Family nurse practitioners need to be more aware of the commercial pressures they face as a result of their increased involvement in prescribing, according to a survey published in the March issue of the UK-based Journal of Advanced Nursing.

"Our detailed study of 84 family nurse practitioners (FNPs) showed low awareness of how marketing by pharmaceutical companies affects clinical decisions and creates conflicts of interest" says Dr Nancy Crigger, from William Jewell College, Missouri, USA.

"However they were clear that some marketing activities, promotional items and gifts were less ethical and acceptable than others. For example, gifts that benefited patients and conferences were more acceptable than resort seminars and office equipment."

Dr Crigger, herself a qualified FNP, adds: "The influence of marketing on physician prescribing has been widely researched and this indicates that the more involved physicians are in marketing, the less likely they are to recognise when their clinical judgement has been compromised.

"Our study suggests that the same is now happening to FNPs who have been given greater responsibility for prescribing some types of medication."

Key findings from the survey included:

• 5% admitted that pharmaceutical reps influenced their prescribing and 26% said they did not, with the vast majority answering sometimes. However they said that other FNP colleagues (18%) and physicians (25%) were more likely to be influenced than them.

• 41% said they were not influenced by drug company marketing, but 17% said they were. 44% believed their prescribing was positively influenced by marketing rather than negatively, with 10% saying it wasn't.

• Two-thirds said that promotional items did not influence their prescribing, with just 1% saying it did. 14% said that pharmaceutical representatives may cross ethical boundaries by giving FNPs gifts, but 42% said they did not.

• Nurses were more in favour of education gifts and those that benefited patients. The majority said that educational gifts were ethical and appropriate (49%) and that non-education gifts were not (47%). 51% agreed with gifts that benefited patients and 52% opposed gifts that did not benefit patients.

• 45% said it was not acceptable or ethical to accept inexpensive gifts but 15% said it was. 59% disagreed with expensive gifts but 7% felt they were acceptable and ethical.

• Nurses felt more comfortable attending sponsored events such as lunches and dinners (48%), trips (45%) and conferences (65%), but resort seminars (32%) and happy hour events (21%) were deemed less ethical.

• 50% felt that events organised by drug companies were more educational than promotional, but 15% disagreed.

• 62% of respondents accepted samples, 50% educational items, 41% office supplies and 30% office equipment.

• 41% said that their advanced practice training covered conflicts of interest when it came to drug marketing and 34% said it did not.

The FNPs who completed the 22-item questionnaire were chosen at random from a list of licensed nurses provided by the Missouri State Board of Nursing. 42% of the 200 nurses who were approached responded. Their ages ranged from 25 to 69 (average 47) and they had been in practice for one to 33 years (average 9.4). The majority (82%) were female and 60% served rural populations.

"Our study suggests that pharmaceutical marketing is widespread among FNPs and that FNPs fail to recognise how they are being influenced by this practice and that greater involvement in marketing may reduce their critical assessment of such practices" says Dr Crigger.

"It points to the need for all FNPs to evaluate their personal attitudes and practices concerning the ethical appropriateness of accepting gifts, meals, educational programmes and trips from pharmaceutical companies.

"We believe that prescription decision making should be based on the best interests of patients and on maintaining the trust of the patients and the public.

"Further research is needed to determine the impact of pharmaceutical marketing, but until then we believe that FNPs should avoid situations that could create a conflict of interest."