Associativism in nursing, public communication, and interaction with the media

Objective: To describe the processes of producing messages and interacting with the media by professional nursing associations. Methods: Qualitative, descriptive study based on semi-structured interviews with managers of five professional nursing associations in Portugal. The data were subjected to thematic content analysis. Results: Regulatory and union associations use public relations services and refer more strategies for interacting with journalists. Professional specialization associations interact less frequently and prefer social media for publishing their messages. Voluntary work and the reduced professionalization of the communication of specialized associations favors a nursing retraction stance towards the media. Final considerations: Organizational and cultural factors may help to explain nursing’s limited access to the media. The use of renewal, cooperation, and education strategies will help overcome some of the limitations experienced by these associations.


INTRODUCTION
Nurses and the care they conceive are essential elements of health systems. These professionals "play a central role in restoring people's health, but also in preventing diseases and maximizing the potential for a healthy living in all places and whenever possible" (1) . Even so, the importance of the profession to society is not always understood or recognized: a systematic review (2) identified the themes "nursing is represented in the media as a problematic profession", "the devaluation of nursing has an entertainment value", "the existing incongruity that is manifested by the fact that the population trusts nurses but does not respect them", and "the public's reduced understanding of nurses' professional roles". The scarce media coverage and focused on the problems of the profession may contribute to society's lack of knowledge towards it, having a negative impact on public opinion, in the choice of nursing as a professional career, in the funding of nursing education and research, in violence against nurses, in working conditions, and in the definition of health policies (3)(4)(5) .
As a space of excellence for civic and political participation (6) , professional nursing associations (PNAs) can provide opportunities for interaction with the media and target audiences. Since statements on behalf of a group are seen by journalists as more credible than individual statements (7) , associations will be able to access the media more easily and contribute to the discussion of nursing in the public space. Having access to the media and obtaining favorable coverage becomes increasingly important: it is an important source of health information for the public and influences their behavior and health decisions (8) ; nurses contribute to citizens' health literacy, and the media is an excellent vehicle for reaching a wider audience (9) ; the unique perspective of the health sector could enrich the news pieces and contribute to the plurality of information sources (10) ; media narratives on the nursing profession influence public opinion, sector policies, and regulatory related issues (5,11) .
Social movements and media theories (12)(13)(14)(15) can help understand the mechanisms underlying the relationship between nursing associations and the media. It is assumed that both social movements (e.g., non-governmental organizations) and PNAs need access to the media to achieve some of their objectives: in the case of PNAs, it may be about defending universal health coverage, support for patient groups, or professional regulation.
PNA's access the media to obtain media attention, defined as the amount and size of coverage given to an event, person, or organization (12) . In addition to media attention, it is intended to increase the importance of the association in the eyes of journalists and the public (standing) and obtain a favorable framing (preferred framing) of messages to be communicated (12) . Research produced in recent years have revealed: the scarce media coverage of the profession, with nurses being news sources in 1.5% to 6.6% of the total published health related news (7,(16)(17)(18) ; the media discourse tending to be negative, focusing on work problems, the shortage of nurses, and scandals in the profession (5,11,16,19) ; the reduced frequency of nurses' interaction with mass media (20) ; the existence of limited resources (reduced number of members and funding), the lack of formal communication structures, such as communication offices or spokespersons trained to interact with the media; and the spread of a discourse centered on professionals and little directed at citizens (21) .
However, the construction of news is not limited to the efforts of associations to gain access to the media, nor is it exhausted in the relationship between sources and journalists. There is a hierarchy of influences on news content: social systems and ideology, formal institutions, media companies, the socialization and attitudes of journalists and editors are fundamental to the creation of the final product, the news (15) . These factors contribute to the definition of the problems (framing), the selection of themes, and the publication or not of the contents.
In Portugal, it is unknown how the growth of PNAs has influenced their strategic communication structures and information about the process of building messages for media coverage, the strategies used by associations to interact with the media and the use of digital communication platforms is lacking. The understanding of these dynamics by the PNAs may help to explain the reduced media coverage of the profession and to find balanced and feasible solutions.

OBJECTIVE
To describe the processes of producing messages and interacting with the media by professional nursing associations, considering their characteristics.

Ethical aspects
This research was approved by the Ethics Committee of the Unidade Investigação em Ciências da Saúde: Enfermagem (UICISA: E) [Research Unit in Health Sciences: Nursing] of the Nursing School of Coimbra, Portugal. Participants were informed about the study and its objectives, as well as the voluntary nature of participation.

Type of study
Qualitative, descriptive study based on the theories of social movements and the media (12)(13)(14)(15) . To guarantee methodological rigor, the COREQ checklist (22) of 32 items was adopted.

Study scenario
The study was carried out in continental Portugal and the Islands (Madeira and Azores). Participating organizations represent members from across the country.

Data source
Of the 11 associations participating in the first phase of the research (21) , those that had interacted frequently with the media were selected. Of the six associations representing different areas (professional regulation, defense of labor rights, and professional specialization), five agreed to participate. The inclusion criteria were to be a professional nursing association and to frequently interact with the media (according to the data collected in the first phase of the research). Each association appointed a member of the board to be interviewed.

Data collection and organization
Data were collected in October 2018, through face-to-face interviews or via Skype, with an average duration of 60 minutes. Invitations were delivered via e-mail, and each participant validated the informed consent detailing the objectives of the study, the methods of data collection, and the ethical and formal precepts. The interviews were conducted by the researcher in a private place, to guarantee the privacy of the participants and the confidentiality of the information. A semi-structured interview script was used based on five themes: association and nursing, health themes, the process of building messages, interaction with the media, online platforms, and the future of communication of nursing profession. The audio was recorded and transcribed in full. A transcript was corrected by one of the participants due to audio problems.

Data analysis
The data were treated using the thematic content analysis of a deductive type. To respond to the objectives of this study, an unconstrained matrix of analysis was created, which consisted of the previous definition of main categories; and, in a second phase, in the open coding of text segments and grouping those segments into subcategories (23) . This technique is adapted to the studied object (public communication practices of the PNAs) and the scarcity of knowledge pertaining to it: on the one hand, the theories of social movements and the media were the foundation for the construction of a priori categories; on the other, it was possible to explore the reality of nursing associations and adapt the findings to the referred categories. The coding and categorization processes were analyzed and validated by two researchers, with units of meaning and subcategories established after discussion and consensus between them. For data analysis, the Nvivo® 12 program was used.

RESULTS
Five PNA leaders from Portugal were interviewed, on the categories of regulation, unionism, and professional specialization. Their testimonies will be identified with the letter A (association) and a number from 1 to 5, corresponding to the initial coding process. A matrix was established with three main categories (Chart 1), whose nomenclature was later refined: "Associativism determinants in public communication", "Production of content between amateurism and professionalism", and "Interaction marked by mutual constraints".
The first category includes the subcategories: "Nature of PNAs", "Recruitment and retention of members", and "Barriers to associative participation". As for the "Nature of PNAs", most were created in the 1980s with the objective of defending the interests of nurses, regulating professional activity, and for adopting best practices that already existed in other European countries. All defend that their mission is current and important for the profession, however, the associations linked to professional specialization manifest some loss of meaning and consequent decline after the career legislation and the creation of the Board of Nursing. Three of the five associations reveal limitations in funding, which affects the number and type of activities carried out, and the absence of remunerated members. The non-remuneration of members of the association prevents professionalization: In professional specialization PNAs, work is based on volunteering and a small number of members who assume almost all the tasks. To this fact, the low rate of effective participation is added: We need that the partners, in addition to being passive partners, would be active partners, so that they could contribute with their knowledge, with their experience. (A1) Another aspect refers to the high productivity that contrasts with the reduced diffusion to society: …eventually, our goal is more doing than properly disseminating what we do and, therefore, dissemination is not really part of our reality. (A5) Finally, the participants classify the associativism in nursing as still not being mature, and one of the associations emphasizes the lack of network organization: …There are a lot of good-willed people, we lack some organization from an associativism point of view.
[…] A simple example, the website, which costs money and could be capitalized if we were partnering with other associations, […] a series of activities that we could do in association. (A5) The subcategory "Recruitment and retention of members" prevailed within the participants' discourse. Nurses identify with their associations and resort to them to clarify doubts. However, recruitment difficulties remain: the conditions offered to members differ little from those of non-members, and they end up having the same access to information (some associations refuse to prohibit access to non-members); many nurses do not pay dues, as they do not see benefits that justify this investment; associations are seen as service providers that can be discarded at any given time. The scarcity of recruitment strategies on the part of some associations and the loss of associative meaning are mentioned as causes: Finally, according to A4, a predominant individualism, which permeates today's societies, prevents the strengthening of associative movements: … we cannot speak of this without speaking of a society in which we are living, in which people look more after themselves than at the collective. (A4) Several "barriers to associative participation" are indicated by the participants. The competition between daily work and the activities of the association leads the participants to complain about lack of time, which slows down the processes and prevents the response in a timely manner. On the members' side, the lack of information, lack of motivation, and personal priorities constitute barriers to associative participation.
The category "Production of content between amateurism and professionalism" have as subcategories: "Message building process" and "Dissemination and sharing of content". All associations have similar mechanisms for creating messages to be publicly disseminated: it is often management members who participate in the creation process, and it is mandatory that all messages be validated by the board before their dissemination. Strong collaboration is noted with the communications office, when the latter exists. To carry out activities that involve the population, build the association's themes and events based on the news values, work on titling so that they become more appealing, send informational materials that complement the article and build news texts that aim at the minimum changes on the part of journalists were the strategies most mentioned by the associations to capture the attention of the media. In the subcategory "Dissemination and content sharing", the participants highlight certain values in the communication process, such as honesty, modesty, silence, and avoiding confrontations. Some associations even impose limits on external communication: …we limit ourselves a little to this, we limit ourselves on the website, Facebook, Twitter, these networks, the mails, this is usually how it works. (A1) Still, three PNAs say they can communicate the topics they wish with relative ease. When asked about the most mediatized themes, the union and regulatory associations indicated those related to the profession, such as safe staffing, nursing careers, or lack of working conditions. The themes of the specialty associations tended to focus on the needs and problems of citizens, such as access to public buildings, the promotion of health literacy, and infection control.
Although seldom, participants resort to various strategies to minimize the risk of misrepresentation of messages: they limit the information given during interviews, ask for questions beforehand, ask to see the news immediately before its publication, and contact journalists to provide feedback on the news they wrote. Spokespersons are selected according to criteria of clinical competence and previous experience in interviews (on television, radio, live interviews...) and feeling at ease when facing the camera. Some participants value prior experience more than training in public communication: The hiring of public relations (PR) services proved to be extremely positive for professional specialization associations: ...I remember that they made good use of and knew how to take advantage of the news and what we did and that we, for example, did not value as news, and they were able to tell us "this is news, this makes interesting news". (A1) Still, the limited availability of the managers generated feelings of frustration and ambiguity with the public communication: if on the one hand they recognize the importance of the work done by PR companies, on the other hand they indicate that these services are expensive and feel less pressured if they have less media exposure.

We run away from it, sometimes… because we don't have time to always be doing these things. (A2)
An PNA states that the professionalization of the association's external communication facilitated the dissemination of messages: The lack of training and structures that enhance public communication were the barriers most frequently reported by four participants: …we never had training, we learned to communicate with our patients, we learned to communicate with our peers, […] but to effectively communicate with large audiences like this, no, we have no training in this area… (A1) Social media platforms occupy an increasingly important position in the communication strategy of associations, which point to accessibility, articulation between platforms, diversification of audiences, low cost, and ease of use as strengths. Two participants expressed concerns about the improper use of social media publications by third parties and about the illusion of active participation created by these networks.
The last category includes the subcategories: "Journalists who have an interest, but limited resources" and "Nurses with little availability to communicate with journalists". Journalists are interested in nursing issues. All associations reported that journalists value content related to the profession: Participants highlight several constraints that influence the publishing of the news: the limited space in written publications, the tight deadlines, the reduction in the size of newsrooms, the decrease in the number of journalists specialized in health, and the increase in the number of interns who do not master this topic. In the subcategory "Nurses with little availability to communicate with journalists" and according to two associations, nurses -individually -do not present themselves as available for approaching the media: The reference of a distrust of nurses in the media and their methods, some healthcare institutions' restrictive communication regulations, and the lack of knowledge about how to approach journalists are some of the factors pointed out for the reduced interaction between nurses and the media. The nurses' attitude is a paradox: …and although it is also one of the complaints that we hear a lot from nurses, that the nursing situation is not well characterized in terms of mass media, the truth is that, afterwards, when they are asked to make themselves available for this purpose, most of them don't want to do it. (A4) Regulatory and union associations were the only ones to indicate strategies for approaching the media: priority in contacting journalists specialized in health, providing exclusive interviews to a particular journalist, always being available to make statements, and always speaking the truth to maintain credibility and legitimacy. Participants in this study indicate that public communication could have a major impact on the social representation of the profession, as well as on the ability to improve health literacy among the population: …if we organize ourselves in nursing to communicate with the population in a better way, we are contributing to making people healthier. (A5) They add that the responsibility for communicating lies with the nurses themselves and that it is non-transferable:

DISCUSSION
Four participating associations have a small number of members and an even smaller number of active members, characteristics that are similar to the majority of Portuguese associative movements in recent years (24) . The low adherence to professional specialized PNAs can be explained, among other reasons, by the small number of specialized nurses in the country (25) . The small size and financial limitations can have a negative influence on health policies (26) and on the communication of the work done by movements and associations (14) : productivity is prioritized, and communication is relegated to the background.
The weakening of nursing associativism, mentioned by the participants, is a phenomenon common to several countries (27)(28) and is related to the decline in civic participation and the withdrawal of citizens from political life (6,25,29) . Olson's theory of exchange states that if individuals do not perceive the benefits of belonging to an association as being greater than the costs, they will not join them (26) . The Civic Voluntarism Model (30) points out three factors that influence the civic participation of nurses: motivation (political interest, information, and self-efficacy), resources (financial, time, and civic skills), and recruitment networks (mobilizing effect). The results of this research are in line with the aforementioned model and theory, with participants indicating the lack of information, personal priorities, and the existence of fees as the main barriers to associative participation. The fact that the exclusive contents of some associations are shared with all nurses, regardless of their membership, and the tendency to promote few membership campaigns can influence the recruitment and retention of members.
The financial limitations of some of these associations affect the number of activities and the (in)existence of remuneration for the work developed in favor of the association (21) . Some PNA leaders expressed their embarrassment at the possibility of being paid for the associative work they carry out, which may suggest the internalization and normalization of the voluntary work. However, they recognized that, if the work were paid, it would be easier to attract more "talents" to the association. The remuneration for associative functions seems to be important, as social movements that depend exclusively on voluntary work have less media coverage than those that remunerate their members (13) .
In this research, PNAs with regulation and unionism purposes had more resources than those of professional specialization and collaborated with PR professionals in the creation of their messages. Perhaps the result of collaboration, the PNAs with competence in regulation and unionism indicated most of the strategies used to make the messages more attractive to the media. Another difference was found in the mediatized themes: the news from the associations of regulation and unionism often covered the difficulties experienced by nurses and "conflict" and "scandal" (denunciation of poor working conditions, unsafe staffing, and strikes) were framed as news values, while the professional specialization PNAs published news about ordinary citizens' problems and solutions provided by nurses. This study adds clues that may help explain the fact that the media coverage of the profession focuses on the professionals' problems, instead of focusing on nurses' responses to people's needs (16,21) . In addition to the growing opposition of nurses to some health policies, widely reported in the media, there are other factors to consider: the fact that the regulatory and unionism PNAs speak publicly more frequently and have professional communication offices allow these themes 8 of Associativism in nursing, public communication, and interaction with the media Cardoso R, Zamith F, Graveto J.
to be mediatized more often; journalists prefer the controversy over the message conveyed by organizations (31) . A transversal characteristic of all the PNAs was the use of social media platforms as a preferred means of communication. The low cost, speed, and ease of use that they provide help to alleviate the limitations previously described, ensuring communication between PNAs and their audiences. The growth of the internet has diversified the communication channels through which movements and associations reach their audiences and transformed the relationship with journalists (32) . The use of social media platforms makes it possible to bypass the media (2,32) and, consequently, reach the target audiences directly. The most used by the PNAs is Facebook, followed by Twitter. In two studies with samples composed of Portuguese representative of the continent and islands, around 69% (n = 1,035) read press news on Facebook (33) and 53.6% (n = 1,018) used the internet to consult newspapers and magazines (34) . Associations should be aware that, despite the undeniable advantages of the internet, 39.5% of Portuguese currently do not access it regularly and television remains the favorite medium for watching the news (34) . If associations base their strategy on an almost exclusive online presence, they risk not reaching a part of their target audiences.
The experience of interacting with journalists is described as positive. Participants state that journalists are interested in nursing topics and can communicate their messages with relative ease. These findings partially differ from the conclusions of other studies, which justify the reduced news coverage of the profession with journalists' lack of knowledge about the career and role of nurses in the health system (10,(35)(36) . Evidence of this is found in a study, carried out in the United States of America, in which ten health journalists were interviewed about the use of nurses as news sources: biases and beliefs about women, nurses, and hierarchies were identified in the health system by journalists, editors, and PR professionals (10) .
This lack of knowledge is reflected in the mediatization that is given to the profession: if nurses are news sources for the profession, the same cannot be said about management issues and health policy, in which they are actively ignored (18) . They must be heard, as they are aware of the impact of health policies on people's health, and their unique experience can enrich the news pieces (10) . The difficulties experienced by journalists when contacting nurses, lead them to interact more frequently with official sources, who are familiar with the logic of news production (7,37) . If PNAs do not professionalize their public communication, they may have fewer opportunities to be chosen as news sources.
The paradox experienced by the participants coincides with a study that identified a low frequency of interaction between nurses and the media (average of 6.24 points on a scale of 92 points) (20) . Some PNA leaders are suspicious of the media and their methods and recognize that they could play a more active role in this interaction. This distrust may be related to fears of being misquoted and being asked about topics outside their sphere of knowledge (36) . Some values that guide the external communication of associations -modesty, silence, and avoiding confrontations -may be related to the culturally imposed silence that is still present in some contexts of the profession (4) . The factors previously mentioned seem to have a common origin: the scarce education of nurses in public communication.
There are renewal strategies that allow to overcome some of the difficulties observed in this study. Associations that specialize in a given topic become experts and increase the likelihood of being called on by journalists to make statements (15) . Specialization in restricted topics optimizes resources and can generate opportunities for paid work (preparation of studies commissioned by official entities) and, consequently, contribute to the recruitment and retention of members. To professionalize communications will allow PNAs to adapt to news production routines and become indispensable news sources (15) . Cooperation can take place at several levels: by PNAs among themselves, by PNAs with patient associations and with educational institutions. As mentioned by one of the participants, PNAs with fewer resources could organize themselves in a network and share the costs inherent to a communications office or PR services. Collaborating with official entities and combining the association's agenda with the media agenda of these entities may increase the opportunities for mediatization of PNA themes (13) . Creating cooperation protocols between PNAs and higher education institutions in social communication will promote knowledge sharing and mutual growth.
Barriers to interaction with journalists can only be eliminated through media education and training (18) . PNAs could provide opportunities for continuing education to their members in areas such as health policy, civic participation, and public communication (26) ; and as a complement to the training provided by nursing schools (10) . Likewise, they could provide and promote training courses for journalists interested in learning about professional roles and research carried out by nurses (18) .

Study limitations
This research has some limitations, so caution is advised when interpreting the results: the findings of this study result from the analysis of Nursing in Portugal at the end of 2018, which may differ from other countries or historical periods; the number of participating associations can be considered small (of the 11 PNAs that participated in the preceding research phase, the 6 that reported interacting with the media more frequently were selected), which is why the findings may not fully reflect reality; an approximation between social movements and PNAs is established, which, although uncommon, proved important for exploring the theoretical bases and concepts of access to the media and media coverage.

Contributions to the nursing field
This study allows us to understand some strengths and weaknesses of Portuguese PNAs in the field of public communications and, therefore, to appeal to the profession's reflection on this theme as well as on the consequences of limited media interaction in the future of the profession. Public communication education is pointed out as an elementary condition to improve nurses' access to the media and increase nursing media coverage. Strategies for improving PNAs are presented, which could be adopted by nursing organizations in different locations around the world, in line with the specificities and cultural context of each country. 8 of