1. Brown, Theresa PhD, RN


Author Quinn Grundy on the undue influence of vendors.


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Quinn Grundy's book Infiltrating Healthcare: How Marketing Works Underground to Influence Nurses (Johns Hopkins University Press, 2018) solved a mystery for me. When working as a floor nurse, I never understood why the required training sessions for new products (called in-services) were always cursory and often left me confused. As Grundy explains, it's because in-services are usually taught not by nurses, but by vendors-salespeople-with no clinical training or experience. In many hospital systems, vendors have replaced nurse educators and clinical nurse specialists who were let go because of cost-cutting measures. That new bed I wasn't taught how to adjust? The insulin pens that were easily misused? The IV tubing caps that fell apart when placed? According to Grundy, these problems result from the way medical equipment vendors have become indispensable and integral to the running of hospitals.

Figure. Theresa Brow... - Click to enlarge in new windowFigure. Theresa Brown

I've never worked in an operating room (OR), so the opening scenes of Grundy's book were a revelation to me. She describes a medical device sales rep, whom she calls Andrew, embedding himself in an OR one morning. He helps the scrub nurse tie her gown once she's scrubbed in, lays out equipment needed for the upcoming operation, and advises the nurse about the best tool to offer when the surgeon, becoming impatient, loses his temper. When the operation ends, "Andrew pulls out an iPad . . . and submits the invoice for the screws [used in the surgery] to the company and the hospital billing department-a total of several thousand dollars."


Andrew works "on 100% commission," characterizing his field as "sink or swim." He will spend his afternoon in another hospital, doing the same things all over again.


Such practices have been going on for years with the tacit assent of hospital management. What's new, Grundy explains, is that vendors now specifically target nurses to make sales. Under the Physician Payments Sunshine Act (part of the Affordable Care Act), companies are required to disclose any payments over $10 that they make to physicians and hospitals. But the act did not specifically name nurses. As legislators increased transparency laws and restricted "gifts" to physicians, the medical equipment industry came to see nurses as "soft" sales targets. Nurses can give vendors access to hospital units and activities, and some have considerable influence over purchasing decisions.


Consider Rachel, a wound care nurse at a busy public hospital. "Rachel loves the [sales] reps," her colleagues said in describing her, but Grundy puts this "love" in context. As the only wound care nurse for her entire hospital, Rachel had an impossible workload: make daily rounds throughout the facility, respond to all wound consult orders from physicians, and keep all staff nurses up to date regarding wound care products. For Rachel, Grundy writes, "interacting with industry was about making her one-woman show possible."


If Rachel needed new supplies fast, she knew she could call Melanie, a vendor, and Melanie would promptly drop them off. When Rachel realized that staff needed "another round of in-services" on ostomy care she ordered them through Melanie. For Rachel, Melanie seemed "'the perfect friend': responsive, understanding, and able to deliver." Indeed, reps often cultivate the appearance of friendship with nurses, and make themselves "indispensable" in order to clinch sales. But as Grundy clarifies, "What the nurses at this hospital really needed was another Rachel. . . . But at a resource-strapped hospital, this was not a priority." The reps were doing work for the hospital in order to sell to the hospital, and nurses served as the go-betweens.


Based on interviews with nurses at several facilities, Grundy reports that many tried to limit reps' influence, engaging in tactics she describes as "policing," "bargaining," "skepticism," and "vigilance." But as she acknowledges, "addressing the effects of the commercialization of healthcare needs to be a collective endeavor." This book shows how insidious that commercialization is, using nurses to advance the financial interests of various health care industries. The companies get richer while nurses get poorer in terms of how little their own hospitals value their knowledge, autonomy, and clinically crucial frontline patient care.