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6. Trust Me, I’m a Nurse. (The Rehabilitation of Hot Lips Houlihan)

How the life science industry leverages the nursing profession’s imbued trust in patient engagement services

I’ve always found it an ironic and somewhat unsettling phenomenon how in Western culture, the field of nursing is simultaneously the most trusted AND most sexualized profession.

It’s all very Freudian the way the male-dominated media has often portrayed a role that, aside from motherhood itself, is most closely associated with that of a caregiver. And it’s been that way for decades, from the cheeky slapstick Carry on Nurse and Carry on Doctor movies of the 1950s and 60s, to the bawdiness of Benny Hill in the 70s and 80s, to the endless loop of scantily clad nurses working in the mental asylums of every rocker and rapper music video since. On occasion though, Hollywood has come to recognize that women (and many men) aren’t keen on the hyper sexualization of a profession that saves lives and therefore seeks to redeem itself. A perfect example is the rehabilitation of Lorretta Swit’s character in the 1970s TV show M*A*S*H, who evolved from a brash one-dimensional man-chasing mistress of Frank Burns known as “Hot Lips” to the more complex, capable and sympathetic nursing and military professional of Major Margaret Houlihan. Over its 11-year run, the character of Margaret Houlihan gradually came to embody why nursing is such a trusted profession. She balanced her grit with compassion, her professionalism with empathy, and her sense of duty to her employer (i.e., the US army) with her sense of humanity to the traumatized individuals that were under her care.

Perhaps unsurprisingly, many of the professionals who are solicited by the life science industry to provide patient engagement services—particularly disease and treatment educators, wellness coaches, and patient advocates—come from the nursing field. The reasoning is logical. Nurses are repeatedly ranked at the very top of annual public opinion surveys of the nation’s most trustworthy careers, placing higher than other healthcare professionals such as physicians and pharmacists [1]. In fact, the participants in my doctoral study on the patient engagement experiences of pharmaceutical-sponsored clinical educators (see Post 2 “Zen and the Art of Relationship Centricity”), almost all of whom were registered nurses, were well aware of the sense of trust imbued upon them by the general public. They often referenced it as a foundation of their professional and philosophical orientation. Throughout their interviews, they frequently articulated the high expectations by which they held themselves for maintaining that trust, even though their clinical educator role was outside of direct patient care:

I think people innately trust and respect us overall. But I think when you’re honest, genuine and transparent with people, it goes a long way. Even telephonically, you can get that across to people. They know when you’re being honest.” -Olivia [2]
“Nurses have that reputation of being trustworthy so that definitely helps. But I think each nurse has to really strive for that trust relationship. If we want to reach that patient, where they are and help them to understand their disease process or why it’s important to change behaviors and such. And that’s all on that foundation of the nurse-patient trust relationship” -Nadine [2]

Importantly, trust is fundamental to the patient engagement specialist role within the context of

Street’s ecological model of communication in medical encounters that was discussed in Post 5: “We were close to compliant..." [3]. As you may recall, that framework portends that patient and HCP behaviors cannot be interpreted in isolation of the environmental and policy contexts in which they occur [4]. For example, the strict and structured compliance regulations that undergird how and what information is delivered by a life science company can directly influence the communication style used by the industry’s patient engagement specialists in their interactions with patients. This was a notion understood by the clinical educators in my study who believed their communication style had a direct bearing on the level of trust given to them by the patient. That meant that when there were high levels of perceived trust, patients were more inclined to actively participate in an engagement in a manner that is characteristic of Emanuel & Emanuel’s [5] interpretive model discussed in Post 3: “Dr. John and the Surreptitious Assessment”. As a quick refresher, that model is the one in which the patient assumes the role of sole decision maker, but allows the HCP to elucidate their values and to assist in the guidance of therapies and medical decisions. Cora, one of the nurse educators summarized it nicely:

“When you develop a trusting relationship with a patient, then they’re able to really expose their inner self and all their fears and concerns, and that’s where you’re really able to build the bridge to help them accept the diagnosis” [2]

Conversely, public opinion polls on trusted industries have shown that the life science industry is often perceived as one of the most distrusted [6] (although the COVID pandemic has helped change that some, for now [7]). Seeking to remedy that perception, the industry has come to recognize that hiring highly trusted professionals is in their best business interest. By employing nurses in roles such as patient engagement specialists, the industry can capitalize on the profession’s implied trustworthiness. Of course, that’s not a bad thing considering that one of the industry’s primary business goals is helping patients be confident and adherent managers of their health.

However, as discussed in Posts 4: “Dr. John…” and 5: “We were close to compliant…” this can present ethical and professional dilemmas. Many of the nurse educators in my study felt their role was frequently handicapped and devalued by overly restrictive and counterproductive compliance regulations. In turn, that devaluation forced them to adopt a communication style akin to Emanuel & Emanuel’s [5] informative model. In that utilitarian communication style, the role of the HCP is simply a technical advisor who provides factual information without imposition of values or active participation in decision making. Further, nurse educators interpreted this to mean that their role was nothing more than that of a “robotic” information transmission conduit between two entities—their company and their patient. And for many of them, this not only negated the hard work their profession has done to be a bulwark of trust, but it was also in direct opposition to the very objectives they are charged with meeting. As Vivian sadly shared:

You know you either fail your patient or you fail the compliance. With the regulations as strict as they are, often, I left the session feeling like the patient really didn’t get what they needed out of the class. But my [sales] rep was happy because I did everything by the book and dotted every ‘I’ and ‘T’ and didn’t stray in any direction off script. But at the same time, I think that’s the kind of patients that eventually fail treatment because they weren’t going to be compliant because they didn’t understand.” [2]

[1] Brenan, M. (2023, January 10). Nurses Retain Top Ethics Rating in U.S., but Below 2020 High. Gallup.Com. https://news.gallup.com/poll/467804/nurses-retain-top-ethics-rating-below-2020-high.aspx

[2] Barshinger, T.A. (2020) Interpretations of communication experiences of pharmaceutical-sponsored clinical educators (Doctoral dissertation). Retrieved from ProQuest Dissertation and Theses database (UMI No. 28086978)

[3] Street, R. L. (2003). Communication in medical encounters: An ecological perspective. In T.L. Thompson, A. M. Dorsey, K. I. Miller, & R. Parrot (Eds.), Handbook of health communication (pp. 63–89). Lawrence Erlbaum.

[4] Sallis, J. F., et al. (2008). Ecological models of health behavior. In K. Glanz, B. K. Rimer, & K. Viswanath (Eds.), Health behavior and health education: Theory, research, and practice (4th ed, pp. 465–485). Jossey-Bass

[5] Emanuel, E. J., & Emanuel, L. L. (1992). Four Models of the Physician-Patient Relationship. JAMA: The Journal of the American Medical Association, 267(16), 2221

[6] McCarthy, J. (2019, September 3). Big pharma sinks to the bottom of U.S. industry rankings. Gallup.Com. https://news.gallup.com/poll/266060/big-pharma-sinks-bottom-industry-rankings.aspx

[7] Ipsos (2022, January 17) Pharmaceutical and banking companies and governments are now seen as more trustworthy. https://www.ipsos.com/en-us/news-polls/global-trustworthiness-monitor-2021


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