Changing Societies & Personalities, 2020 Vol. 4, No. 2, pp. 190–204 http://dx.doi.org/10.15826/csp.2020.4.2.097 Received 26 October 2019 © 2020 Natalia A. Akimova, Elena N. Medvedeva Accepted 21 June 2020 not@bk.ru Published online 9 July 2020 fargonom@mail.ru ARTICLE Factors Influencing Nurses’ Decision to Join a Professional Association in Russia Natalia A. Akimova, Elena N. Medvedeva Saratov State Medical University, Saratov, Russia ABSTRACT Many professional associations of nurses in Russia and other countries struggle to increase their membership. Even though there are obvious advantages of membership in a professional organization, many people decide against it, which makes the study of factors that affect their decision-making a pertinent task. The aim of our research is to study the factors of membership or non- membership of nurses in professional organizations in Russia. We conducted semi-structured interviews among nurses in different Russian regions (N = 16). Their responses were analyzed by qualitative content analysis. We identified the main factors that determine nurses’ membership or non-membership in professional associations and distinguished between objective and subjective reasons as well as active or passive attitudes demonstrated by our respondents in this regard. The conclusion is made that nurses often adopt a “formal” approach to membership in professional associations, seeing it primarily as a certification requirement. This means that their interests may not coincide with the goals and mission declared by these associations in their charters. Some respondents, however, demonstrated a more active attitude, pointing out such reasons for membership as professional growth, opportunities for advanced training, socialization, exchange of ideas and so on. KEYWORDS nursing, motivation, professional organizations, nurse, membership, qualitative content analysis ACKNOWLEDGEMENT This research was supported by the Russian Fund of Federal Property, project No. 18-013-01154А. https://changing-sp.com/ Changing Societies & Personalities, 2020, Vol. 4, No. 2, pp. 190–204 191 Introduction Professional culture based on shared beliefs and values is crucial to any profession. Professional organizations are important elements of civil society and provide collective protection of the interests of their members. In our study, we are going to focus on professional associations of nurses in Russia and their role in the life of the nursing community. The first professional nursing organization appeared in the USA: it was the American Society of Superintendents of Educational Institutions for Nurses, founded in 1893 (later renamed as the National League of Nurses). In 1896, the second nursing organization was founded – the Associated Graduates of Trained Nurses in the United States and Canada, which later became the American Nurses Association (ANA). Professional nursing associations went global in 1899, when the International Council of Nurses appeared, which was the first international professional nursing organization. There are currently more than 100 national professional organizations all over the world and their number is steadily growing (Matthews, 2012). Together, they have a significant impact on the healthcare sector by tackling various professional, political, regulatory, clinical and educational issues. There is vast research literature on the work of health care professionals that demonstrates that professional associations provide their members with numerous benefits, including mentoring, continuing education opportunities, leadership development and professional development prospects (DeLeskey, 2003; Esmaeili et al., 2013; Greggs-McQuilkin, 2005; Goolsby & DuBois, 2017; Wynd, 2003). In addition, researchers have drawn attention to the relationship between an employee’s membership in a professional association and the level of their professionalism (Hall, 1982; Wynd, 2003). It was shown that professional associations help health care professionals improve their competencies and ensure continuous improvement of their professional skills (Bruhn, 2001). Wynd (2003) studied nursing professionalism by using Hall’s Professionalism Inventory Scale (Hall, 1982) and found that professionals tend to adhere to the concepts of faith in public service, the right to self-government, faith in self- regulation, and a sense of vocation. Moreover, compared to those professionals who do not belong to professional associations, their members demonstrate significantly higher levels of professionalism (competence, integrity, etc.) (Wynd, 2003). Wynd’s work highlights the importance of professional membership for retaining qualified and dedicated nurses and for ensuring the overall efficiency of a medical institution. Membership in professional organizations contributes greatly to the development of medical practitioners (American Nurses Association, 2016). Professional organizations disseminate information and create evidence-based professional standards that enable nurses to be informed and educated. The opinions of deans, teachers, supervisors and fellow students play an important role in nursing graduates’ decision to join a professional association (Bailey, 1987). Nurses who continued their education and joined professional organizations in https://changing-sp.com/ 192 Natalia A. Akimova, Elena N. Medvedeva most cases were able to make their own decisions regarding the patient’s treatment and participated in solving problems related to the organization of work in a medical institution (Haley-Andrews & Winch, 2001). Despite numerous advantages of membership in professional associations, not all medical practitioners are keen on joining them (DeLeskey, 2003; Esmaeili et al., 2013; Goolsby & DuBois, 2017; White & Olson, 2004). 50 percent of registered nurses who were not members of a professional organization cited high membership fees and inconvenient location or meeting times as reasons for not joining or leaving the organization (DeLeskey, 2003). DeLeskey showed that nurses unsubscribed from membership because they did not feel that the benefits they received covered the cost of their membership in the organization. Exchange theory (Alotaibi, 2007; DeLeskey, 2003; Esmaeili et al., 2013; Walton, 2017) has been used as a theoretical and methodological basis for understanding why health workers do not join professional associations. The advantages of membership in a professional association are often compared against its cost. Yeager & Kline (1983) developed the Professional Association Membership Questionnaire (PAMQ), which is now widely used to identify factors that contribute to employees’ decision to join a professional association. PAMQ helps determine the factors that influence nurses’ decisions and to identify the most important ones, including continuing education, professional development and leadership development, networking, mentoring and professional development. The most common barriers are the lack of time, cost of membership and family responsibilities (DeLeskey, 2003; Esmaeili et al., 2013; White & Olson, 2004). Professional organizations can create positive social change by improving the quality of medical services. They provide medical professionals with opportunities for enhancing their expertise through continuing education and professional development (Esmaeili et al., 2013). Professional organizations help nurses expand their powers and exercise their professional rights. Kung and Lugo (2015) found that participation in professional organizations, knowledge of legislation and political processes were important predictors of nurses’ political participation in the development and decision-making process of a health system reform. Dollinger (2000) notes that professional organizations provide healthcare professionals with opportunities to discuss and develop standards, share experiences, and create a platform for enhancing professional relevance. In Russia, professional associations of nurses have appeared relatively recently. The Russian Nurses Association (RNA), which is now the largest professional association of this kind in the country, was established in 1992. The second organization uniting nurses of a certain specialization – The Transregional Public Organization of Scrub Nurses (RSNA) – was set up in 2001. In addition, in 2010, the Department of Nursing Management and Social Work of the Faculty of Higher Nursing Education and Psychological and Social Work of the I. M. Sechenov First Moscow State Medical University established a non-profit partnership called “Association of Specialists with University-Level Nursery Education”. In 2015, the association of organizations supporting specialists with higher and secondary nursing education and pharmaceutical education founded the Union of Medical Professional Organizations Changing Societies & Personalities, 2020, Vol. 4, No. 2, pp. 190–204 193 (MPOU), which is currently the youngest and the most active professional organization of nurses and pharmacists. Only legal entities can be members of the MPOU; it comprises regional organizations of medical workers, including nurses, from 24 regions of Russia. There are practically no studies of professional nursing associations in Russia. We believe that one of the reasons behind the apparent lack of academic attention to this question is that the institution of professional associations as such is not sufficiently developed in Russia. In this paper, we are going to address this research gap. Research Methodology For our study, we interviewed 16 professional nurses from different Russian cities. We selected respondents from the regions where RNA’s offices had more than 2,000 members. To this end, we used the list on the association’s official website1. Another important criterion was the number and density of the population in cities and regions. According to the RNA’s website, it has most members in the central part of the country (Central Federal District) as well as in other large regions – the Southern, North-Western, Ural, Siberian and Volga Federal Districts. Thus, we considered Moscow region (8,000 RNA members), Bryansk region (5,189 RNA members), Kursk region (4,981 RNA members) and Voronezh region in the Central Federal District (13,448 RNA members); Saint Petersburg in the North-Western Federal District (2,902 RNA members); Rostov region (4,200 RNA members), Astrakhan region (6,700 RNA members) and Volgograd region (5,820 RNA members) in the Southern Federal District; Kemerovo region (12,159 RNA members) and Omsk region (15,924 RNA members) in the Siberian Federal District; Tyumen region in the Ural Federal District (7,236 RNA members); and the Mari-El Republic in the Volga Federal District (3,853 RNA members). In total, 16 experts were interviewed: two representatives from each region (Moscow, St. Petersburg, Voronezh region, Rostov region, Volgograd region, Kemerovo region, Tyumen region, Mari-El Republic) with at least five years of nursing experience. The median work experience of our respondents was 18 years (from 7 to 37 years). The median age of nurses was 42 (from 27 to 56). All participants in the study were women. They work in different hospital units and medical organizations, such as TB care, intensive case, reception, physiotherapy unit, and so on. However, the data on the respondents’ medical specialization were not taken into account when analyzing their responses due to the fact that there are no professional nursing associations for nurses of a certain specialization in Russia. At the first stage, this study used the semi-structured interview method; at the second stage, the data were analyzed by applying the qualitative content analysis method. Since not all of our respondents were affiliated with the RNA or a similar organization, we included two options in our interview guide: for those respondents who 1 https://medsestre.ru/regions https://changing-sp.com/ https://medsestre.ru/regions 194 Natalia A. Akimova, Elena N. Medvedeva were members of a professional organization and for those who weren’t. Respondents were then divided into two subgroups for subsequent analysis (N = 16, n1 = 9, n2 = 7). For those respondents who were non-members of a professional association, we included two questions in the interview: questions about the conditions and factors that influenced their non-membership in an association and about their awareness of the activities of professional associations. For those respondents who were members of an association, there were three questions: concerning the factors that influenced their decision to join an association; the role of associations in their personal life and work; and their personal interest in activities of professional associations (see Appendix 1). In addition, the structure of each interview guide included questions related to respondents’ gender, age, work experience, place of work, medical specialization, and education. The data were interpreted by applying the qualitative content analysis, based on the “infrequent model of text content” (Pashinyan, 2012). In other words, the analysis focuses only on those elements of the text content that serve as indicators for the interpretation of meanings and correspond to a certain category of content. In this paper, the method of qualitative content analysis is based on an inductive approach similar to the one applied by Elo and Kyngäs (2008) in processing the data of their interviews with nurses. The key feature of this method is that the text is divided into several smaller categories. While preparing for data interpretation, we selected units of analysis, specific topics and categories. The next step is to organize high-quality data through open coding, which means highlighting the main categories (or titles) during the reading of communication texts (in our case, interviews). Then, in accordance with the induction categories, headers of a higher order are identified, which helps us reveal the relationship between the data, identify various subgroups of categories and describe their values. The transcribed interviews that were the units for content analysis were assigned identification numbers in accordance with the division of the respondents’ responses into two subgroups. We compiled a general categorical matrix based on five main topics for analysis and discussion of the received material (see Table 1). Table 1. Categorical Matrix Subgroups Reasons for membership/non-membership Awareness scale Members of a professional association Subjective Active position a) Obligatory participation 3 Passive position b) Voluntary participation 1; 2 Non-members of a professional association Objective c) Activity/passivity is not determined Subjective Active position d) Professional agnosticism Passive position e) Personal indifference 0 As far reasons for membership or non-membership in professional organizations is concerned, we distinguish between obligatory and voluntary participation. Voluntary participation corresponds to such personal motives as as obtaining professional knowledge, professional mobility and similar. Obligatory participation includes such reasons as confirmation of qualifications, membership required due Changing Societies & Personalities, 2020, Vol. 4, No. 2, pp. 190–204 195 to one’s senior position. There are also objective and subjective reasons: the former include, for example, absence of a professional association in one’s region or one’s lack of awareness of such associations. Subjective reasons may vary: for example, professional agnosticism is characteristic of non-members and correlates with an active attitude and skepticism about professional associations’ efficiency; personal indifference is also characteristic of non-members but is based on a passive attitude and the lack of personal interest. We have also used the following 4-point awareness scale: from “0” denoting a complete lack of awareness to “3” corresponding to full “insider” knowledge of a professional association’s activities (for members). Our respondents were divided into two subgroups corresponding to their participation or non-participation in a professional association. The reasons that influenced their opinions of professional associations could be objective or subjective, which, in their turn, were related to active researchers identified the main reasons that influenced the assessment of professional associations by informants. These reasons are most commonly determined by objective or subjective factors, which in turn is associated with the active or passive position of the respondents themselves. Positions of activity or passivity are expressed in certain personal practices in relation to professional associations, and depend on the level of awareness of nurses. This study complies with ethical requirements for high-quality sociological methods. All potential respondents received verbal and written information about the research being conducted; voluntary participation in the study was emphasized. In addition, confidentiality was kept; in particular, all names were removed from the transcripts of the interview; the interviews got their identification numbers. The results are presented in such a way that it is impossible to identify participants by their specific statements. Audio recordings and transcripts of interviews are available only to the researchers. Results The length of an interview ranged from 37 to 49 minutes, with the average length of 42 minutes. In total, we identified five main topics, two of them for the first subgroup and three for the second subgroup (Table 2). Table 2. Key Interview Topics Topics for discussion for the first subgroup (1) Reasons (factors) for non-membership (2) Awareness of the activities of medical associations Topics for discussion for the second subgroup (1) Reasons (factors) for membership (2) The role of professional associations in the nurses’ work (3) Assessment of the nurses’ interest in the activities of a professional association (obligatory or voluntary membership) Response Analysis of the First Subgroup (Non-Members) 1. Reasons for non-membership in a professional association In this section, we are going to discuss the factors and conditions that influence nurses’ decision not to join a professional association. https://changing-sp.com/ 196 Natalia A. Akimova, Elena N. Medvedeva The first reason cited by our respondents was the lack of personal professional need or interest: Well, I heard something about it but somehow I never got around to looking into this topic properly (nurse working in TB care, 33 y.o., 9 years of experience). Another reason behind unwillingness of some Russian nurses to join professional associations was the relatively short history of such associations in Russia or their absence in some regions: Because it has just appeared, and the organization has not yet recruited members (nurse working at hospital reception, 38 y.o., 15 years of experience). The third factor is our respondents’ skepticism about the efficiency of professional association and its inability to help their members to achieve their personal professional goals: I do not see any prospects for myself in the future. (...) I can’t say that my colleagues are happy with their work. Many of them have already left associations, some are only planning since they’ve received nothing. It is only annual membership fees and empty talks (nurse working in TB care, 44 y.o., 22 years of experience). 2. Nurses’ awareness of the activities of medical associations In general, when being asked about the nature of the activities of professional medical associations, many respondents demonstrated either a total lack of awareness or only a superficial knowledge thereof. Some nurses pointed out that professional associations fail to meet their expectations regarding the functions such organizations should perform: Creating opportunities for development of the medical staff; organization of training and conferences; assistance in professional growth (nurse working at hospital reception, 38 y.o., 15 years of experience); Yes, of course, they greatly facilitate the solution of many problems and tasks that medical personnel face in their professional activities. ... Professional associations in my town do not provide support for their members (nurse working in TB care, 44 y.o., 22 years of experience). Response Analysis of the Second Subgroup (Members) 1. Reasons for membership in a professional association On average, those nurses who answered affirmatively to the question about their membership in a professional association have been affiliated with various regional associations for 3–6 years. The main reasons for membership include access to knowledge; confirmation of their qualifications and professional skills; and upward professional mobility. Such factors as protection and development of nursing in the region were cited much less frequently: Changing Societies & Personalities, 2020, Vol. 4, No. 2, pp. 190–204 197 To pass the accreditation at work, you need to score a certain number of points. Participation in activities of a professional association contribute to the accumulation of points for promotion or serve as confirmation of qualifications (chief nurse of a private multi-purpose clinic, 47 y.o., 25 years of experience); The main reasons are the opportunities for professional development, for obtaining new information (...) for gaining practical knowledge. They hold various conferences at the regional level, there are online conferences, training seminars, which is very useful and relevant. They also support participation in professional contests (...), and they share their first-hand knowledge. (...) And membership fees (...) are spent on the development of nursing in this region; they also help in difficult life situations, in conflict situations directly with the employer who provides protection (senior nurse of the physiotherapy department, 53 y.o., 32 years of experience). It should be noted that some respondents indicated that for some nurses their membership in professional association was more an obligation rather than a voluntary impulse. For senior and chief nurses, membership in a professional association is determined by their job responsibilities and status: In our area, all chief nurses are members of the association (chief nurse of a private clinic, 56 y.o., 37 years of experience). Nurses noted that in practice, what professional associations offered was in line with their personal expectations. Those respondents for whom confirmation of their qualifications was an important factor pointed out that their membership in a professional organization helped them raise their social status: I guess, yes. They have a charter, everything is spelled out, what are the pros and cons. It is also publicly available. In our country, the head of this association is the chief nurse of the region (...), there are very competent people who can give advice, if something is not clear, discuss some orders, or something else, that is, from the professional point of view, they support you very well (senior nurse of a physiotherapy unit, 53 y.o., 32 years of experience). 2. The role of professional associations in nurses’ daily practices Nurses’ decision to join a professional association often depends on their opinions about the role such associations play in everyday life of the professional nursing community, including the lives of respondents themselves. Nurses pay attention to such functions of professional associations as training and exchange of experience, support in professional growth, communication platform, and, in some cases, financial support: They gather us every month, conduct training in different fields, talk about innovations in medical education. They also congratulate us on professional holidays. They also hold large educational events, a lot of people come there: students, doctors and medical staff, but this happens just several times a year. https://changing-sp.com/ 198 Natalia A. Akimova, Elena N. Medvedeva They gather chief nurses for conferences on a monthly basis (chief nurse of a private clinic, 56 y.o., 37 years of experience). All respondents in this group agreed that professional associations not only contributed to their personal success but also to the general prestige of the profession: Yes, professional contests prove it. (...) But then again, if you are constantly advancing in your profession, only [then] the association can help you with something, promote and support you (senior nurse working in intensive care, 45 y.o., 25 years of experience). Respondents, however, also observed that in their daily work they did not face the need to contact a professional association in order to protect the rights of workers: No, we didn’t have it; there was no need to contact the association (nurse working in a laboratory, 27 y.o., 7 years of experience). 3. Nurses’ interest in activities of a professional association A sign of respondents’ interest in the activities of professional associations can be their willingness to participate in the events organized by such associations. Our respondents mentioned that they took part in scientific, educational and qualification activities that raised their status in the profession. In other words, respondents of the second subgroup, considered membership in a professional association as an essential practical component of their work: Yes, I take part in such events. For example, (...) the annual conference ‘Sanitary Autumn’, it is held both for doctors and nurses. There are different sections there, and I participate in it every year (senior nurse of a physiotherapy unit, 53 y.o., 32 years of experience). All nurses of this subgroup answered affirmatively to the question about membership, explaining this by the need for continuing education, obtaining relevant medical information and professional development: The association is very active in organizing events, contests, and it provides information, so it has a developed structure (senior nurse working in intensive care, 45 y.o., 25 years of experience). Some respondents pointed out the importance of leadership skills in raising nurses’ awareness of the activities of professional associations. In some regional offices, apart from the members who were obliged to participate as a part of their duties as a senior or head nurse, there were also active members who participated on their own accord: You know, some people say: ‘Where is my money? I don’t see what I get in return’, but that doesn’t mean that everyone is like that. (...) You understand, leadership qualities are needed here, that’s how one gets by in this profession. (...) Personnel, nurse leaders who can show by personal example what is really necessary at this stage. (...) It’s not only the head nurses that are members, no. Changing Societies & Personalities, 2020, Vol. 4, No. 2, pp. 190–204 199 So, in 2014, I invited 60 people, I have their applications. We just need to speak more about it, the information should be accessible to people (chief nurse of a multi-purpose private clinic, 47 y.o., 25 years of experience). Discussion and Conclusions The lack of nursing associations in many Russian regions is connected with the paradoxical situation in the country’s health care management. On the one hand, the existence of public associations and their active work in Russia shows the professional community’s desire to transition to the public management model in the healthcare sector; on the other hand, the above-mentioned management model is a relatively new phenomenon in this country. The Federal Law of the Russian Federation No. 315-FZ “O samoreguliruemyh organizacijah” [“On Self-Regulatory Organizations”] was adopted only in 2007. According to this law, a self-regulatory organization can develop and adopt standards and rules for professional activity, disciplinary measures, business ethics, that is, requirements for all members of this organization. The RNA’s Charter published on the association’s website makes a reference to this law (Russian Nurses Association [RNA], 2008, Clause 1.5). Thus, membership in a professional nursing association entails acknowledgement of the norms and rules stipulated by the Law and the Charter and thereby the consent to comply with them. The latter indicates a specialist’s willingness to take responsibility. The structure of regional nursing associations in Russia is extremely diverse: in some regions, this function is performed by associations of medical workers, in others – by regional branches of national public organizations, and in some regions there no professional associations at all. It should be noted that not all Russian regions have branches of medical and other professional organizations (Ivanova, 2013). Thus, even those nurses who are willing to join a professional organization may be not able to do so. Other factors preventing nurses from joining professional organizations are the lack of interest or motivation as well as the lack of awareness of the activities and functions of such organizations. According to L. Rapp and P. Collins (1999), the lack of information about the goals and objectives of an association as well as the practical benefits of membership were often mentioned by nurses as important reasons for their decision not to join. Thus, broader information support in regions can be recommended as one of the strategies for attracting members into professional organizations. Studying the problem of membership in professional nursing organizations in Iran, M. Esmaeili et al. (2013) found out that the lack of motivation was one of the reasons for refusing membership as people didn’t consider the organization’s performance as efficient. Other reasons included the general lack of interest in profession and negative publicity of professional nursing organizations (Esmaeili, et al., 2013). The factors contributing to the popularity of professional nurses associations can be quite diverse: starting from the formal obligations (chief and senior nurses are expected to be members of such organizations) and ending with personal interest and commitment to the organization’s goals and mission. The need for https://changing-sp.com/ 200 Natalia A. Akimova, Elena N. Medvedeva certification and the support of nursing managers can be indicative of a rather formal and passive attitude of the respondents to membership. These factors, however, can play a serious role in people’s decision to join an organization or leave it: a study of professional nurses communities in Kuwait has shown that people’s decisions were often influenced by the policies initiated by senior managers of nurses in their workplaces (Alotaibi, 2007). The Order of the Ministry of Health of the Russian Federation No. 240n of April 23, 2013 “O poryadke i srokah prohozhdeniya medicinskimi rabotnikami i farmacevticheskimi rabotnikami attestacii dlya polucheniya kvalifikacionnoj kategorii” [“On the Procedure and Dates of Certification for Medical and Pharmaceutical Workers for a Qualification Category”] specifies the evaluation criteria, which include participation in the work of a scientific society and professional association (Par. 24). Thus, nurses may decide to join a professional organization in order to improve their qualifications and pass the certification. The same Order states that the expert group’s report should include the assessment of the specialist’s theoretical knowledge and practical skills necessary to assign the declared qualification category, including knowledge of modern diagnostic and treatment methods, participation in the work of a scientific community and professional association; publications (Par. 24, Section III of the Order). The Order was amended in 2019 and it now specifies that the appointment of the chairman of a territorial certification committee should be agreed upon with a medical professional non-profit organization. Thus, the RNA is directly involved in the process of nurses’ certification. As active members of professional associations, nurses pay particular attention to professional development programs, prospects related to continuing professional education and the benefits of social interaction with other members of the organization. Membership in professional organizations provides opportunities for professional growth, for obtaining advanced training, exchanging new ideas and knowledge, learning about advanced achievements of medical science, and professional socialization. Professional organizations enable nurses to develop a sense of identity with their professional community. Indeed, real career prospects, opportunities for improving the qualification and skills contribute to the prestige of the profession in society – the latter, in turn, can affect the change in the public perception of the nursing profession and help retain the nursing staff. In many countries, membership in professional organizations is associated with the protection of workplace rights. Such organizations assist nurses in demanding a pay increase, the reduction of working hours, improvement of the working conditions. They also promote professional independence, organize leisure activities, and arrange meetings with government officials and prominent public figures to express their professional concerns and legislative initiatives. Despite the fact that the RNA Charter mentions the protection of the rights and legitimate interests of medical personnel with secondary special and higher education specializing in nursing among its goals, there is no established practice of applying to public associations for protection of employees’ rights in Russia. The development and discussion of professional standards is the main area related to the support of labor rights Changing Societies & Personalities, 2020, Vol. 4, No. 2, pp. 190–204 201 of medical personnel by professional associations. Our respondents noted that they were not aware of the cases when their colleagues applied to a professional organization for legal assistance or protection. In its 2017 report, the RNA indicated the following areas of work: accreditation and development of continuing medical education; scientific and practical activities; public activities to improve public health literacy; development of professional standards; protection of professional interests and international cooperation. Protection of interests is described the following way: In 2017, The Russian Nurses Association conducted a continuous dialogue with the heads of the Ministry of Health of the Russian Federation and the Central Committee of the Trade Union of Health Workers of the Russian Federation concerning nurses and junior personnel salaries (Russian Nurses Association [RNA], 2017). We believe, however, that the legal protection of nurses’ interests provided by this professional association is limited to counselling on certain legal aspects of labor activity. This situation is quite different from the practices of professional organizations in other countries, where members are provided with comprehensive legal protection, including representation in court. The factors determining the decision of nurses concerning their membership in a professional association include objective and subjective factors; the latter correspond to respondents’ active or passive attitude towards the activities of professional associations, regardless of their membership (subgroup of members and subgroup of non-members). Members of professional associations that demonstrate a passive attitude tend to view their membership as an opportunity to confirm their qualifications or as related to their job responsibilities (obligatory participation). Non-members demonstrating a passive attitude usually lack interest in public associations (personal indifference). Members of professional associations with an active attitude generally seek to acquire new knowledge and to improve their status (voluntary participation). Non-members demonstrating an active attitude are quite skeptical about the efficiency of professional associations (professional agnosticism). The awareness of nurses of the functions and nature of work conducted by professional associations in Russia is of great importance. According to our study, nurses’ degree of awareness ranges from the complete lack of knowledge to sufficient “insider” knowledge about the activities of such associations. Based on the answers of some respondents, it can be concluded that the professional associations exist only formally in the territories of certain regions, and they fail to fulfill the stated promises and functions mandatory for self-regulatory organizations. Limitations In this paper, the method of qualitative content analysis is used for interpreting the interview data. 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Akimova, Elena N. Medvedeva Appendix 1 Guide to the semi-structured interview (for respondents who are members of professional associations). 1. Are you a member of a professional association? 2. What professional medical association do you belong to? 3. How long have you been a member of a professional association? 4. What were your reasons for joining a professional association? 5. What were your expectations when joining a professional association? 6. What role does a professional association play in your life? 7. Have there been cases when a professional association managed to protect your rights or the rights of your colleagues? 8. Do professional associations help to enhance the prestige of nursing as a profession? 9. Have you participated in any events organized by a professional association? 10. Do you plan to renew your membership in a professional association in the future? Why or why not?