Analyzing Recognition of Clinical Nurses Health Care using Q-methodology

Analyzing Recognition of Clinical Nurses Health Care using Q-methodology Mihye Kim Department of Nursing, Hanyang University - Seoul Hospital, Wangsimniro, Seongdong-gu, Seoul 133-792, South Korea. E-mail: nurmi@hyumc.com Yeon ja Kim Department of Nursing, Dongseo University, 47, Jurye-ro, Sasang-gu, Busan 617-716, South Korea. E-mail: yakop1052@gdsu.dongseo.ac.kr Abstract In this study, PC-QUANL Program was used for data analysis as exploratory research applying Q method to investigate recognition types on health management of clinical nurse. As result of the research, 5 types with unique features were found. Among a total of 40 subjects, 11 subjects were included in type 1, 12 subjects were included in type 2, 4 subjects were included in type 3, 9 subjects were included in type 4, and 9 subjects were included in type 5. According to characteristics of each type, they were named as mind control type, family centered type, timid stress relieving type, continuous effort type, and development oriented type. We suggest to use this study s resultto develop arbitration program of clinical nurses health care and verify a effectiveness. Keywords: Clinical Nurse, Health Management, Q-methodology Introduction Necessity: Nurse is a profession which gives take-care nursing to recipient who have problem on health. Nurses should keep the best physical condition and role as a health model but they have to constantly check patient s condition 24 hours and to provide adequate nursing, they are shift working which causes insomnia, lack of sleep, digestive problems, depressions (1). Especially, lack of sleep caused by working a night shift makes concentration and work accuracy lower and increase fatigue during daytime which finally leads to negative effect on work (1, 2, 3, 4). Not only this problem, nurses are required to learn new knowledge, and acquire technology, team work between other type of occupation, and heavy workload affects negatively on their physical, mental health problem. Also they are exposed to harmful environment including contacting with patient and guardian, nosocomial infection which can cause health problem (5, 6). If nurse who have to take care patients with health problem has health problem, they can not get faith from the recipient. This also affects negatively on building healthy life habit. This is why nurse who is performing nursing professional s health care is important (7). Therefore, nurses should change their action to increase their physical condition and should aim to increase quality of nursing patients. This will make them to be recipient s promotion of health acting role model (8). The nurses recognition toward health care varies between nurses and shows difference according to subjective perception degree. So, attitude toward subjective health care should use Q-methodology which measures subjectivity operant process not by operational definition. Purpose of the study: This study is to patternize clinical nurses recognition toward health care and understand characteristics of the types. The definite objective is the following. 1) Figuring out types of clinical nurses recognition toward health care. 2) Analyze and describe characteristics of clinical nurses recognition toward health care by type Methodology Design: This study is a probe study using Q-methodology to figure out subjective structure of clinical nurses recognition toward health care. Composition of Q Parent Population and Q Sample: Q-Population is a aggregate of items collected for Q study, can be collected by literature review related with the study subject and by interview with participants. In this study, to extract statements related to perception of health care, interviewed ten nurses working in H university hospital in S city from March 1st 2015 to March 31st 2015 targeting clinical nurses. Also, this study extracted 130 Q Population by literature review and counseled to one nursing science professor and two clinical specialist to verify validity during categorizing statements. After counseling, we exchanged opinions and readjusted and selected final 34 Q-Sample. We built open questions by studying advanced research related with clinical nurses health care and literature review about internal and external specialty publications. The questions include How do you think about your physical condition, Have you felt abnormal symptom on your body 1142

last one year?, Do you feel rewarding and pleasure related to your work?, What did you do to feel pleasure about your work?. Sampling of P-Sample: P-Sample is respondents participating in Q-Sorting, and does not infer P-Population s characteristics from P-Sample s personal characteristics or difference but how respondent structure Q-Samples statements. Which means, selecting a P-Sample does not follow stochastic sampling method and sample counts are not big. Therefore, P-Samples are random sampled 40 clinical nurses based on small sample theory. Q-Sorting: Q-Sorting is each recipient selected as P-Sample modeling their attitude toward the study subject. In this study, 40 clinical nurses selected as P-Sample have to read thoroughly 34 statements chosen as Q-Sample and measure their opinion in 9 point scale. Firstly scale is divided in to three parts, agree (+), neutral (0), and disagree (-). Nextly, P-Samlples are to read the statements again and measure points. Strongly agree is scaled 4 points, neutral is scaled 0 points and strongly disagree is scaled -4 points. This away, we prepared the study by following Q-methodology which makes forced distribution to make it close to normal distribution. After Q-Sorting, They are told to choose most positive and most negative two statements in Q-Sample contents and to write the reason why they chose it. Before writing the questionnaire, we asked them intention of study involvement by telling them all-round explanation about study and told them to record general qualities. Then, they are told to classify statements to help them understand the materials. The time took to fill out the questionnaire was 30 to 45 minutes. Data Analysis: After 40 clinical nurses selected a s P-Sample finishes the questionnaire, we collected the data and coded into computer and verified the number on the Q-Sorting distribution chart. Giving 1 point to Strongly disagree(-4 points), -3 points are now 2 points, -2 points are now 3 points, -1 point to 4 points, 0 point to 5 points, 1 point to 6 points, 2 points to 7 points, 3 points to 8 points, 4 points to 9 points (Table 1). We used PC-QUANL Program for material analysis and found out average, standard deviation, standard deviation score of each 34 options. We also used principal component factor analysis (axis P-Sample) to factor analysis. To find out optimum numbers of factor, using Eigen value 1.0 over criterion, we entered various number of factors and chose five types which have representativeness among the calculated results. Table 1: Q-Population Distribution Most Neutral Most Disagree agree Distribution -4-3 -2-1 0 1 2 3 4 Score 1 2 3 4 5 6 7 8 9 Number of statements 2 3 4 5 6 5 4 3 2 Ethical Considerations: This study is agreed by recipients after explaining purpose and method of the study, recording of the interview to guarantee their autonomy, dignity and rights. They were rewarded for participating the study. The contents will be secret, coded, and the computer files will be locked. Only researchers will be given endemic password and no one else will be able to access to the files. Also, after the study is completed, every information will be eternally deleted. We told recipients that every data will be used only for study and the result of the study will be published. They are also told that they can stop participating the study whenever they want to. Results Clinical Nurses Health Care s: After analyzing perception of clinical nurses health care, we found 5 types having distinctive features. We named Mind Control, Family Centered, Timid Stress Relieving, Continuous Effort, and Development Oriented after their features. Among 40 recipients, there were 11 recipients who have type 1. 12 recipients were having type 2, 4 recipients with type 3 type, 5 recipients with type 4, and 4 recipients with type 5. The more weighted factor a recipient have, the more representative the recipient is in each factor. The total variable is 0.4580 which has 45 percent of explanation ability in total variable (Table 2). Table 2: Eigen Value of Aspects and Variant Percentage Aspect #1 Aspect #2 Aspect #3 Aspect #4 Eigen value 8.9605 4.9404 2.3063 2.1144 Variant %.2240.1235.0577.0529 Cumulative frequency.2240.3475.4052.4580 Table 3: P Sample's Demographic Characteristics and Factor Weight by (N) Ⅰ (11) Ⅱ (12) Subjects Factor Age Sex religion Clinical Marital (ID) weight (weight) experience status 12 1.1213 28 Female None 1y Single 26 1.1201 26 Female Protestant 2y8m Single 31 1.1037 22 Female Protestant 4m Single 4 1.0158 24 Female None 2y7m Single 1.9321 54 Female Protestant 31y8m Single 7.9.56 24 Female Protestant 10m Single 40.8664 33 Female Protestant 9y4m Married 30.7236 25 Female None 2y7m Single 39.6731 42 Female Protestant 21y5m Single 22.6422 30 Female Protestant 6m Single 33.3792 25 Female Protestant 2y6m Single 27 2.4620 24 Female None 2y9m Single 17 1.7673 26 Female None 2y11m Single 28 1.1472 24 Female None 3y7m Single 25 1.3383 23 Female Catholic 6m Single 34 1.0264 36 Female Buddhism 15y Married 2.9246 26 Female Protestant 4y6m Single 5.7592 31 Female None 9y6m Married 1143

Ⅲ Ⅳ Ⅴ 15.6378 34 Female None 6y8m Single 13.6325 33 Female None 9y Single 29.5270 35 Female Protestant 11y10m Married 21.5021 25 Female None 3y6m Single 3.3837 26 Female Protestant 4y3m Single 38 1.1466 55 Female Buddhism 20y1m Married 35.7572 50 Female None 26y Single 24.6708 51 Female Protestant 29y Married 10.5480 25 Female None 2y Single 9 1.7336 44 Female None 20y Married 23 1.1227 30 male Protestant 6y2m Single 20 1.0819 25 Female None 2y6m Single 19.7763 24 Female Protestant 2y6m Single 8.7742 37 Female None 15y7m Married 18.7637 23 Female None 2m Single 32.7097 45 Female Protestant 23y8m Married 14.6848 24 Female None 11m Single 6.6182 23 Female Buddhism 8m Single 11.6993 32 Female None 1y8m Single 36.5480 31 Female Protestant 2y Single 37.5197 40 Female None 18y7m Single 16.4138 24 Female Protestant 1m Single Correlations of the different types were of low levels, and it could be deduced that the types were independent of each other (Table 4). Table 4: Coefficient of correlation between different types 1 2 3 4 5 1 1.0 00 2.233 1. 000 3.160.060 1.000 4.600. 361.237 1.000 5.099.486 -.330.261 1.000 Characteristics and Interpretations of the Different s: 1) 1: mind control type When analyzing statement of type 1 with standard deviation score +-1.00 and over, recipient with type 1 recognize importance of health care as a nurse and try to think positively for euphoria, satisfaction and thankful heart. No.12 recipient(weighted factor 1.1213) representing type 1 is 28 years old unmarried woman. According to face-to-face talk statement, she said I feel thankful to live healthy because I am working in intensive care unit., I care my health well as a nurse and I believe this will last longer, I have to take myself well to care more patient so I believe health care is important.. She feels importance of health care of herself and feels thankful and satisfaction seeing patients in intensive care unit. No.26 recipient(weighted factor 1.1201) representing type 1 is 26 years old unmarried living alone. According to face-to-face statement, Every jobs can have stress and mindset to get rid of stress is important, getting stress is not because of jobs but their own problem., When all is said and done, health care is the most important thing., When I get stress, I think this stress will develop me, and when I think this way, stress reduces.. She knows the importance of health care and to be healthy she are trying to keep positive mindset by thinking stress is a nourishment to develop herself. Therefore, we named type 1 a Mind Control (Table 3) (Table 5). 2) 2: Family Centered types and Q-Statement, of type 2 with standard deviation score of +- 1.00 and over, recipients with type 2 are encouraged by family. No.27 recipient(weighted factor 2.4620) is 24 years old single woman. According to the statement, she said When thinking of family, I am encouraged and feel meaning of life., Because of three shift working environment, it is hard to eat high quality diet menu and studying, putting effort to develop myself is a stress., It is smarter to learn ways to cope with stress from nearby people not learning by myself.. We can learn from No.27 recipient that they feel necessity how to cope with stress but they want to learn it from other people, especially they are encouraged by family. No.17 recipient(weighted factor 1.7673) representing type 2 is 26 years old single woman. In the statement, she said What I believe the most is family and when I think of family, I feel encouraged., When I get stress, I get rid of it by talking with colleagues or friends. No.28 recipient(weighted factor 1.1472) representing type 2 is 25 years old single woman. In the statement, she said To get rid of stress, I believe there need to be someone to open myself up and I have that person to do so., I think stress is origin of all illness so it is necessary to learn how to get rid of it.. This recipient knows the necessity of health care and believe someone nearby s support is needed to cope with stress. According to results above, type 2 recipients believe marginal man s support is important to deal with stress than effort of themselves as a main agent. Especially, they think family s support is the most important thing. Therefore we named type 2 Family Centered (Table 3) (Table 5). 3) 3: Timid Stress Relieving types and Q-Statement, of type 3 with standard deviation score of +- 1.00 and over. Recipients with this type try to get rid of stress by themselves but give up if they find out that it is impossible to do so. No.38 recipient (Weighted factor 1.1466) is 55 years old, married woman. In the statement, she said I try hard to live positively being thankful and try hard to keep healthy., I cannot react actively toward stress caused by work.. We can know that this kind of type recognize necessity of health care but being passive. Therefore, we named this type Timid Stress Relieving (Table 3) (Table 5). 4) 4: Continuous Effort types and Q-Statement, of type 4 with standard deviation score of +- 1.00 and over, type 4 think self-development for health care is important, and try harder to be better than 1144

present. The recipients think stress should be get rid by themselves and get proper hobbies. No.9 recipient (Weighted factor 1.7336) representing type 4 is 44 years old, married woman. According to the statement, No matter what occupation, it is important to invest time to self-develop., Living in 100 years period, I need to try hard to live healthy without relying on other people. The recipient says it is important to actively put effort to keep healthy not relying on other people. No.23 recipient (Weighted factor 1.1227) representing type 4 is 30 years old single man. In the face-to-face statement, he said, Spending free time working out is helpful for both stress relieving and physical health., Relying on others can disappoint me one day and if I put my effort to do it myself, I have no fear about anything. If I only sleep saying I am tired, it gives negative effect to me for example, regret about not doing things that have to be done and changed rhythm of life., Even though I feel tired, when I work out and manage diet, in long term, there are more positive effects. He emphasized on continuous effort on health care. Aggregating statement above, type 4 recipients believe health care very important and think that everyone should put effort by themselves. Accordingly, we named type 4, Continuous Effort (Table 3) (Table 5). 5) 5: Development Oriented types and Q-Statement, of type 5 with standard deviation score of +- 1.00 and over, type 5 recipients know the importance of health care and think that they should put effort for self-development but their three shift work is too tiring and feel unable to release energy. No.11 recipient(weighted factor.6993) representing type 5, in the statement, said Nurses have to endeavor not to be behind medical knowledge., Nurses who are faithful to the basics and solve the work assigned to them can be confident., Because the work is too much and busy, sometimes I feel hard to control my mind.. No.36 recipient (Weighted factor.5480) representing type 5 is 31 years old single, stated, Nurses three shift work is too hard. Putting together statements above, type 5 recipients realize that nurses should keep healthy to be health model, they feel it hard because of excessive work according to working environment. They feel physically, mentally exhausted. Consequently, we named type 5, Development Oriented, because they long for continuous self-development but they feel realistic limit to make it on action (Table 3) (Table 5). Table 5: Q statement and Z-score by (N) Q statement z-score 27 Family is power. 1.96 Ⅰ 15 I have a positive way of thinking. 1.72 (11) 25 I am happy with life and feel a sense of 1.38 22 I have someone to whom I can open myself up. 1.32 24 I live a thankful life. 1.24 14 I try to maintain normal weight and walk as much -1.11 as possible. 20 I do not eat foods known to be harmful for health. -1.14 Ⅱ (12) Ⅲ Ⅳ 17 I consider nutritional balance, adjust diet, and try -1.15 to eat quality foods. 28 In three-shift system, health management is -1.38 impossible. 29 For health management, I should quit this nursing -1.52 18 I largely eat home-made foods rather than eating -1.89 4 I have nothing to do with health management. -2.32 27 Family is power. 2.11 22 I have someone to whom I can open myself up. 1.55 11 For health management, I should learn how to 1.51 deal with stress. 2 I can t afford to manage my health because I am 1.34 too tired and hard. 30 In shiftwork situation, if you don t manage your 1.26 health with passion, you will fail. 26 Colleagues or friends are most helpful for 1.03 overcoming stress. 29 For health management, I should quit this nursing 1.02 16 I try to eat regular meals. -1.00 19 I take a proper amount of sleep and avoid -1.03 overwork. 34 If I grow, I gain less stress as such. -1.06 5 I am satisfied with my life. -1.11 23 I am interested in health related articles or books. -1.13 17 I consider nutritional balance, adjust diet, and try -1.55 to eat quality foods. 32 Religious activities are helpful. -1.80 3 I try to seek to relieve tension and pressure on my 1.53 own. 14 I try to maintain normal weight and walk as much 1.31 as possible. 13 If I determine that it is impossible to do on my 1.29 own, I give up quickly. 1 I have had regular checkups and if there is any 1.22 abnormal signal in my health, I go to hospital right away and get treatment. 15 I have a positive way of thinking. 1.20 10 To overcome stress, I should strengthen my mind 1.09 rather than relying on others. 24 I live a thankful life. 1.05 16 I try to eat regular meals. -1.03 4 I have nothing to do with health management. -1.73 34 If I grow, I get less stress as such. -1.80 32 Religious activities are helpful. -1.85 31 If I get tired, I just sleep. -1.85 27 Family is power. 1..00 33 Continuous learning for self-development is 1.80 important. 6 I enjoy spare time as a hobby. 1.25 7 I try to develop better than now. 1.19 10 To overcome stress, I should strengthen my mind 1.13 rather than relying on others. 15 I have a positive way of thinking. 1.06 25 I am happy with life and feel a sense of 1.04 1145

Ⅴ 1 I have had regular checkups and if there is any -1.09 abnormal signal in my health, I go to hospital right away and get treatment. 18 I largely eat home-made foods rather than eating -1.12 13 If I determine that it is impossible to do on my -1.21 own, I give up quickly. 20 I do not eat foods known to be harmful for health. -1.49 2 I can t afford to manage my health because I am -1.79 too tired and hard. 32 Religious activities are helpful. -1.93 4 I have nothing to do with health management. -2.12 31 If I get tired, I just sleep. 2.35 34 If I grow, I get less stress as such. 2.31 33 Continuous learning for self-development is 1.90 important. 29 For health management, I should quit this nursing 1.48 8 If I work harder when it s hard, I believe that I 1.11 can overcome. 16 I try to ear regular meals. -1.00 5 I am satisfied with my life. -1.12 18 I largely eat home-made foods rather than eating -1.27 4 I have nothing to do with health management. -1.39 25 I am happy with my life and feel a sense of -1.61 [6] S. H. Hwang. Level of Practice for Health Promotion Lifestyle of some university hospital worker and its Related Elements. Unpublished master s thesis, Catholic University, Seoul (2007). [7] K. A. Lim. An Analytical Study on the Health Perception and Health Promotion Behavior between Hospital Nurses and Public Health Nurses. Unpublished master s thesis, Yonsei University, Seoul (2010). [8] Y. J. Kim. A study on Determination of Health Promoting Behavior in Hospital Nurses. Unpublished master s thesis, Keimyung University, Taegu (2000). [9] H. K. Kim. Q-Methodology: Philosophy, Theories, Analysis, and Application (2008), Seoul: Communication Books, Inc. [10] M. H. Kim, Y.J. Kim. Subjective Analysis on Health Management s of Clinical Nurse, Advanced Science and Technology Letters (2015). Vol.116, pp151-157. Conclusion This study is to enhance clinical nurses health care by using Q-Methodology and understand types of clinical nurses attitude toward health care and characteristics of each types. As a result, we could find out five types including Mind Control, Family Centered, Timid Stress Relieving, Continuous Effort, and Development Oriented. We suggest to use this study s result to develop arbitration program of clinical nurses health care and verify a effectiveness. References [1] S. W. Shin, S. H. Kim, Influence of Health-Promoting Behaviors on Quality of Sleep in Rotating- Shift Nurses, J Korean Academy Fundam Nurse (2014)Vol.21, No2, pp.123-130 [2] K. H. jo, Y. J. Kim. The Experience of Night Duty among Clinical Nurses Who are considering job Transfer, Journal of Qualitative Research (2012), Vol.15 No.1, pp. 1-12. [3] Culpepper, L. The Social and economic burden of Shift-work disorder. Journal of Family practice, 5, S3-S11. [4] K. S. Han, E. Y. Park, Y. H. Lim, H. S. Lee, E. M. Kim, et al. Factors influencing sleep quality in clinical nurses. Journal of Korean Academy of psychiatric and Mental Health Nursing (2011), Vol.20, No.2, pp.121-131. [5] H. Y. Kim. The Relationship between Health Problems and Working Environment of Clinical Nurses. Unpublished master s thesis, Hanyang University, Seoul (2009.) 1146