A Study on Subjectivity of Nursing Students on the Homeless
Sunyoung Jang
Associate Professor, Dept. Nursing, Hanseo Univ., 46 Hanseo1 Ro, Haemi-myun, Seosan-si, Chungcheongnam-do, 31962 South Korea
Corresponding author*: mobile Phone: +82-010-3451-2250
Abstract
Background/Objectives: The purpose of this study is to grasp the subjectivity of the nursing students on the
homeless, describe characteristics by type of the homeless, and grasp the typology of the homeless.
Methods/Statistical analysis: Q methodology was applied to describe the characteristics by type and to classify the
homeless. 18 students enrolled in the Department of Nursing at A University were asked to classify 44 statements about the homeless. The collected data were analyzed using QUANL PC Program.
Findings: As a result of this study, the nursing students' perception on the homeless was divided into 2 factors. The
subjectivity on the homeless appeared as two factors and explained 38.31% of the total variance. The first factor was 32.17% and the second factor was 6.14%. As the first factor has an explanatory power of 32.17%, the homeless can be seen as the most explanatory factor. Of the 18 subjects surveyed, 16 were in one factor and two were in two factors.
The types of subjectivity were classified into ‘Political Support Recognition Type’ and ‘tendency of the Homeless Recognition Type’.
Improvements/Applications: This study provided basic data for understanding and education of nurses on the
homeless in the clinic.
Keywords: The homeless, Nursing student, Subjectivity, Q methodology, Nurses
1. Introduction
The homeless problem in Korea began to emerge as the number of unemployed homeless people began to suddenly increase due to the economic recession under the International Monetary Fund (IMF) management system in 1997 and has been recognized as a social problem till now. Homelessness goes beyond simply sleeping outside, and significantly effect on the life of the homeless, which can cause serious problems in their health as well as their families and society[1].
If no continuous attention and service are provided to the homeless people who are left on the street due to no place to go away, their social function will be further deteriorated and they will be difficult to return as members of society[2]. Therefore, homeless people should be paid attention to both physical and mental health care since they have both psychological problem and physical problem otherwise they cannot be maintained as a social functioning member[3]. These homeless people are very dependent on society and are greatly influenced by the support of society, so services from the community have an important effect on the resurgence of their social life. Herth(1996) said that the support and interest of society are very important for the homeless to return to their families[4].
Herth(1996) said that since the homeless falls into chronic lethargy when they lose self-esteem because they cannot perform what they had accomplished in the past[4], and Muhlenkamp(1986) discussed the importance of the period of resurgence of the homeless because the loss of their position and role makes it ineffective and negatively affects the satisfaction of the overall life[5].
Active participation of nurses is required for physical, social and psychological health management for such difficult homeless people to return to healthy society members[6]. This is the nurse's immediate duty. In other words, nurses recognize the totality of the healthless aspects of the homeless, provide a new perspective on health care nursing practice to solve the homeless problem, and have a positive impact on the homeless through nursing access in the community. You can[7].
However, the conceptual study of nursing students on the homeless is insufficient. Therefore, the Q methodology is used for this study since it can understand the characteristics of each type according to the subjectivity structure of humans and starts from the perspective of the actor rather than the assumption of the researcher[8]. Therefore, nursing students' perception on the homeless is an appropriate research method for confirming the type of nursing students' perception on the homeless through the Q methodology, which is a research method considering the subjectivity of the subject, because the subject's perception on the homeless is a subjective and unique experience.
Therefore, this study grasps the subjectivity structure of the homeless from the perspective of nursing students and aims
to provide basic data necessary for developing a differentiated education program according to the type-specific characteristics of the recognition of the homeless as a preliminary nurse before going to the nursing site that manages the health of the homeless.
The purpose of this study is to identify subjective perception types and characteristics of nursing students on the homeless by applying Q-methodology to provide information about the homeless to the nursing students and basic data in presenting strategies for nursing student education. The specific research purpose for this is as follows.
1) Categorize the subjective perception of the nursing students on the homeless.
2) Analyze and describe the characteristics of the nursing students' perception on the homeless by type.
2. Materials and Methods
2.1. Research Design
In order to achieve the research objectives, the researcher reviewed the literature, media materials, and prior research on the homeless, and discovered the subjectivity of the nursing students who have experienced the homeless and see the type of subjective perception on the homeless.
2.2. Selection of Q Population and Q Sample
The Q population was drawn from domestic and foreign literature review, open questionnaire, and individual in-depth interviews to extract a comprehensive statement about the homeless, focusing on current nursing students. Through this process, about 200 Q populations were derived, and documents collected through domestic and foreign literature review were combined to extract total 100 Q populations. The extracted 44 samples of this study were reviewed and corrected to select the final 44 samples with high discrimination power.
2.3. How to select P-sample
The Q-methodology is a qualitative research study that emphasizes individual inertia by focusing on differences in meaning or importance within the individual, not between individual differences. In addition, the Q-methodology is based on a small sample doctrine, in which a large number of people are biased by one factor when the P sample is large [8]. The P samples of this study are 18 nursing students to whom the researcher fully explained the purpose of the study to students and they agreed to participate in this study.
2.4. Q Classification and Data Analysis Method
The Q-classification process is a process where individuals selected as P-samples make a voluntary definition on the homeless by classifying them as a forced normal distribution method with the statements of the Q-sample [8]. Data was collected by using Q-card for 18 students enrolled in the Department of Nursing at A University. The time it took for one research subject to complete the Q-classification was 30-45 minutes. For the distribution of the Q sample, the statements selected as the Q sample were classified from strong positive to strong negative according to the importance according to the opinions of the subjects. The statement about the homeless (Q1) was categorized on a 12-point scale. Subsequently, a follow-up interview was conducted with the subject regarding the statements classified at both ends. For the Q factor analysis, the Principle Component Factor Analysis and varimax method were used. The classification of the type was selected considering the result calculated by entering various numbers of factors based on the Eigen value of 1.0 or more and the total explanatory variance. The collected data was scored from 1 to 12 points based on the cards forcibly distributed in the Q sample distribution table, and the conversion scores given to each data were scored. The assigned conversion scores were coded in the order of the Q sample number and processed by the main factor analysis by the QUANL PC Program. The analysis of the data was processed using the QUANL pc program.
2.5. Ethical Consideration for Research Subject
Subjects were informed that they could discontinue at any time during the study after obtaining voluntary consent from the subjects prior to the study. In order to respect the subject's rights and to ensure the confidentiality of the subject's privacy and personal information, all information collected through this study is handled anonymously and coded in the entire process of data analysis to ensure confidentiality.
3. Results and Discussion
3.1. Subjectivity on the homeless and type-specific characteristics 3.1.1. Characteristics by type for the homeless
In order to analyze the subjectivity of the nursing students on the homeless by type, the characteristics of each type were first described based on the statements belonging to each type. The Q response of the P sample (research participants) was divided into upper and lower questions, and two factors were extracted. The Q methodology indicates that the higher the factor weight among the persons belonging to each type, the more typical or ideal person representing the type.
In order to analyze the characteristics of each type related to the homeless, the meaning was interpreted by focusing on statements with a standard score (z-score) of ±1.00 or higher among the items in the classified statements. In this study, 16 persons in type 1 and 2 persons in type 2 belonged to those with a factor weight of 1.0 or more.
As a result of analyzing the subjectivity on the homeless using the PC QUANL program, it appeared as three factors and explained 38.31% of the total variance. The first factor was 32.17% and the second factor was 6.14%. As the first factor has an explanatory power of 32.17%, the homeless can be seen as the most explanatory factor [Table 1]. Of the 18 subjects surveyed, 16 were in one factor and two were in two factors. Those who correspond to each factor refer to groups that respond similarly to the homeless.
Table 1: Eigen Value, Variance, and Cumulative Percentage
Type Ⅰ Type Ⅱ
Eigen Value 5.7907 1.1057
Variance(%) 0.3217 0.0614
Cumulative 0.3217 0.3831
3.1.2. Analysis by Type
The subjectivity type for the homeless calculated by this type analysis method is as follows.
- Policy Support Cognition Type: Total 16 subjects belonged to the first type. The statement that the subjects of type 1 showed a strong affirmation: 'The homeless may have a physical disability due to malnutrition (Z=1.99)'. Z=1.83)','The longer the period of the homeless, the greater the risk of mental health. (Z=1.58)” [Table 2]. The subjects with the highest factor weight in type 1 were 8 (1.8955), and the most agreed statements were 6 and 10. In the statement that the subject of type 1 showed strong injustice, 'The homeless should maintain the status quo or be isolated from the society (Z=-2.30)', 'Men have a positive attitude toward the homeless than women. .(Z=-1.95)' and 'The homeless is a social threat (Z=-1.78)' [Table 2]. The subject with the lowest factor weight in type 1 was No. 17 (0.3079), and the most negative statements were No. 17 and 24.
The characteristics of the first type consider the physical and psychological effects that may occur due to homelessness as the main consideration. They thought that the homelessness would need social support because of the high risk of bringing about physical health abnormalities such as malnutrition and infectious disease, and mental health abnormalities such as lethargy.
However, they do not think that the homeless are inherently suffering from mental illness or are a social threat. They also disagreed that laziness, etc. is a characteristic of the homeless. They thought that political support would be needed to address the various aspects of health problems that frequently occur to the homeless. Therefore, the first type was called the “Political support cognition model”.
- The tendency of the homeless recognition type: There were total 4 subjects in the second type. Statements in which the subject of type 2 showed a strong affirmation are 'The homeless will suffer difficulties (Z=2.40)', 'The homeless loses the purpose and hope of life (Z=1.64)', 'The Homeless is mostly pessimistic (Z= 1.64)' [Table 2]. The subjects with the highest factor weight in type 2 were No. 12 (0.9607), and the most agreed statements were No. 41 and 28. The statement that the subject of type 2 showed strong injustice was ‘If you spend most of your money on entertainment expenses, you can become the homeless. (Z=- 2.24)', 'After the IMF, the homeless have increased.(Z =-2.08)' and ’Become the homeless due to the burden of family support (Z=-1.64)' [Table 2]. In type 2, the subject with the lowest factor weight was No. 1 (0.5581), and the most negative statements were No. 42 and 43.
The characteristics of the second type considered the characteristics of the homeless in the current situation of the homeless.
They said that the homeless are pessimistic, highly likely to lose purpose and hope in life, critical, high in depression and anxiety, and have characteristics of laziness, weakness, and loss of motivation. They said that the characteristics did not change in the times, and did not think that the homeless would become the homeless due to the burden of family support. Therefore, the second type was called ‘The homeless tendency recognition type'.
Table 2: Typical questions on the homeless and Z-score (N=18) Representative items of type
Factor No Representative items Mean(SD) Z-score
Factor1 (N=16)
6 The homeless may develop physical disabilities due to malnutrition. 9.63(2.062) 1.99 10 The homeless need emotional support to become members of society 9.69(1.352) 1.83 25 The risk of mental health increases as the length of homelessness
increases 8.94(1.879) 1.58
18 Social inclusion is necessary for return to the society 8.81(2.136) 1.46 15 The homeless have a high incidence of infectious diseases. 8.62(2.094) 1.45
17 The homeless must maintain the status quo or socially isolated. 2.63(1.746) -2.30 24 Men have a more favorable attitude toward the homeless than women. 3.31(2.120) -1.95
26 The homeless is a social threat. 3.38(2.156) -1.78
22 The homeless are often mentally ill. 4.44(2.394) -1.27
21 The homeless are examples of laziness and loss of motivation. 4.88(2.886) -1.26
Factor2 (N=2)
41 The homeless will have difficulty in residence 12.00(0.000) 2.40 28 The homeless lose the purpose and hope of life. 10.00(1.414) 1.64
29 Most of the homeless are pessimistic. 10.00(1.414) 1.64
32 The homeless have high anxiety and depression. 9.00(4.243) 1.44 21 The homeless are examples of laziness and loss of motivation. 9.50(0.707) 1.37 42 You can become homeless if you spend most of your money on
entertainment. 1.50(0.707) -2.24
43 The homeless have increased since the IMF. 2.00(1.414) -2.08
39 They may become the homeless due to burden of family support 3.00(1.414) -1.64 24 Men have a more positive attitude toward the homeless than women. 3.50(2.121) -1.48
44 The homeless are often exposed to crime. 3.50(0.707) -1.25
As a result of this study, the subjectivity types on the homeless perceived by the nursing students were identified as the first type, 'policy support cognitive type', and the second type,'the homeless tendency recognition type'.
The first type in this study was 'Political support cognition type'. They thought the homeless are highly prone to physical and mental health problems. When living a long homeless life, it is impossible to maintain physical health due to the effects of nutritional imbalance, exposure to infectious diseases, and poor personal hygiene, and psychological support is also highly required because of the high risk of mental health such as lethargy and depression. Furthermore, they said that social inclusion was necessary for social return of the homeless.
An individual's physical and mental health is an important prerequisite for a stable professional life. In other words, it is easy to get a job when an individual is supported by a physically or mentally healthy function, and a stable job can be maintained thereafter. However, recent studies have reported that the vulnerable, including the homeless, experience a health gap reflecting social inequality and economic problems[9]. In particular, it is known that the homeless are exposed to poor living conditions during homeless life, have a high risk of physical illness due to irregular eating and poor nutrition, and have difficulty in accessing health care services. Therefore, it is necessary to pay attention to the health condition of the homeless and to improve their health function[10].
The homeless has health risk factors and various health problems due to family and economic problems, or the homeless life itself, and these problems have emerged as important public health problems[11-12]. In reality, they complain of various physical and mental health problems such as acute and chronic diseases, infectious diseases, and mental health problems, and the mortality rate is about twice that of the general population, and it is reported that about 50% of the homeless have mental health problems[12, 13]. However, the homeless do not have the ability to manage their health, so the longer the homelessness is, the worse the health becomes. Therefore, it is necessary to manage these vulnerable groups[13-15].
In order to maintain health care of the homeless, it will be necessary to connect with community resources. Linking community resources is absolutely important not only in the management of acute diseases, but also in the management of chronic diseases such as alcoholism, mental illness and pulmonary tuberculosis. Since linking to the nursing facility can carry out case management along with medication management, it is essential for self-sufficiency through health recovery, so linking with community resource discovery will be an important factor in the homeless health management[16, 17].
It is necessary to provide a foundation for health care providers who provide services to the homeless to provide qualitative and non-discriminatory services with an understanding of them through prior education on the characteristics and health problems of the homeless. In the research report of Seo et al. (2013), health care workers were not mentioned separately, but the important goal was to enhance the quality of services by strengthening their capabilities through sufficient training for employees in the homeless management facility[11], this context is considered to be a necessary item for health care providers who provide health care services to the homeless.
The second type was ‘the homeless tendency recognition type’. They focus on their current status as the homeless. They think the first priority is to recognize the homeless through the difficulties, depression, and loss of motivation experienced by the homeless. It is reported that the political support at the national level is important, but it is also necessary to support what is needed in the current state.
The homeless have very diverse characteristics in terms of demographics, such as children, adolescents, adults and the
elderly, and immigrants[12]. The proportion of the elderly among the homeless is gradually increasing and the characteristics and health needs of the elderly increase because they are different from general adults, so a differentiated approach is needed according to the characteristics and health needs of the homeless.
In addition, Moon (2012) reported that in the study of physical activity in middle-aged adults in low-income families, the level of health behavior was reported to be relatively low when social and economic levels were low [18]. In particular, drinking is the medium that makes the homeless forget loneliness, relieve stress, such that the homeless make a lot of drinking, which exacerbates trauma and disease, depression, cognitive impairment, and loss of appetite. Drinking causes various problems such as malnutrition, sleep disorders, etc., and brings a vicious cycle of deteriorating health by drinking more with the feeling of desperation[19, 20]. It needs a strategy to approach peers to practice health behavior naturally in daily life with continuous education so that the non-healthy behavior of the homeless does not develop to disease, and very simple and practical support such as only handing out toothbrush and toothpaste may avoid tooth decay, gingivitis and loss of teeth[21].
The homeless of the shelter are under socially vulnerable treatment, so they are virtually outside the scope of the health area, making them difficult to access to health care. In addition, in the event that the patient is not interested in health care, the disease becomes serious or a traumatic accident occurs. The situation is mainly using health care institutions[22]. Garibaldi, Conde-Martel and O'Toole (2005) suggest that other factors, rather than the absence of health insurance, affect health care, as the homeless often have medical insurance but do not go to the hospital to manage the disease even if they have the disease. Therefore, it was suggested that they need an out reach or shelter-oriented program[23].
This study analyzed the nursing students by dividing them into two types by exploring the subjective perception of the homeless. The characteristics of each type are ‘Political support recognition type', which recognizes that political support is needed to solve the health problem of the homeless and ’The tendency recognition type of the homeless,' which needs to grasp the current characteristics of the homeless and provide appropriate help. This study of subjectivity could be used as the basic data for support program for new nurses to start nursing in the field to maintain and promote the homeless health. In addition, th is study is expected to be used as the basic data for the development of differentiated educational programs by presenting subjective structures and characteristics of each type of nursing students as the pre-medical students.
However, since this study was carried out on one university and the subjects were not selected considering factors affecting the perception of the homeless, there is a limitation on generalizing the results of the study, so Q samples with various backgrounds need to be composed through subsequent studies, that additional verification for the type is required.
4. Conclusion
This study applied the Q methodology to prepare the basic data necessary to find a way to activate the support for the homeless based on the subjective data analyzed by exploring and analyzing the subjective perception of the nursing students on the homeless. As a result of this study, the types of the homeless perceived by the nursing student were two types: 'Political support recognition type' and 'The tendency recognition type of the homeless'.
This study categorized the subjectivity of the nursing students on the homeless and provided the basic data necessary to introduce or apply a policy to activate the program supporting the homeless in the future. Through this study, since nursing students' perception type on the homeless is analyzed and characteristics were confirmed, it is expected that an education program considering each type of characteristics would be developed. In addition, the researcher proposes a further study on the type analysis by selecting samples considering various factors and a qualitative study to identify such various factors affecting the nursing of the homeless.
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