit companies giving practitioners inducements to prescribe their product in the form of payments, lavish gifts or extravagant hospitality. The ABPI Code states that gifts from companies must cost less than £6, and be relevant to the doctor’s work. The guidance explains that pens, diaries and surgical gloves are acceptable, whereas tablemats, plant seeds and music CDs are not.

The Code of Professional Conduct [13] gives clear direction to a nurse actions and responsibilities:

• 7-2: You must ensure that your registration status is not used in the promotion of commercial products or services.
• 7-3: Where you recommend a specific product, you must ensure that your advice is based on evidence and not on your own commercial gain.
• 7-4: You must refuse any gift, favour or hospitality that might be interpreted, now or in the future, as an attempt to obtain preferential consideration.

From the examination of the codes from each agency suggest that principles of acceptable behaviour are reflected. Clearly identifying that both parties are governed by the same principles for expected behaviours. However, it is interesting to note that not all drug companies are the members of the ABPI [14].

This is particularly worthy of note when the concept of ‘gift’ is analysed. Stokamer [3] presents the view that gifts are cultural, and have cultural meaning. This is explained that a gift could be perceived as an offer of friendship that can be accepted or rejected out of hand. Arguing that by accepting a gift is an acceptance of a certain degree of intimacy, and that a return of reward is expected at some level. While it may be difficult to think that a gift from a pharmaceutical representative may influence a nurse prescriber, nevertheless, the research suggests differently. Stokamer [3] assets that health care professionals are constantly faced by friendly sales people offering tempting gifts. A view supported by Moyniham [11], who states that there is a culture of industry gift giving to doctors. Therefore, from this perspective, it would suggest that some obligations are expected, which in turn has the potential to present the practitioner with ethical dilemmas when considering products to prescribe.

The National Prescribing Centre [5] makes this concept more concrete and easier to define, and presents a list of expected behaviours:

• Free gifts from representatives should be worth no more than £5.
• Free gifts should be relevant to practice.
• The standard of hospitality should be the same as you would routinely pay for yourself.
• Only health professionals and not family members may receive hospitality.

It would appear that the ethical dilemma lingers. Are nurses expected to perceive the pharmaceutical industry as a friend or a foe? The challenge remains, how can nurses ensure that their prescribing practice decisions are not overtly or covertly influenced by the pharmaceutical sector; while at the same time develop their own knowledge and skills.

The relationship between the pharmaceutical industry and health care could be described as significant; it needs nurses to assess its potential to patient care. Nurses perhaps need to grasp this opportunity to recognise the influences of the pharmaceutical industry, and reflect and evaluate the ethics of their actions. While the value of the pharmaceutical industry in health care is divisive, it will take the skills of the informed nurse to assess their potential as either a hindrance or a force that can be more of a partnership to quality education and patient care.

Shaughnessy and Slawson [6] present the acronym of ‘STEP’ as a way to evaluate the information from drug representatives: Safety, Tolerability, Effectiveness and Price. Suggesting that the four attributes should be considered when weighing the purported advantage of one drug over another.

Interestingly, similar concepts are reflected in the ‘principles of prescribing’ [4], where the acronym ‘EASE’ is a way of considering the product. E – how Effective is the product, A – how Appropriate for the patient, S – how Safe is the product, E – is it cost Effectiveness.

It may also be worthwhile to visit the principles of ethics when considering and discussing awkward issues of conflict of interest, when health care meets business. These principles include, respect for patient autonomy and to make informed choices, non-maleficence and beneficence, and justice [15]. Therefore, when a nurse comes to the ethical dilemma of whether to accept services in any way, shape or form from the pharmaceutical industry, whether it is an invitation to an educational event or a free lunch, it may be appropriate to assess how this might affect their own morals, values and beliefs. Nurses have a duty of care to the organisation, themselves and the patient, could this duty of care be influenced in any way, and their subsequent care compromised by accepting resources from the pharmaceutical industry. Every nurse is different; they have different knowledge and experiences which will affect their professional behaviour. But relationships with the pharmaceutical industry are the business of every nurse, and nurses must be clear as to where their interests lie, and the recommendations to their actions that are set in the Code of Professional Conduct [13].

Although it is questionable whether the behaviours of doctors can be transferred to prescribing nurses remains controversial, the reality of dealing with drug representatives is entwined with ethical dilemmas. The challenge to nurses is how best to use these resources without compromising their professional, moral and ethical status. Aware of the certain influence of the pharmaceutical industry is a beginning. Nurses need to develop strategies to make the best use of educational resources that are provided from the industry, and to reflect and evaluate their own practice in relation to the ways in which they access the material.

It may be worthwhile for prescribing nurses to judge the wider context, and content of the information from the pharmaceutical industry, and analyse and reflect on this.

Nurses will continue to be bombarded with information, educational events, gifts and free lunches from pharmaceutical representatives eager to promote their products; but nurses are powerful too. Nurse prescribers should think more laterally, and use the skills that are central to their profession, to assess and evaluate objectively all sources of information. To stand firm and to counter the claim by Lipley [12] that ‘nurses are seen as a soft touch and in too many instances correctly so’ [p. 12].
 

ARTICLE HISTORY

The main author is a qualified and practicing Supplementary and Independent prescriber, and has also been prescribing from the Health Visitor/District nurse formulary since 1998.While practising as a prescriber, she became more aware of the development of prescribing and related relationships with the pharmaceutical Industry is becoming more overt.

As Program leader for the Nurse Prescribing course, the role of the pharmaceutical Industry is an area of some considerable debate amongst students.

The second author is closely involved in the local and national development of non-medical prescribing in mental health care, teaches on the nurse prescribing course, and has published an article on the relationship of the pharma industry and mental health nurse prescribers.
 

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