Perspectives of the Value in Life among Nursing Professionals: A Q-methodology Study

An individual’s values of life (VL), considered important to coordinate and practice behaviors that are required to accomplish a task in a profession, may vary widely depending on the practice environment. It is important to know and understand the values in life (VL) of nursing professionals who are charged with patients’ health and safety because they are key human resources in health system organizations. This study aims to identify and understand the subjective perspectives of VL in Korean nursing professionals. This study used Q-methodology because it synthesized the advantages of quantitative and qualitative methods. A convenience sample of 29 nursing professionals participated in this study. Twenty selected Q-samples obtained from each participant were classified into a forced distribution using a 7-point grid. The collected data were analyzed using a PC-QUANL program. Q-factor analysis revealed that three types of VL are held by nursing professionals: family-based values, ideal-oriented values, and individual achievement-oriented values. Perspectives of these three types of VL can provide the baseline data to develop customized interventions to support the quality of life of nursing professionals and can also be used to inform health professionals in other countries about the perspectives on VL of Korean nurses.


Introduction
The word "value" conjures up thoughts about what is important in people's personal lives and implies choices or evaluations related to faith, motivations, abstract goals, behaviors, and events (Sherman et al., 2021). The values in life (VL) are formed not only by external conditions or situations but also by emotions and thoughts, which can be experienced as selfesteem, pleasure, faith, and life satisfaction (Lee & Kawachi, 2019).
An individual's VL to coordinate and practice behaviors that are required to accomplish tasks in a chosen profession may vary widely, depending on the practice environment (Dordunoo et al., 2021;Park et al., 2016). People recognize nursing professionals as those who assume the moral responsibility to protect universal human rights and the inherent dignity and equality of others within the context of healthcare. Nursing professionals help patients maintain their optimal level of health by caring for them and respecting their basic human rights. Therefore, it is crucial to understand the VL of nursing professionals who are charged with patients' health and safety because they are pivotal human resources in health system organizations .

Literature Review
Nurses provide care to patients based on various human relationships and at the same time play a coordinating role with the different departments in the hospital. It is a profession that requires frequent emotional exchanges by gaining patients' trust and ensuring a sense of stability at work (Lee, 2018;Park, & Kim, 2013). Nursing educators also play a pivotal role in the development of professional values in nursing students. Therefore, the positive VL inherent in nursing professionals is important and needs to be explored (Kim, 2020).
Considering hitherto published research, qualitative studies conducted so far on nursing professionals have predominantly examined their experiences with work-related stressors, difficulties, and happiness (De Almeida et al., 2016;Lee, & Kwak, 2017;Lee, & Suh, 2014). A few studies have used quantitative measurement tools to investigate similar topics (Barattucci et al., 2019;Han et al., 2020;Ju et al., 2015). However, it is difficult to find studies focused on the VL of nursing professionals in terms of their personal and professional lives. In other words, studies about nursing professionals' VL are insufficient. Therefore, studies about nursing professionals' VL should be conducted to help enhance the quality of life of nursing professionals, and to offer effective and safe nursing services for patients.
A person's subjective perspectives can be defined by internal factors such as individual attitudes, behaviors, values, feelings, and opinions. The use of Q-methodology in the current study offers nursing professionals an opportunity to realize their VL independently by exploring their various characteristics and identifying their essential meanings. It also provides basic information to plan strategies to enhance nursing professionals' awareness and practice of VL in their personal and professional lives.

Aim of the Study
The aim of this study was to identified nursing professionals' perspectives on VL to understand the structure and characteristics of their perspectives based upon these perspectives.

Research Design
This study was conducted by using Q-methodology to identify and describe nursing professionals' perspectives of VL.

Q-Methodology
Q-methodology is an integrated research approach that synthesizes the advantages of quantitative and qualitative methods to understand a participant's point of view about an attitude, phenomenon, interest, or concern. Subjective viewpoints can be defined by internal factors, such as interpersonal relationships, individual attitudes, impressions, perceptions, feelings, and opinions, rather than external facts (Brown, 2019). A study using Q-methodology involves the development of a concourse using diverse sources, the production of a set of statements known as a Q-sample (or Q-set), the selection of a sample of participants called the P-sample (P-set), and a process of Q-sorting using a bipolar Q-sort table designed as a grid (or  data collection table). After these processes, the collected data are analyzed using factor analysis with varimax rotation. Several factors are eventually identified and labeled by a team of domain experts. The participants are asked to provide more information about the two Q-statements with which they most agree and disagree, to help interpret the emerging factors. Q-methodology is an efficient method of determining subjective perceptions and converting them to an objective outcome. The results of a Q-study not only suggest how people might be approached but can also predict the success of the approach. To conduct this analysis, the Q-study protocol was divided into five sequential steps: (1) construction of a concourse, (2) developing the Q-sample, (3) selecting the P-sample, (4) performing the Q-sort procedure, and (5) analyzing and interpreting the data from the Q-sorts (Yeun et al., 2020).

Research Procedure
The practical steps to use Q-methodology are shown in Figure 1.

Construction of the concourse (Q-Population).
The concourse is developed by reviewing relevant literature, interviewing research participants, or collecting data from various sources such as scientific papers, books, newspapers, and television programs (Brown, 2019). In this study, the Q-population was assembled using various sources: relevant literature, studies, and interviews about VL. A researcher and two research assistants reviewed and analyzed the source material to define the Q-population of statements. Subsequently, in-depth interviews were conducted to extract self-referent statements from 10 nursing professionals who did not study participants. The statements covered broad areas such as feelings, experiences, and impressions about VL. After deleting redundant and unclear statements, 87 statements were compiled as the Q-population. The procedures to develop the Q-population were carried out by one of the researchers and by domain experts on VL.
Development of the Q-sample. The 87 statements were reviewed by three professors of nursing and one methodologist and classified by meaning and theme. A list of 45 statements with repetitive viewpoints was edited and reduced to 24, to eliminate duplication. After pilot testing the statements with three participants to identify how the statements performed, the number was further reduced to four statements. This process, which entailed rewording and rewriting statements, eliminated superfluous statements and ensured the expression of contrasting viewpoints. After these procedures, a final set of 20 Q-samples was identified as the most representative and distinctive statements, which were used in the Q-sorting process.

Recruitment of study participants (P-sample).
One of the most salient characteristics of Q-methodology is the use of small samples, which is possible because intra-individual differences rather than inter-individual differences are considered important (Brown, 2019). Thirty employed professional nurses who were recruited at a university nursing conference in Seoul, Korea, agreed to participate in the study. Of those who attended the sorting process, 29 participants (96.7%) completed the Q-sorting. Thus, data from 29 participants were used (after excluding one participant because of incomplete data). Socio-demographic characteristics varied within the group. Of the 29 participants in this study, 96.6% were female and 3.4% were male. The characteristics of the participants are shown in Table 1.
Q-sort procedure. Participants were asked to rank the Q-samples using a grid called the Q-sort table. The Q-sorting by the 29 participants yielded for each, a systematic forced distribution of 20 Q-statements ranked on a scale of 1-7. For the Q-sort procedure, following the general principle of sorting, they sorted statements they agreed with on the right, those they disagreed with on the left, and neutral statements in the middle. Next, for the statements they agreed with, they placed the ones they most agreed with at +3 and sorted the rest toward the middle. Likewise, for the statements they disagreed with, they placed the ones they most disagreed with at −3 to wrap up the neutral statements. After each Q-sort, the participants were interviewed about the items they placed in the extreme columns: strongly disagree (−3) and strongly agree (+3). The resultant Q-sort was a matrix representing the participant's operant subjectivity of their perspectives of the VL under consideration (Figure 2).
Validity and reliability. The types of validity examined in a Q-study include content, face, and Q-sorting validity, and the reliability of a Q sorting is verified using a test-retest procedure. Repeated Q-sorting usually is conducted at one-or twoweek intervals (McKeown & Thomas, 2013). To establish the validity of these statements, the literature associated with VL was reviewed by a researcher and two research assistants, and the statements were examined by three professors of nursing and a methodologist, who were a part of our team of domain experts. For face and Q-sorting validity, a final panel of 20 Q-samples extracted through content analysis was evaluated and tested by five volunteer nursing professionals. The nursing professionals were retested 2 weeks later. The correlation coefficients between the respective Q-sorts were between 0.89 and 0.94.

Data Collection and Analysis
The researchers completed the data collection by using a standardized script in February 2020 through a face-to-face, Q-sort procedure. A principal component factor analysis using the PC-QUANL program revealed groupings or patterns in the data after each participant's score was entered into the database. The best types were selected from the results obtained by inputting the number of factors based on an eigenvalue of 1.0 or higher, and the standard scores (Z-scores) were used to select the appropriate items.

Ethical Considerations
This study was approved by the institutional review board of the ethics committee of the author's university (BUIRB-201506-HR-011) and was conducted in accordance with the principles of the Helsinki Declaration. All the information gathered was treated as confidential and anonymous. All the participants were provided with an explanation about how these data would be used and that they would never be used for any purpose other than this study. Written informed consent was obtained when the nursing professionals agreed to participate in the study.

Formation of Q Types
The Q-factor analysis of the data provided by the 29 participants revealed that distinct perspectives of VL existed among Korean nursing professionals. As presented in Table 1, there were three significant types related to the nursing professionals' perspectives of VL: family-based values, ideal-oriented values, and individual achievement-oriented values. The three types of perspectives of VL explained 53.7% of the total variance: 34.3%, 12.4%, and 7.1%, respectively. The characteristics of the perspectives were analyzed and interpreted based on the typal array and participants' extreme ratings.
Type 1: Family-based values. Eight of the 29 participants loaded on type 1. The statements that they positively agreed with and disagreed with are listed in Table 2. Those who loaded on type 1 strongly agreed with the importance of the family's safety, well-being, and peace of mind. Compared to other groups of participants, the type 1 participants strongly agreed with the importance of the success of the child.
Participant no. 20, who had the highest factor weighting (2.35) in the type 1 group, was a 41-year-old female who stated: "It is most important to pursue family's safety, well-being, and

happiness. I think that living with my family occupies a large portion of time in my life. I am working, studying, and striving for our family rather than for self-realization. As a result, the final goal in my life is to seek the happiness of my family."
The participants who loaded on type 1 also revealed that they were very interested in the success of children and that their family was the source of their lives. In addition, the pursuit of their family's happiness was their life's goal, and ultimately, they wanted a comfortable life with their family. They also believed that social justice is important and that if the heart is open, one can be concerned with the safety and well-being of their country. Therefore, type 1 was named "Family-based values." Type 2: Ideal-oriented values. Type 2 included 13 of the 29 participants, which made it the largest group. The statements that they most positively agreed and disagreed with are listed in Table 2. These participants strongly agreed with values related to self-esteem, the pursuit of happiness, wisdom in life, and peace of mind. In contrast, the Q-factor analysis revealed strong disagreement with values related to the safety and well-being of the country, comfortable living, and the success of children.
Participant no. 23, who had the highest factor weighting of 1.49, was a 51-year-old female. She showed the strongest agreement with self-esteem and true love. She stated that a "person who respects himself/herself can love others. A man may belong to many classes in this world. Passionate love does not last for long. But the essence of true love does not change over time." The participants who loaded on type 2 believed that it was most important to appreciate life. They believed that people who respected themselves also loved others. Those who thought that the goal of life was self-realization were less

Raw Scores
Transformed Scores 1 2 3 4 5 6 7 Strongly Disagree N eutral Strongly Agree interested in the safety and well-being of the country. Beauty is transient, so it cannot give meaning to the ultimate value of life. Therefore, type 2 was named "Ideal-oriented values." Type 3: Individual achievement-oriented values. Type 3 consisted of eight of the 29 participants. The statements that they most agreed and disagreed with are listed in Table 2. The type 3 participants placed importance on the pursuit of happiness, achievement, social recognition, and comfortable living. On the contrary, there was a strong negative perception of social justice and the success of the child among this group.
Participant no. 13, who had the highest factor weighting of 3.11, was a 28-year-old female. She showed the strongest agreement with achievement and the pursuit of happiness. She stated: "It is most valuable to feel a sense of accomplishment. Umm. . . and I am happy when I feel self-fulfilled." In contrast, she showed the strongest disagreement with the values of social justice and the success of children. She believed that the basic reason for living was the pursuit of happiness. Type 3 participants believed that receiving recognition from others confirmed their abilities, and this feat made it possible for them to achieve their goals. Type 3 could achieve their life's goals and feel happiness through self-satisfaction. They hated regulation and a repressed life. Type 3 thought that world peace did not have a direct effect on individuals and that social justice was not related to the individual. Therefore, type 3 was named "Individual achievement-oriented values." Consensus on the VL among the three types. The three different types overlapped despite their independent characteristics, and the consensus views are shown in Table 2. The following results summarize the feelings of the most participants: the pursuit of happiness (Z = 1.19), peace of mind (Z = 1.08), and the safety and well-being of the country (Z = −1.37). A common opinion among the participants about the VL was that it was most important to have a goal to lead a happy life. Therefore, they thought that people should seek and choose happiness. They focused on maintaining peace of mind because they wanted a comfortable life. However, they insisted that the safety and well-being of the country was a natural value rather than a personal goal. To them, the country's safety and well-being were independent of a person's ultimate worth, and therefore, did not have a significant impact on personal safety and well-being.

Discussion
This study attempted to allow nursing professionals to realize their VL by exploring their perceptions of the various types of VL and identifying their essential meanings. Q-factor Family's safety and well-being 1.7 0.8 0.7 Q20 The realization of social justice −1.6 −0.6 −1.6 Consensus views

Q16
The pursuit of happiness 1.19 Q17 Peace of mind 1.08 Q4 Safety and well-being of the country −1.37 Bold, factors z-score above +1.0 or below −1.0, p < .05.
analysis revealed three distinct factors reflecting three types of VL: family-based values, ideal-oriented values, and individual achievement-oriented values. Participants who loaded on type 1 recognized children's success as an important value and the family's happiness as their goal; they also wanted to live a comfortable life with their family. Experienced nursing professionals regarded their families as their source of life because they felt emotions such as intimacy and warmth from living with their family and were more comfortable with these feelings in their work areas (Yeun et al., 2017). As a result, they practiced their VL ultimately by living a comfortable life with their family. These participants thought that social justice was important, but they could pursue their nation's safety and peace when they felt comfortable in life. The characteristics of type 1 are congruent with the traditional Korean ideas of Confucianism, which is 家和萬事成 (Ga-Hwa-Man-Sa-Sung), which means that when one's family is harmonious, all are happy (Napa et al., 2020). According to Schwartz's theoretical model of the relationships among ten motivational types of values, the conservation model includes conformity, traditional values, and security, which is similar to type 1 with its emphasis on traditional, family-centered values (Schwartz, 2012).
Type 2 included 13 participants, the largest number among the three types. These participants thought that their ultimate goal in life was self-actualization and acknowledged themselves as being most important in their lives. Type 2 contrasts with type 3, which focuses on self-satisfaction. The participants who loaded onto type 3 wanted to be accepted by other people. One of the characteristics of type 2, acknowledging oneself, was congruent with Schwartz's research (2012), which stressed two models: self-direction and openness to change. Self-direction includes freedom and creativity, and openness to change includes stimulation, that is, exciting life. These two models focus on independent action, thoughts and feelings, and readiness for new experiences (Schwartz, 2012). Modern man pursues self-actualization, which is considered the highest of human needs, because human beings are existential, and their spiritual existence cannot be reduced to a material condition (Lee & Kawachi, 2019). In addition, self-actualization means the "pursuit of values and practice of morals," which can exalt humans to a higher level of existence. To strive to live a life based on spirituality is the essence of humanity and can be expressed in all areas of human activity. In the end, the meaning of self-actualization is to let humans live their lives by understanding the relationship between the self and the world (Sherman et al., 2021). Therefore, it is necessary to interpret the life of humans as the process of pursuing the need for self-actualization.
Type 3 included those participants who confirmed their abilities and achieved their goals through recognition by others and experienced a sense of happiness through self-satisfaction. The results pertaining to type 3 were similar to those of two previously published studies. Ko's research (2013) revealed that participants felt happier when their work period increased, and when they had more clinical experience. Han et al., (2020) reported that experienced nursing professionals felt happy when they had feelings of self-satisfaction, such as professional self-esteem, passion for self-actualization, satisfaction through performing their duties, the gratitude of those in the work environment, and emotional intimacy. Therefore, type 3 stressed the importance of self-satisfaction to nursing professionals' VL. The participants who loaded on type 3 recognized that world peace and social justice cannot be obtained through individual efforts, and they strongly denied valuing their children's success. According to Schwartz's (2012) theoretical model, self-enhancement focuses on the pursuit of self-interest, such as success and ambition, and it is similar to type 3, which consisted of selfsatisfaction and a sense of accomplishment.
VL is a multi-faceted construct that has been conceptualized in diverse ways. The term refers broadly to the purpose of life, important life goals, and for some, spirituality (Lee & Kwak, 2017). The opinions that were common among the nursing professionals about their VL has the pursuit of happiness and peace of mind. VL have been reported to contribute to a sense of peace and happiness throughout an individual's life and is an essential feature of a good life (Lee & Kawachi, 2019). Happiness characterized by joy is not the only type of happiness that people are able to feel subjectively; self-actualization, personal growth, and meaning in life may bring happiness Park & Choi, 2014). Therefore, nursing professionals can regard the pursuit of happiness as their common VL. Further research needs to develop a measure of VL based on this conceptualization and design it to be a synthesis of relevant theoretical and empirical traditions. People tend to behave in ways that balance their positive values. Almost all behaviors have positive implications for expressing or upholding some values (Pantaléon, Chataigné, Bonardi, & Long, 2019). As a result, VL influence most, if not all motivated behaviors. Therefore, it is necessary to enhance the positive elements of VL for the pursuit of goals and individual growth.

Strengths and Limitations
This study has several strengths. It is the first study to explore the VL of Korean nursing professionals and it will be a foundation that can raise awareness of their values to plan future research. This study found a unique pattern and common perceptions among nursing professionals' subjective perspectives of VL. Some limitations of this study should also be considered. The first concerns the small sample size, Moreover, the study's setting was confined to a particular geographic location. Despite these limitations, this study provides some valuable insights into the perspectives of VL among nursing professionals in a Korean socio-cultural context.

Conclusion
This study was significant because it illustrates Korean nursing professionals' perspectives about VL from a socio-cultural context using Q-methodology. We found some patterns in nurses' subjective perspectives about VL. Thus, to maintain or improve the VL of Korean nursing professionals, it is important to develop different interventions tailored to the characteristics of each type. Based on these findings, customized intervention strategies for VL need to be developed, consequent to future studies.

Relevance to Clinical Practice
This study is significant because the findings' basic data can help develop and confirm various tailored intervention programs that focus on the characteristics of each type to positively reinforce VL among nursing professionals. The perspectives of these three types of VL (family-based values, ideal-oriented values, and individual achievementoriented values) can provide the baseline data to develop customized interventions to support the quality of life of nursing professionals and can also be used to inform health professionals in other countries about the perspectives on VL of Korean nurses. Our findings also suggest the need to develop a scale to measure the VL of nursing professionals and enhance strategies that consider the characteristics of each type.