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Financial inequity and the impact of acquiring technology competency within the emergency medical service community
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Financial inequity and the impact of acquiring technology competency within the emergency medical service community
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Content
Financial Inequity and the Impact of Acquiring Technology Competency Within the
Emergency Medical Service Community
by
Brian Lee DeFluri
Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education
May 2022
© Copyright by Brian Lee DeFluri
All Rights Reserved
The Committee for Brian Lee DeFluri certifies the approval of this Dissertation
Corinne E. Hyde
Anthony B. Maddox
Emmy J. Min, Committee Chair
Rossier School of Education
University of Southern California
2022
iv
Abstract
Research has found that EMS organizations are chronically underfunded. Additionally,
healthcare staff workers juggle multiple competing priorities with the increasing need to leverage
technology. This qualitative study aimed to discover a relationship between technology barriers
relating to organizational funding inequities through the lens of healthcare staff members’
perceptions of technology they use in their professional duties. Seventeen participants were
interviewed from various locations within the organization studied. Also, documents like
instructor directions and training materials were analyzed. The participants were staff members
of a volunteer EMS organization. The outcomes show the extent to which funding is a barrier to
the acquisition of technology competency. Therefore, the interventions for this study are to
provide recommendations for EMS organizations to support the investment of technology with
limited funding and resources. In addition, this research can provide insight into their technology
work processes and implementations.
Keywords: social cognitive theory, collective efficacy, emergency medical services,
healthcare, technology competency, finance
v
Dedication
To all EMS organizations, volunteer and paid, let this research provide insight for process
improvement to provide the best care possible to our patients. Patient care is the number one
priority. Be safe out there.
vi
Acknowledgments
First and foremost, I would like to thank Arthur Blake, my mentor from the beginning of
my EMS career. He has guided me through my education and brought much-needed
improvements to my maturity and leadership so that I can provide the best patient care possible. I
also would like to thank the EMS community that participated in the interviews. They all have
gone and will continue to go above and beyond.
I would also like to thank my dissertation committee and the USC support staff. While a
student at USC, I achieved my dream of furthering my education beyond my wildest dreams.
Also, a special thank you to my cohort 14 classmates. I enjoyed and looked forward to
participating in each synchronous classroom session. Each class allowed me to network and
collaborate with the best leaders I have had the privilege to meet.
Finally, I would like to thank my wife, Jennifer, for putting up with my long hours and
absenteeism from family outings. Her support and coaching have made my pursuit of my
doctorate possible. Thank you.
vii
Table of Contents
Abstract .......................................................................................................................................... iv
Dedication ........................................................................................................................................v
Acknowledgments.......................................................................................................................... vi
List of Tables ...................................................................................................................................x
List of Figures ................................................................................................................................ xi
Chapter One: Introduction to the Problem of Practice.....................................................................1
Context and Background of the Problem .............................................................................2
Purpose of the Project and Research Questions ...................................................................3
Importance of the Study .......................................................................................................4
Overview of Theoretical Framework and Methodology .....................................................5
Definitions............................................................................................................................6
Organization of the Dissertation ..........................................................................................8
Chapter Two: Literature Review .....................................................................................................9
Best Practices .......................................................................................................................9
Review of the Research .....................................................................................................10
Characteristics of the Stakeholders ....................................................................................13
Challenges and Barriers in Context ...................................................................................14
EMS Funding .....................................................................................................................18
Conceptual Framework ......................................................................................................19
Summary ............................................................................................................................23
Chapter Three: Methodology .........................................................................................................25
Research Questions ............................................................................................................25
Research Setting.................................................................................................................25
The Researcher...................................................................................................................26
viii
Data Sources ......................................................................................................................26
Trustworthiness and Credibility .........................................................................................29
Ethics..................................................................................................................................30
Chapter Four: Findings ..................................................................................................................32
Participants .........................................................................................................................32
Setting ................................................................................................................................34
Findings..............................................................................................................................35
Summary ............................................................................................................................47
Chapter Five: Recommendations ...................................................................................................49
Discussion of Findings .......................................................................................................49
Recommendations for Practice ..........................................................................................51
Integrated Implementation and Evaluation Plan ................................................................53
Organizational Purpose, Needs, and Expectations ............................................................55
Strengths and Weaknesses of the Approach ......................................................................64
Limitations and Delimitations ............................................................................................65
Recommendations for Future Research .............................................................................65
References ......................................................................................................................................69
Appendix A: Interview Questions .................................................................................................79
Appendix B: Informed Consent Form ...........................................................................................81
Purpose ...............................................................................................................................81
Participant Involvement .....................................................................................................81
Payment/Compensation for Participation ..........................................................................82
Confidentiality ...................................................................................................................82
Investigator Contact Information .......................................................................................83
IRB Contact Information ...................................................................................................83
ix
Acknowledgement .............................................................................................................83
x
List of Tables
Table 1: Participant Demographics ................................................................................................33
Table 2: Supporting Information That Identifies Technology Barrier Themes .............................38
Table 3: The Amount of Self-Reported Self-Efficacy of the Participants .....................................43
Table 4: Outcomes, Metrics, and Methods for External and Internal Outcomes ..........................57
Table 5: Critical Behaviors, Metrics, Methods, and Timing for Evaluation: ................................58
Table 6: Required Drivers to Support Critical Behaviors: .............................................................59
Table 7: Evaluation of the Components of Learning for the Program. .........................................61
Table 8: Components to Measure Reactions to the Program .........................................................62
Table A1: Interview Questions ......................................................................................................78
Appendix C: Sample Level 1 Assessment Response Data Chart ..................................................84
Appendix D: Sample Level 3 Survey Questions ...........................................................................85
Appendix E: Sample Level 3 Instructor Lead Training Survey Questions ...................................86
xi
List of Figures
Figure 1: Social Cognitive Triadic Healthcare Technology ..........................................................21
Appendix F: Sample Level 1 Assessment Data Bar Chart for Reporting ......................................87
1
Chapter One: Introduction to the Problem of Practice
This study examined the challenges with acquiring technology competency among
emergency medical service (EMS) professionals and the influence funding has on staff
motivation. Like other industries, healthcare organizations face challenges implementing and
integrating technologies necessary to support their businesses. Healthcare organizations need to
manage their ever-changing technology portfolio, balance their staff’s cognitive load, and
address perceptions of the technology with limited financial resources. According to Edwards
and O’Connor (2011), nursing students struggle with navigating web-based technologies.
Edwards and O’Connor (2011) also stated that research shows a knowledge gap in using
information technology (IT) in the computer software, email, and other software leveraged. To
provide an example of healthcare’s leadership involvement, Ruiz Morilla et al. (2017) stated that
while physicians utilize technology in their private lives, 60% of physicians studied use medical
apps within their public or private practice. According to Mamedova and Pawlowski (2018), 31.8
million Americans are not comfortable using technology at the universal level.
Daim et al. (2016) stated that comfort with technology solutions to bridge a gap at the
implementation stage is vital for healthcare stakeholders and is a factor in adoption (p. 16). Also,
Daim et al. presented the technology acceptance model, where healthcare staff’s attitudes,
education, personality, and career stage influence how technology is utilized (p. 19). Based on
the research stated, acquiring technology competency within health care is a challenge. As a
result, organizations struggle to implement, train, and ultimately leverage technology to bridge
the gaps for which it was intended.
There are unique challenges within EMS healthcare organizations due to the nature of
their work and their funding structures. For example, Koutitas et al. (2021) stated that the
2
training of first responders is analog, and the usage of digital technologies is minimal. Another
challenge Koutitas et al. stated is that training repetition is marginal due to cost and logistics
challenges needed to recreate scenarios that the EMS community may face.
Context and Background of the Problem
Edwards and O’Connor (2011) stated that healthcare workers struggle to learn new
technology needed for their role. Healthcare staff workers juggle multiple priorities with the
increasing need to leverage technology. Edwards and O’Connor (2011) stated that healthcare
organizations’ demand for medical IT will increase. Technology implementation needs to be
completed methodically and includes stakeholders in all project design phases to address this
increase. Daim et al. (2016) stated that many healthcare IT projects are failing or abandoned due
to the lack of understanding of the project goal. This will lead to physical technology barriers,
which leads to a self-efficacy gap (p. 190).
The healthcare organization studied in this research is a volunteer EMS. This study
examined the staff’s capacity to become competent in technology as defined by their job
description. Daim et al. (2016) suggested that inadequate training initiatives and poor project
management may cause a lack of technology competency in healthcare (p. 121). Another
influencer is that the EMS community’s prehospital setting threatens workforce stability due to
high stress working conditions (Crowe et al., 2018).
Many healthcare-related volunteer organizations have virtualized their regulatory content.
They have also included training programs to address their staff’s knowledge gaps when
implementing technology content delivery. Synchronous face-to-face training has been the
primary strategy to acquire the needed skills to interact with the technology required for an EMS
worker’s role. Koutitas et al. (2021) stated that the reason for this is that face-to-face moulage
3
type training exposes first responders to the risk involved in their work. Koutitas et al. also stated
that first responders receive new training methods, specifically by leveraging a learning
management system (LMS). The organization studied in this research uses an LMS.
According to Daim et al. (2016), the lack of technical training regarding the new
technology is a barrier to the success of the implementation (p. 121). In addition, using Daim et
al.’s technology acceptance model, several key factors have been identified, such as the lack of
stakeholder involvement within technology rollouts and poorly executed communication plans
for major initiatives (p. 138).
Purpose of the Project and Research Questions
This study explored the relationship between technology barriers and EMS staff
members’ perceptions of technologies used in their roles. The primary barrier studied is financial
inequity among several EMS entities in the same organization. The technology reviewed in this
study was limited to the LMS supporting continuing education for staff and other educational
support technologies.
A relationship between the barriers to gaining technology competency and perceptions of
its utilization was established by interviewing EMS workers. In addition, the root cause of the
lack of technology competency among healthcare staff was established with a focus on financial
security. Two research questions were addressed in this study:
1. What perceptions do healthcare workers have concerning how their organization
leverages technology with funding as a barrier?
2. What role does self-efficacy have when healthcare EMS staff implement or leverage
technology?
4
Importance of the Study
New technology has become available in the healthcare industry over the last few
decades. However, Furukawa (2011) stated that poorly designed electronic medical record
systems lead to user dissatisfaction. Based on his research, poorly implemented projects
combined with technology integration complexity create barriers, leading to negative attitudes
toward technology. These negative attitudes create additional obstacles to obtaining the
competency required to complete healthcare tasks. Rahman et al. (216) found a positive
relationship between individuals’ self-efficacy and goals to adopt technologies. Daim et al.
(2016) suggested that each healthcare staff member utilizing technology has an opinion of how
well and how fast they can learn the technology to complete a task (p. 212). This opinion is
influential on the perceptions that will ultimately impact an organization’s overall effectiveness.
Therefore, one hypothesis of this research is that the perception of technology utilization must be
a positive experience and an asset to the employee.
Haji et al. (2015) stated that negative emotions increase anxiety when they overwhelm
cognitive resources and reduce performance. Negative experiences lead to negative emotions
when staff is exposed to poorly implemented technology solutions, negatively impacting self-
efficacy. Low self-efficacy increases cognitive loading, which creates a barrier to acquiring
technology competency. Another factor leading to negative experiences with technology is the
cognitive load needed to interact with technology with inadequate governance to sustain the
technology after implementation. Purkayastha et al. (2017) stated that fragmented electronic
medical systems were barriers. They also said that, on average, staff requires 6.4 passwords to
log into the systems they interact with, which leads to the perception that technology is
challenging to use.
5
According to Rahman et al. (2016), behaviors influence attitudes. Therefore, it is
essential to identify actions that support positive self-efficacy. In addition, research is needed to
identify technology barriers, self-efficacy concerns, and the relationship between the two. Once
these concepts are discovered, this knowledge can then be used to boost staff technology
competency, increasing positive patient outcomes by reducing errors and addressing patient
needs with shorter patient wait times.
There are many challenges and barriers for healthcare professionals to overcome due to
its complexity and pace of the industry. There are competing priorities placed on staff to keep up
with the advancements in medicine and the technology that enables its progress. Having a
marginal technology proficient team will be shown in adverse patient outcomes. Increasing
technology competency within healthcare needs to be placed high on the priority list since
technology is present in every industry.
Overview of Theoretical Framework and Methodology
The theoretical frameworks used in this study are self-efficacy and collective efficacy
theory. Rahman et al. (2016) defined self-efficacy framed within healthcare as a user’s
perception of IT. Self-efficacy research performs an essential role in technology adoption
decisions. Since healthcare is an organization where staff members interact, forming a collective
efficacy will also be investigated. Bandura (2000) stated, “the higher the perceived collective
efficacy, the higher the groups’ motivational investment in their undertaking, the stronger their
staying power in the face of impediments and setbacks, and the greater their performance
accomplishments” (p. 78) Bandura’s statement relates to technology competency because a
group’s perception of technology will influence how successful the implementation will evolve.
To support this, Swenson-Britt and Berndt (2013) stated that perceived collective efficacy is not
6
the sum of individual members of the group. This ownership refers to the technology being used
by staff. Using that research as a guiding principle, collective efficacy was applied to practice by
considering the influence group beliefs have on utilizing technology in the healthcare setting.
When the data is analyzed, collective efficacy will reveal technology adoption patterns within
staff groups such as hospital floors, departments, or teams.
In this study, data was collected through qualitative methods. As Creswell and Creswell
(2018) described, qualitative research is an approach that tries to comprehend the meaning of an
individual’s or group’s attribute to a social or human problem. The qualitative design aligns well
with the research conducted within this study since its goal is to identify systematic technology
barriers and staff perceptions of the technology they use within their role. Measuring attitudes
and perceptions of healthcare staff was captured effectively by interviewing healthcare workers
about their opinions through a qualitative approach. Merriam and Tisdell (2016) stated that
qualitative analysis assesses and captures how participants make sense of the world (p. 15). This
data collection method provided insight into the interviewees’ perceptions. It examined the
research questions to see a self-efficacy gap. In addition, Creswell and Creswell stated that
qualitative research offers insight into the participant’s perspectives related to their experiences
with the implementation and interaction of healthcare technologies.
Definitions
• Barrier: A physical or perceived wall that must be overcome to proceed to the next
step or process (Lluch, 2011).
• Collective efficacy: The willingness of a group to improve their technology
competency (Bandura, 2004).
7
• Competency: The ability to perform a task or job function with skill and knowledge
(Moskos and Isherwood, 2019).
• Emergency medical services (EMS): This group includes emergency medical
technicians, paramedics, police, and firefighters (Debenham et al., 2017).
• Financial Inequity: Funding disparity across an organization. (Zhang et al., 2011).
• First Responder: The healthcare staff that is the first to attend to a patient’s needs,
primarily outside the hospital setting (Debenham et al., 2017).
• Huddle: A meeting between staff members that discusses just-in-time topics (Marx
and Mihaljevic, 2019).
• Network: Technology or process solution that provides delivery of resources within
the organization. This term can also refer to a collection of people that a staff member
communicates with formally or informally to solve work-related issues (Lluch, 2011).
• Self-efficacy: An individual’s belief in their capacity to improve upon their
technology competency. (Bandura, 2004)
8
Organization of the Dissertation
Five chapters organize this dissertation. The first chapter presented the problem of
practice, its importance, and a review of the rationale for researching this topic. Chapter Two
will provide a review of the literature surrounding this problem. Chapter Three discusses the
methodology of this study and speaks to the ethics associated with this research. Chapter Four
describes the qualitative survey and presents the findings discovered throughout the data
collection process. Finally, Chapter Five provides recommendations based on the results and
suggests additional research study topics to conclude this dissertation.
9
Chapter Two: Literature Review
There has been much new technology in the healthcare industry throughout recent
decades. Eastman and McCarthy (2012) stated that healthcare organizations try to manage their
challenges by increasing technology to bridge organizational gaps. Eastman and McCarthy also
noted that the effort often fails when implementation focuses on the technology and not the user.
As a result, the user is uneasy with the change needed to adapt to the new solution. This study
examined the acquisition of technology competency and how it relates to collective self-efficacy
among healthcare professionals with financial inequity as a barrier. Technology competency
includes utilizing any piece of technology within a specific EMS role. Using Bandura’s (2018)
social cognitive theory as the methodology for this study, healthcare staff perceptions and
physical barriers to obtaining technology competency were analyzed. This literature review on
the practice problem examines literature under three primary topics. These topic areas are
technology challenges in healthcare, organization culture effects, and technology disruption. The
scope of this review encompasses all healthcare and does not focus solely on one specific
department or role. The types of technology referenced in this review are patient-focused,
educational applications, communication technologies, and cybersecurity.
Best Practices
Healthcare organizations use best practices when implementing technology solutions as
with other industries. Kaplan and Harris-Salamone (2009) stated that IT implementation projects
are often unsuccessful despite utilizing best practices. Grimes (2019) stated that professional
medical organizations do not collaborate at a level that supports evolving and converging
healthcare technologies. These organizations use a mix of internally derived best practices
realized by conducting lessons learned and additional tools that provide documented hindsight.
10
They also use external benchmarking, such as when a children’s hospital sought knowledge on
implementing their electronic medical record system (EMR; Marx and Mihaljevic, 2019). An
organization can benefit from leveraging best practices. Such exercises are valuable and help
technology implementation by reducing trial and error and increasing end-user’s cognitive load.
Similar to this study, Sheng et al. (2013) showed that knowledge transfer rates at
hospitals improve when staff members are competent with information communication
technology. As staff leverage technology, efficiencies in the work process increase, providing
several patient and financial benefits. Sheng et al. (2013) also stated that technology competency
improvement could be achieved by utilizing computer-assisted instruction, interactive
videoconferencing, and hand-held technology. In addition, knowledge transfer will increase self-
efficacy concerning end-user competence.
Review of the Research
The research regarding technology competency in healthcare is not just technical but
cultural centered and, according to Barnard (2016), has a relational link with historical, social,
professional, and cultural contexts. With this statement in mind, many influences can affect the
outcomes of technology implemented at the organization. For example, Daim et al.’s (2016)
research revealed negative attitudes healthcare staff have toward technology if it is not
implemented correctly. One key piece of research that discusses attitudes was conducted by
Rahman et al. (2016). They stated that an individual’s self-efficacy has a positive relationship
with goals to adopt technologies (Rahman et al., 2016).
Negative perceptions can also be driven by negative emotions when staff is exposed to
poorly implemented technology solutions. As Haji et al. (2015) stated, negative feelings would
increase anxiety when it overwhelms cognitive resources and reduces performance; therefore, a
11
high level of performance is needed by staff to improve positive patient outcomes through higher
staff technology competency. These negative feelings, such as frustration, manifested in a lack of
engagement when learning new technology. On the other side of the spectrum, per Juris Bennett
et al. (2015), training is a significant part of how staff members perceive benefits or barriers. He
stated that there is something unique about training sessions that help employee perception.
where the learners have the opportunity to engage with the technology in a safe environment
To support the influence that a staff member’s perception of the technology has on
technology, Holden and Rada (2011) named two categories of self-efficacy: computer self-
efficacy and technology self-efficacy (TSE). Both types have two attributes: commonly
perceived ease of use and perceived ease of use plus usability. These two attributes show the
correlation between staff members’ perception of their computer skills and the more extensive
macro-organization comprehensive of technology solutions. Furthermore, both CSE and TSE
significantly influence staff members’ behavior towards technology. For example, suppose there
is a lack of technology competency in one. In that case, there is a high probability of a lack of
competency in both.
This lack of engagement can have several causes. Blumenthal (2009) stated that if
technology constraints are set too high, then staff will rebel. The common theme throughout this
research that can exacerbate engagement difficulties within larger organizations is that they can
add to the cognitive load of the team by making technology implementation mandatory.
Dünnebeil et al. (2012) stated that larger institutions’ implementation efforts often fail due to
resistance within groups of key stakeholders. They identified that well-defined administration
and information systems (IS) security processes would improve the performance probability of
technology implementation. In addition to technology influencing engagement, external factors
12
such as the lack of finances can affect engagement. Heggie and Heggie (2008) state that EMS
organizations within their study are chronically underfunded. Heggie and Heggie (2008) also
stated that workload rates are different depending on the location and require more resources,
such as funding, depending on the number of incidents.
How healthcare assimilates technology solutions into their processes differs with the
organization. Angst et al. (2010) concluded that the organization’s age impacts the efficiency of
technology adoption. They also stated that younger or smaller organizations are less likely to
hold on to legacy technology and are more willing to adopt and experiment with new
technologies (Angst et al., 2010). This was important for this study to analyze and address its
findings since the organization studied has seven decades of tenure. Angst et al. also introduced
social proximity within a social group and stated that group interaction influences behavior. This
concept has significant implications for social cognitive theory and collective efficacy in this
study. Finally, Angst et al. suggested that larger healthcare organizations look to smaller, more
agile companies to test the technology first.
Technology is an ever-changing landscape. Lluch (2011) stated that the number of
possible applications implemented by IT within healthcare organizations is large. This large
number of applications can also be a significant barrier to adoption when resistance to a change,
leading to a barrier to acquiring technology competency. Petrakaki and Kornelakis (2016) stated
that once the technology conflicts with the discretion of introducing technology, the technology
meets with resistance. In addition, the speed at which technology is implemented and the lack of
governance through poorly planned rollouts can convolute workers’ daily tasks by adding
passwords, multiple tools needed to complete a job, and downtime events. Kaplan and Harris-
Salamone (2009) stated that IT-related failures in healthcare are covered up, ignored, or
13
rationalized, leading to the reputation of errors. When this happens, staff will become less
engaged, and self-efficacy will be lowered.
Due diligence must be completed in the infancy of technology projects to bolster
engagement. To support this claim, Chumbler et al. (2011) stated, “Usability studies can provide
rapid feedback to a design team so that the appropriate modifications to health IT tools
iteratively before the implementation when design changes are easier and less costly to make.”
(p. S39). Additionally, Cresswell and Sheikh (2012) stated about technology implementation,
If the goal is an implementation that satisfies the majority of stakeholders, a system needs
to be not only usable (i.e., technically sound) and valuable (e.g., fulfilling the needs of
users, organizations, and/or patients), but it also needs to be appropriately introduced by
organizations (e.g., through engaging with, training and responding to the needs and
expectations of relevant stakeholders). (p. e81)
Completing the upfront work needed to ensure the successful implementation of
technology in the healthcare setting is just one aspect of the entire solution. Alotaibi and
Federico (2017) stated that healthcare information governance is necessary for an organization’s
framework. Other components of this framework are safety risk identification, stakeholder
involvement, informed decisions, sufficient training, gradual implementation, continuous
evaluation and monitoring, and technology optimization.
Characteristics of the Stakeholders
In healthcare organizations, many roles support the organization and its operations. For
this analysis, a volunteer EMS healthcare organization was studied. This population is patient-
facing and has a high impact on patient outcomes based on the critical nature of their role since
this group is often the first interaction a patient has within the healthcare system. For example,
14
the National Highway Traffic Safety Administration (2011) stated that EMS provides an
improved patient outcome and financial savings by giving triage and transport when patients
present with severe injuries. These roles have many specializations and require different types of
technology to support them. This study's findings documented a sampling of the most common
technologies.
Along with the first responders studied, this research has a broad influence on other areas
of the healthcare system, such as emergency departments, the hospital systems, administrators of
these systems, the community, and the patients themselves. Healthcare IT staff members are
essential stakeholders and third-party vendors that provide IT services to these organizations.
Grimes (2019) cited an absence of collaborations between all stakeholders as a contributing
factor in fracturing the healthcare technology support industry. Focusing on EMS providers as
stakeholders are crucial to success since their decisions and actions negatively affect the health
provider chain. The National Highway Traffic Safety Administration (2011) stated that EMS
interventions show positive outcomes in short- and long-term care.
As a sampling of the most common technologies, EMS staff utilize communication
devices, global positioning devices, and computer stations to interact with EMRs and LMSs. In
addition, Reay et al. (2020) stated that EMS utilizes multimedia and location data to plan for
prehospital care. With the utilization of such a broad portfolio of technology, the stakeholders of
this study were also as comprehensive.
Challenges and Barriers in Context
There are many challenges and barriers in healthcare relating to technology. In addition
to self-efficacy and collective efficacy, Grimes (2019) stated that support, leadership, alignment,
collaboration, and resource barriers keep organizations fully engaged in the implementation and
15
acquisition of technology competency. This study concentrated on three areas: challenges with
healthcare technology, the effects of technology on organizational culture, and disruption as a
barrier to success.
Challenges With Technology in Healthcare
Technology usage in healthcare has many problems due to its complexity in computer
literacy, which increases competency gaps. However, Esmaeilzadeh et al. (2010) stated that
computer literacy is essential in interacting with IT systems individuals. Esmaeilzadeh et al.
(2010) also noted that increasing computer literacy could ease anxiety between human and
computer systems. Even though healthcare technologies transform nearly every interaction with
patients, according to the World Health Organization (2015), only 12% of countries have
formally evaluated mobile healthcare (mHealth). As Hopia et al. (2015) stated regarding broad
application tools, these tools “create new challenges in analyzing and compiling the data on the
health and activities of individuals for such information to be used personally by individuals,
health professionals, and public health monitoring authorities” (p. e2).
In addition to the number and complexity of the tools associated with healthcare roles,
keeping technology-driven tools secure adds challenges to acquiring technology competency.
Cresswell and Sheikh (2012) stated that it is essential to have an organization-wide change plan
that supports an organizational culture that contains incentives and participation by leadership.
Many influences have led staff to become disenchanted with achieving technology competency
within healthcare when these factors are not present within the organization. Difficulties with
technology may also harm a company culture and slow the organization’s agility to create
learning solutions that increase technology skills.
16
One way to increase positive technology perceptions to promote acceptance is to provide
a use case. Strudwick (2015) stated that if nurses believe that technology is useful and enhances
patient safety, improves quality care, or increases efficiencies, they are more likely to accept the
technology solution. Also, Strudwick (2015) stated that another factor leading to the likelihood
of acceptance is the ease of use. Strudwick noted that the perception of being easy to use is
related to usefulness.
Effects of Technology on Organizational Culture
Healthcare culture may not be agile enough to adapt to fast-paced advancements in
technology solutions and support the needed technology competency associated with job-related
tasks. According to a survey of 314 participants, Rahman et al. (2016) found a clear healthcare
technology adoption gap. Their study validated the need to examine individual efficacy
perceptions. They also found that two existing self-efficacies (general self-efficacy and computer
self-efficacy) have positive relationships with healthcare technology self-efficacy. Concerning
letting go of past processes and leveraging technology, Adler-Milstein and Bates (2010) stated
that there is awareness of the benefits of using EMRs. Yet only 17% of private physician
practices have transitioned to this technology.
Another example of healthcare’s lack of agility is that applications are created without
direct healthcare staff involvement. For example, a review of 111 pain management applications
for patient use (released on the market in 2009 and 2010) found low participation, as 25% of
healthcare providers were involved when developing such apps (Richardson & Reid, 2013). The
lack of agility will lead to the staff lacking motivation to learn new technologies and maintain
current skills, thus impacting collective efficacy. Grimes (2019) stated that the healthcare
industry underestimates professional roles concerning technology implementation. Grimes
17
(2019) also noted that this leads to under-sourced support programs, leading to solutions failing
to address issues. These issues lead to organizational barriers to the implementation of
technology. Grimes noted that IT support professionals are at a disadvantage and ultimately
require leadership to act.
Technology Disruption
Some technologies disrupt healthcare and add to the complexity of workers who already
struggle using technology. Hope and Zhang (2015) presented results from 250 surveys
distributed to five emergency departments and found that, on average, healthcare staff has 12
unique usernames and passwords to protect against intrusion. Hope and Zhang stated that Single
Sign-On (SSO) improves the user experience by decreasing the continual logins required to
interact with multiple devices. Autocompleting user login fields increases productivity as well as
reduces cognitive load. But Hope and Zhang also stated, “only recent research indicates that
approximately 36 percent of healthcare organizations in the United States utilize some form of
SSO” (p. 109)
Vassilakopoulou and Marmaras (2015) presented other ways of decreasing the cognitive
load on healthcare staff in a study concerning file uploads. They stated that options for file
uploads by the laboratories supporting healthcare organizations to diminish the administrative
burden are not widely adopted (Vassilakopoulou & Marmaras, 2015). In July 2012, almost 70%
of data entry was still manual (Vassilakopoulou & Marmaras, 2015).
Technology disruptions affect the self-efficacy of healthcare staff. Of the 749
questionnaires distributed by Juris Bennett et al. (2015), “perceptions of poor system
performance or inefficiency are less desired because they breed frustration: the system is not
functioning as it should, and its lack of performance negatively impacts the employee’s
18
performance” (p. 278). This lack of performance affects self-efficacy, which increases the time it
takes to gain technology competency. The pace of technology implementation does come at odds
with learning and adds to negative perceptions. The degree of technology needed to be learned,
combined with the need to continue to perform, is the primary reason healthcare professionals
are apprehensive about learning new technologies required for their role.
EMS Funding
According to Al-Shaqsi (2010), EMS services face various industry concerns: funding,
staffing, and increased utilization. Its funding issues are unique to the EMS community. Al-
Shaqsi (2010) says that these issues are a global problem, and innovative solutions are needed to
address these challenges. Also, EMS differs from other healthcare organizations because it is
highly mobile and agile to the community’s needs. Kahn (2012) stated that a large portion of an
EMS organization's expenses are maintaining readiness to respond to emergencies promptly over
many geographic regions. Other unique budget items are transportation and communication
solutions. According to Kahn (2012), additional items needing funding are augmenting staffing
based on demand, competency training, equipment, administration expense, and supplies.
In general, EMS organizations acquire funding from various means. Al-Shaqsi (2010)
stated that funding comes from both public and private. (2012) noted that these sources include
healthcare payers, municipal financing, direct patient billing, and periodic subscription fees. Also
stated that the reliability of direct billing falls short due to the patient not being able to afford the
services. This is problematic for an organization’s ability to keep up with the pace of
technology’s evolution. Hagen (2012) stated that reimbursement is below cost for 72% of all
ambulance transports.
19
One aspect often overlooked as a resource is future human capital for healthcare
organizations. Most healthcare staff start their careers within EMS. In addition, (2012) stated that
it is not uncommon for residents to begin their interests with EMS. Mandal (2018) noted that the
importance of human capital is essential within a healthcare organization. It can provide an
advantage by delivering faster patient response times, suggesting that when an organization
invests in its workforce to provide needed services, it will decrease patient wait time and
improve patient experience and outcomes. Mandal (2018) also stated that their research observed
significant IT influences in data networking and communication technologies related to human
capital.
There have been significant change initiatives within how healthcare organizations secure
funding. Brousseau and Chang (2013) stated that the future would hinge on the capacity to adapt
to change within a financially thin margined industry. Since the EMS community exists within
the healthcare industry, it sees significant change. Brousseau and Chang also stated that even
though change improvements support healthcare finance, these changes have not been uniform
or universal.
Conceptual Framework
The conceptual framework used for this research is based on Bandura’s (2018) social
cognitive theory causal model using healthcare technology as its scope. This study’s qualitative
analysis involved behavioral, personal, and environmental factors within this scope. Cognitive
and environmental factors were investigated concerning how they interact with behavioral
factors that influence outcomes of technology implementation expectations. Figure 1 is a visual
interpretation of the conceptual framework used in this study. Self-efficacy and collective
20
efficacy were discussed by referencing the developmental factors captured during qualitative
research.
Bandura (2000) stated that social-cognitive theory is differentiated into three forms:
personal, proxy, and collective agencies. Both self-efficacy and collective efficacy can be found
in personal agency. Still, collective efficacy can also be an environmental factor since healthcare
workers work within departments where individuals influence others. Figure 1 shows collective
efficacy within environment factors and self-efficacy within personal or cognitive factors. This
chart also shows how the environmental factors relate to the other factors within Bandura’s
social cognitive triadic. Wang et al. (2021) supported this by identifying a dark side to the social
sharing of information. The work environment can exact an emotional toll on cognition. The
recent global pandemic, COVID-19, and the way the organization addresses it draws parallels to
acquiring technology competency in that both can take an emotional toll on staff. Wang et al.
(2021) also stated that social sharing could mitigate emotional exhaustion regarding healthcare’s
dealing with COVID-19 and its impact on the industry.
21
Figure 1
Social Cognitive Triadic Healthcare Technology
Note. This graphic represents the conceptual framework of this study based on Bandura’s social
cognitive theory and adapted from “Emotional exhaustion in front-line healthcare workers during
the COVID-19 pandemic in Wuhan, China: The effects of time pressure, social sharing, and
Cognitive appraisal” by H. Wang, X. Zhou, X. Jia, C. Song, X. Luo, H. Zhang, H. Wu & J. Ye,
2021, BMC Public Health, 21(1), p. 829. (https://doi.org/10.1186/s12889-021-10891-w)
22
Self-Efficacy
The theoretical framework used in this study is self-efficacy and collective efficacy.
Rahman et al. (2016) defined self-efficacy in healthcare as the perceptions and user attitudes
towards IT. Chau et al. (2019) provided an example of self-efficacy by identifying a link
between perceived convenience and usefulness when adopting technology in healthcare. Thus,
self-efficacy research is vital to improving technology adoption decisions. Since healthcare
organizations strive for positive change with technology adoption, Tuck and Yang (2014)
defined a theory of evolution as a belief or perception about improving a situation.
Bandura’s (2018) self-efficacy theory is well suited to examine this problem of practice.
Understanding the perceptions of healthcare staff is key to improving obtaining technology
competency. Bandura (2018) stated,
that findings from diverse lines of research clarified the structure of self-efficacy,
specified how to build it, explained the mechanisms through which it works, and
provided guidelines on how to better people’s lives by strengthening belief in their
individual and collective capabilities. (p. 135)
Bandura’s structure provided the mechanism needed to implement this research’s change within
healthcare organizations.
Collective Efficacy
In addition to self-efficacy, this study examined collective efficacy. Bandura (2004)
stated,
People do not operate as isolates. On the contrary, they work together to improve the
quality of their lives. Their shared beliefs in their collective efficacy to accomplish social
23
change play a vital role in the policy and public health approaches to health promotions
and disease prevention. (pp. 159–160)
Understanding both self-efficacy and collective efficacy of healthcare staff regarding technology
revealed its influences on their daily work and gauged confidence levels when their organization
implements new solutions.
Collective efficacy was critical to this study as it relates to how a group of people who
have a common task interact and the efficiency of these interactions based on their efficacy.
Bandura (2000) stated that effort toward a particular outcome could be predicted based on
collective efficacy. In this study, that effort applies to how quickly technology competency can
be achieved during implementation. Bandura (2000) also stated that members of a group might
support each other. Still, the group’s outcome is the sum of the individual contributions rather
than an individual’s working together. Thus, this study examined both self-efficacy and
collective efficacy in presenting it.
Summary
Healthcare is a technology-driven and highly complex industry. This complexity leads to
many tasks that are needed to achieve a goal. Healthcare’s plan is ultimately centered around
providing high-quality patient care to all patients. Two factors contribute to the lack of obtaining
technology competency within healthcare.
Physical barriers or barriers caused by negative self-efficacy can influence the number of
tasks needed to obtain technology competency by adding complexity. Physical barriers can occur
when organizations implement technologies poorly by not benchmarking, following a sound
project management strategy, or having poor governance. Grime (2019) supported this statement
by stating that the healthcare technology support structure is fractured and identifies that this
24
results from differing priorities, cultures, and available resources. A negative perception of
technologies implemented will add to a disinterest in acquiring technology competency. The
second factor that impacts technology competency is the organization’s culture. Culture can
influence collective efficacy by creating an environment where acceptance and adoption can be
stifled. For example, Kaplan and Harris-Salamone (2009) stated that health requires
collaboration. There is difficulty among specialties, stakeholders, clinicians, and implementers
that results in a culture clash.
The common themes found throughout the studies discussed in this study are summarized
by Dhagarra et al. (2020). First, they stated the criteria for technology acceptance within
healthcare: the usefulness to the patient, the ease of use by the provider, and the trust in its
utility. All three must be in place for a successful implementation. The overarching qualitative
design of this research study will be defined in the next chapter. Chapter Three will identify three
research questions used to determine the scope of this study. These research questions focused
on staff’s perceptions of technology within their workplace and their mindset toward
implementing technology solutions. Also included in Chapter Three will be a description of the
data collection and analysis procedures.
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Chapter Three: Methodology
This study examined technology barriers and healthcare staff perceptions of technology
used within their professional duties. The relationship between the barriers and perceptions has
been established. One of the root causes of the lack of technology competency is financial
inequity among providers.
Research Questions
This study addressed two research questions:
1. What perceptions do healthcare workers have concerning how their organization
leverages technology with funding as a barrier?
2. What role does self-efficacy have when healthcare EMS staff implement or leverage
technology?
Research Setting
The research for this study was conducted at a volunteer EMS healthcare organization. I
chose this organization because it has a high impact on patient outcomes and was accessible to
me. Located in the United States, the organization is governed by a central body of directors. Its
day-to-day operations are managed by individual site personnel who incorporate local and state
protocols into organizational processes. The staff consists mainly of volunteers. Leadership and
support staff are either full-time, part-time, or per diem.
A sample of this population was selected by reaching each local entity and asking for
volunteers. Participants from three different roles were solicited as study subjects. The three
focus areas are EMS workers, support staff, and leadership roles. Both support staff and EMS
workers were recruited through mass email communication sent through their individual
organization’s distribution lists, flyers posted within their work areas, and face-to-face
26
communications during their work-related meetings. The search for leadership participants
focused on their roles within the organization. A personalized, focused email and a one-to-one
discussion were conducted to facilitate their help.
The Researcher
I am a healthcare professional who works within the studied organization, holding several
different leadership and individual contributor roles. Merriam and Tisdell (2016) stated that
insider issues may create positionality. My positionality may have conflicted with the
interviewees’ statements since I have high technical competency. The axiology of the research is
that technology is utilized to support the organization and is needed to fulfill current and future
needs. Therefore, my perception may have conflicted with or been confirmed by the data
collected, leading to bias. I used several strategies to provide high trustworthiness and credibility
for this study.
Data Sources
A qualitative approach was taken to collect data for this research. This approach provided
the best insight into the topic because of participants’ perceptions of their technology within the
role. Qualitative research was used to understand the participants’ experiences, capturing their
reality of technology competency acquisition. Merriam and Tisdell (2016) stated that qualitative
analysis assesses and captures how participants make sense of the world. Two sources of data for
this study were taken into consideration. First, interviews and documents collected from the
organization were assembled. The interview data was collected using focused discussions from
several roles within volunteer healthcare organizations being studied to have a high level of
credibility. This interview data provided a narrative of what was planned for technology
implementation. The second data source came from a documentation collection method. This
27
data source allowed triangulation of the statements taken from the participants during the
interview process. In addition, documents such as project management records, lessons learned,
and instructor training directions were reviewed.
Interview Data Analysis
The interview data analysis involved line-by-line coding. The analysis used a priori
codes. Priori codes were created after the interviews took place by analyzing common terms that
frequently appeared during the discussions. Reliability was increased by comparing coded texts
across all transcripts. Reflective memos during data collection helped to identify themes. The
coding software Atlas.ti was leveraged to organize the coded interviews and provide structure to
the data.
Document Data Analysis
The second data source that was researched was organizational documents. Again,
documents such as project management and training materials were leveraged. This organization
has an extensive library of documents supporting learners and instructor resources, such as
instructional manuals, mentoring guides, and LMS development documents. These documents
provided insight into challenges this organization faces regarding virtual learning, especially
narratives included within the instructor resource materials.
Strategies to Collect Interview Data
I interviewed participants using semi-structured protocols. The protocols were modified
slightly to address the staff member’s role. The interviews were conducted with a high level of
confidentiality by removing each participant’s personal information when presenting the data.
Pseudonyms were assigned to the participants and the organizations they are employed. The
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interview questions were aligned with research questions and written so that staff could respond
appropriately (Appendix A).
Participant recruitment took place via three methods. The first was direct emails to
potential participants. Also, flyers were posted at each physical healthcare provider’s location.
The third was introductory meetings with leadership to ascertain their interest in participating in
a formal interview.
The conceptual framework used for this study is social cognitive theory. Therefore,
perceptions of technology within the participant’s job function were measured. Interviews were
employed to determine complex technologies as barriers and perceptions through self-efficacy
and collective efficacy lenses regarding acquiring technology competency. The discussions
strived to shed light on self-efficacy and collective efficacy compared to physical technology
barriers.
The interview protocols included a semi-structured approach. This approach allowed me
to make the interviewee more relaxed and bolster honest answers. This approach also allowed
me to observe the non-verbal cues, as Bowen (2009) described. This non-verbal communication
can provide insight into the participants’ perception of technology in their workplace and offer
their reality.
Participants
The interviewees were 17 individuals from three different areas of the organization. This
study performed purposeful selections of participants identifying leadership, support roles, and
EMS staff across the organization. Each participant was scheduled for 60 minutes for each
interview. The participants represented a cross-section of the organization’s demographics.
However, tenure with the organization and the participants’ role was not a deciding factor for
29
selection. The goal was to have a wide-ranging selection of participants, including all employee
demographics.
Interview Data Collection Procedures
Merriam and Tisdell (2016) described the data collection procedures that this study
followed as an unstructured interview approach. The interviews took place in one sitting over a
45- to the 60-minute interval. Due to the COVID-19 epidemic that had a global impact, all social
distancing requirements were strictly adhered to during the interview process. At the beginning
of the interview, the interviewer read a brief introduction of the study’s purpose. Additionally,
confidentiality information statements were provided, and participants were allowed to stop the
discussion. None of the participants took the option to stop the interviews.
Trustworthiness and Credibility
The following three strategies were embedded into the interviews to support
trustworthiness and credibility: detailed descriptions, adequate engagement in data collection,
and triangulation (Merriam and Tisdell, 2016). These strategies ensured that the highest possible
validity and reliability were achieved by examining my position and the checks and balances
embedded in the three methods. As Merriam and Tisdell (2016) discussed, I provided a detailed
description so that the reader could match the context by leveraging a full report. The adequate
engagement in this data collection strategy achieved thoroughness of the respondents measured.
Lastly, multiple interviews and data sources ensured data triangulation. Merriam and Tisdell
(2016) stated that using various data sources and cross-checking this data from multiple
observations conducted at different times and locations would increase the trustworthiness of this
study. These strategies enabled high reliability and internal validity so that, if this study is
repeated, the findings would be consistent (Merriam & Tisdell, 2016).
30
Ethics
The ethics of this study adhered to high research standards. This adherence included the
engagement of the institutional review board (IRB) process and understanding of this study’s
limitations and the researcher’s positionality. For example, this study did not engage patients
who were in the care of the interview participants directly. No patient health information was
collected. Therefore, no patient confidentiality was violated through this research
The Rationale for the Institutional Review Board
Participants signed or verbal agreed via a recording to a release form informing them of
their rights regarding the interview and informing them that they could withdraw the data they
shared at any time. The interviews were held confidentially, and the participants’ names and any
other identifiers were removed. There was no incentive given for completing this interview. The
primary researcher conducted the administration of this interview. The interviewees were
selected so that no hierarchical influences would skew the results.
Underlying Ethics
This study indirectly served patients by providing an increase in positive outcomes. This
study can help healthcare workers identify deltas that, if addressed, could reduce the cognitive
load of remembering processes involved within technology interactions. In addition, the findings
of this study could impact patient patientcare in the form of wait times. The wait time is the
interval between seeking medical intervention and initial review by a medical professional (Marx
& Mihaljevic, 2019). Interviews were scheduled when a participant was not responsible for
direct patient care and would not be taken away from job tasks. I designed the discussion
questions and their scope.
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Patients were not in direct contact or within the interviews area during data gathering.
Therefore, no question was asked about patient information or related directly to patient care.
When a participant did use examples of technology during patient care, that participant was
guided to provide generalized models without using patient identifiers so that HIPAA regulations
were maintained.
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Chapter Four: Findings
This study aimed to identify challenges with acquiring technology competency among
EMS healthcare professionals with funding as a barrier to determine what role self-efficacy plays
within this acquisition. This research has leveraged Bandura’s (2018) social cognitive theory
causal model using healthcare technology as its scope. Two questions provided the basis for this
research:
1. What perceptions do healthcare workers have concerning how their organization
leverages technology with funding as a barrier?
2. What role does self-efficacy have when healthcare EMS staff implement or leverage
technology
Participants
17 participants were interviewed. All were located in the Northeastern United States. The
participants’ tenure ranged from 5 to 37 years in the organization. Therefore, the mean of the
participant’s longevity with the organization is 22 years. Five of the participants hold leadership
positions. Eleven have roles with multiple EMS organizations. Three are female. Five hold paid
positions.
The participants interviewed in this study come from diverse backgrounds. Four of the
participants are educators within their full-time occupations. Eight participants have full-time
careers within various regional healthcare organizations. Finally, five participants have jobs
outside of both healthcare and education.
Within their roles for their EMS organization, they all contribute to staffing field
operations. In addition, they require time spent with the organization to fulfill their annual
certification requirements. All participants are in good standing within their organization,
33
including maintaining several certifications, including CPR and practical patient care
demonstrations. Within the participation pool for this study, most of the EMS staff are
responsible for different roles within the organization, such as leadership, administration, and
educational functions.
Table 1
Participant Demographics
Participant
ID number Years active Leadership role Multiple EMS roles Volunteers/paid
1 27 Yes Yes
Volunteer
2 27 Yes Yes
Paid
3 17 Yes Yes
Paid
4 16
Paid
5 16
Volunteer
6 7 Yes
Paid
7 11
Volunteer
8 19 Yes
Volunteer
9 5
Volunteer
10 15
Volunteer
11 35 Yes
Volunteer
12 35 Yes Yes
Volunteer
13 18 Yes
Volunteer
14 22 Yes Yes
Paid
15 37 Yes
Volunteer
16 21 Yes
Volunteer
17 22
Volunteer
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Setting
The organization’s setting provides the context for interpreting the finding of this
research. The culture and leadership were the focus due to their influence on efficacy and
financial decisions relating to technology implementation.
Organizational Culture
The EMS organization consists of volunteers and paid personnel. A national component
oversees educational processes and provides consistency for local providers. In addition, the
organization has a divisional and regional subset made up of leaders in each competency area.
Each of the organization’s areas collaborates very differently. Therefore, each EMS staff
member is responsible for maintaining their certifications, which each area supports with
educational opportunities. These certifications can be national, state, or local.
Twelve of the EMS personnel are volunteers. Staff may also be members of several
different EMS providers in a region. Membership in multiple providers creates challenges and
benefits. One positive aspect is that a member serving with various organizations may bring a
diversity of thought and experience to facilitate change in a sphere of influence. Ultimately, all
must follow the scope of practice that governs the local EMS provider for which they currently
work. That organization may not be as technologically advanced as others, such as in the areas of
EMR documentation work processes.
Leadership
The organization is very flat regarding its leadership within the EMS organization
studied. Each member, including leaders, must maintain a baseline core competency. Although a
member may have specialized certifications or roles, all need a core set of competencies. There
is also a requirement regarding how many days a person needs to be active in their role per year.
35
Some exceptions apply to students and military personnel. However, the staff member still needs
to participate in ongoing annual professional development to maintain their required
certification. As for leaders, there is specific leadership for the organization’s operation and an
education arm that owns the educational processes for the organization. Each content area is
responsible for maintaining the mechanism for creating and maintaining competency. This
includes maintaining a positive culture that manages volunteers and paid staff to cultivate a
safety culture. Crowe et al. (2017) suggested that a critical EMS leadership competency is to be
safety conscious and advocate for safety. Leadership wears multiple hats and may be responsible
for numerous content areas.
Findings
The findings of this study were gathered from interviews and aligned to the conceptual
framework of personal or cognitive factors, environmental factors, and behavioral factors. There
were significant themes discovered within the data collected explicitly relating to barriers. Many
participants thought that funding and the lack of resources contributed to the lack of technology
competency. The findings illuminated a deficiency in several environmental factors. An example
is the lack of training and resources like computer terminals, communication devices, and Wi-Fi
access.
This research also suggests that the interviewees understand the need for implementing
and leveraging technology. They provided several examples of how technology improved their
educational experiences or work processes. The potential for improved productivity has been
realized, but technology itself was often a barrier to achieving the gains. In addition, the
participants stated that they have self-efficacy in their level of technology competency. Still,
36
when discussing questions relating to collective efficacy, there are opportunities for
improvement.
There is a need for additional research. One area where research is needed is how EMS
organizations implement technology projects and how they incorporate training into project
management. In addition, the correlation between funding and omitting stakeholder analysis was
identified for further research. More details on additional research options are discussed in
Chapter Five.
Technology Barriers
The interview data yielded several significant themes as technology barriers. The most
significant obstacle to acquiring technology competency was identified by Participant 14 by
stating that “the biggest barrier was the perception by the software and hardware developers that
their audience knew what they knew.” This statement suggests that the organization has assumed
that staff already knows how to leverage the technology needed for their role without conducting
a stakeholder analysis to measure the current state. Leggio (2014) stated that EMS on-the-job
training is a “sink or swim” within the exploration for outside research (p. 480). Several
participants described that leadership assumes staff members will already have technology
competency.
Another theme articulated by Participant 2 related to the LMS content design, specifically
related to learning pathways and the way the content was designed. They stated, “Another
blockade was that there wasn’t a great tutorial on navigating the marriage between registering a
class and registering the class through the publisher.” This statement suggests there is an
opportunity for improvement in educating staff regarding integrating tools. Another barrier is
using different devices and software to access the LMS content. Participant 14 stated, “When this
37
first rolled out, there were barriers to using iOS versus MS, the Android versus an Apple-type
system.” Also, several participants emphasized Wi-Fi access. Participant 4 stated,
Barriers affect my work … with the [place] itself and not giving us access to enough
technology. As a result, I don’t have Wi-Fi available, or I’m blocked out of certain sites
where I could use that to make my job a lot better.
Participant 11 also articulates the same experience of poorly designed content interfaces at a
different EMS organization located within another geographic region:
The one for the patient record system we have, the systems we have … interface through
Wi-Fi, and the Wi-Fi connection is very choppy and slow. So, that even frustrated people
even more because, it wasn’t a good, robust interface. It kept on locking up when they
were trying to learn and frustrated everybody.
With the advent of cloud-based technologies, access to the internet is essential. The lack of
connectivity will impact productivity which will intern impact patient care. Table 2 organizes
additional quotes from participants that support the three themes identified relating to technology
barriers.
38
Table 2
Supporting Information That Identifies Technology Barrier Themes
Theme Quote Remarks
Assumption of
technology
competency
So, they keep us disconnected
from the existing LMS
technology.
This disconnect and users’ lack
of trust adds to the collection
efficacy issues and is an area
for improvement.
Their audience knew what they
knew.
Assumptions reflect a lack of
project management due
diligence.
Learning design and
access
It’s not designed or not used in
a way that facilitates
learning.
This perception can be
addressed through content
development.
It’s used as a compliance tool
only.
The right technology selection is
critical for implementation
success.
They don’t send students to
create an activity.
This can be addressed through
better instructional design.
They’re missing learning
activities altogether.
This can be addressed through
better instructional design.
Wi-Fi access The Wi-Fi is terrible. This is a physical barrier to
completing one’s role.
Not being able to connect to
Wi-Fi, it’s a frustrating issue.
This can add to low self-
efficacy.
Wi-Fi is very choppy and slow.
I don’t know why they didn’t
try to get a better, stronger
Wi-Fi signal.
This can add to low self-
efficacy.
39
Productivity
Several participants mentioned productivity barriers several times throughout the
interview process. The most striking statement came from Participant 14, who discussed that the
IT group at their local organization decreases their productivity:
I have colleagues who have talked about how valuable that was to them in resolving an
issue in a much more timely fashion. My problem is you open the ticket. You hear back a
couple of days later, either with an answer, which is great, or, “Hey, we need more
information,” and now they’re chasing you. And it’s like this back-and-forth phone call,
email, and email to finally connect. And I got to tell you, over all the years I’ve been
doing this, there were many times I put tickets in, and I never got an answer as to what
the real issue was because we could never connect after that ticket placement.
This comment speaks to inefficiencies in time management and low service response levels
where communication is lacking. All three items identified connect to the lack of staff due to few
IT staff members.
Since EMS organizations operate in the rural setting, Participant 9 stated a limitation
when collaborating virtually: “With Zoom, it all depends on connectivity. There are some people
in the program, but unfortunately, their connectivity was in the rural area, and you couldn’t stay
connected.” Additionally, the need to communicate long distances via tools such as Zoom has
been more prevalent due to the COVID-19 epidemic. As a result, this organization sees
challenges with connectivity in this area.
Not all comments regarding the LMS were negative. Participant 10 provided a positive
response on implementation and productivity regarding the LMS: “The great thing about it is
after you’re done building your LMS-based course, this course can last for 10, 15 years. And the
40
next year, you’re just managing students through a course and managing grades and managing
their compliance certificates.”
Another area in which technology within the organization shows productive gains is
concerning EMR technology. Participant 13 provided an example:
So, electronic medical records or electronic incident reports of accidents certainly have
an upside. For starters, you’re not trying to decipher somebody’s handwriting. So, in
theory, it’s all legible. You can set it up so that you can’t not answer a question before
closing out a report demanding that the information be filled out completely. So, people
can’t miss something or skip something.
There seems to be a positive understanding among participants who use the EMR tool for patient
information gathering. However, connectivity in the field and the lack of resources to complete
the data entry were challenges.
Lack of Funding and Resources
The findings of this study suggested there is a lack of funding. Without adequate
financing or resources an organization may not achieve their goals as well may impact patient
care such as increasing wait times. Additionally, 35% of the respondents offered examples of
financial and resource deficits.
Resources
Participant 12, which is responsible for the governance and maintenance of one of the
two LMSs within the organization, stated that they lack IT resources,
The [organization] does have an IT person. However, I rarely see that person, seems like
maybe once or twice a season because he comes in to do something with the IOP phones
or something, and that’s about it.
41
As mentioned previously, the lack of IT and service levels is another example of a lack of
resources. Finally, Participant 4 stated that there are limited technology resources available:
“Here for our daily job, we do everything from hands-on with a pencil and a pen to maybe using
a television to see what the weather report’s going to be.” In addition to the lack of staff to
support technology, this statement illustrates the lack of technology due to funding.
Funding
Participant 14, which has a holistic understanding of the organization’s LMS, points out
the lack of funding and resources relating to education. They stated, “Typically, there’s never
been enough funding or resources to do it. And when I speak to the resource piece, I’m not just
talking hands. I’m talking about qualified resources involved in the development and deployment
of educational content.” This statement speaks to the interrelationship between funding and
resources, specifically regarding education as a resource. Participant 14 also mentioned, “Not
enough funding to adequately continually improve and monitor the software,” speaking to the
organization’s agility and the importance of human capital. Mandal (2018) stated that enhanced
performance would enhance healthcare agility, and human capital is essential to positive
performance.
Participant 15 is convinced that “funding would increase the usability and is the root
cause because the in-person help desks have gone away.” To support funding for human capital,
Respondent 16 stated, “Maybe paying somebody to teach people how to use this software and be
available for that software, be available when they were issues with or questions, concerning the
software.” Participant 2 tied the lack of project management into the scope of financial
resources:
42
I think it would help to improve some of those things. But again, if you throw money at
anything and you don’t use it wisely, or you put it in the hands of the wrong individual,
that’s not going to fix the problem for sure.
Without the resources to adequately fund IT, training and project management departments’
efforts to successfully implement technology will be stifled.
Self and Collective Efficacy
As presented in Table 3, the participants were asked about their confidence when using
technology. Forty-seven percent of the participants stated they were very confident, 29% said
they were satisfied, and 24% stated they had an average technology competency. They also
mentioned whether they were technology advocates or leaders within their EMS role or occupied
a technology-related position outside their EMS role. Forty-one percent of the participants are
technology advocates or leaders at the organization studied, and 24% stated they held
technology-related positions outside their EMS role.
Self-Efficacy
Participants were asked how comfortable they were with technology in general terms.
This question proposed a starting point for each person regarding where they were on the self-
efficacy scale. Also, each participant indicated their role within and outside the EMS
organization and if it involved technology. Table 3 summarizes the participant’s responses when
asked self-efficacy-related questions.
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Table 3
The Amount of Self-Reported Self-Efficacy of the Participants
ID
Technology role outside
EMS
Technology advocate/leader
within EMS
Self-efficacy
rating
1 No No Confident
2 No No Confident
3 No Yes Very confident
4 No Yes Very confident
5 No No Average
6 No No Average
7 Yes No Confident
8 No No Average
9 No Yes Confident
10 Yes Yes Very confident
11 No No Average
12 No Yes Confident
13 Yes Yes Very confident
14 Yes Yes Very confident
15 No No Very confident
16 No No Very confident
17 No No Very confident
The participants also made some condemning assertions. Participant 5 stated, “Basically,
it depends. I’m open to new things, to new technologies, but when it’s annoying, or when it
doesn’t work, or when it’s a hassle, I don’t like it.” A majority of the respondents shared this
sentiment. Participant 6 stated that they had trouble getting on the training website. They usually
have someone help get them online to complete their required training.
Collective Efficacy
The collective efficacy of the participants had several undesirable effects. The
interviewees articulated two key areas. The first is how the content’s design. The second is the
resistance to utilizing technology in the organization.
44
Participant 11 stated an opinion regarding the organization’s thought processes regarding
the LMS rollout and its evolution:
Since it’s a volunteer organization, they didn’t want to put more effort out than they had
to learn a new system. So, in the beginning, there was some reluctance and hesitancy
because they just didn’t feel comfortable with the system.
Participant 10, a technology advocate for the organization, stated, “I receive mostly complaints
about how boring or tedious or how difficult it was to listen to these lectures and work through
and answer the questions to move on.” This issue speaks to the organization’s instructional
design processes. This process is not necessarily a technology barrier, but this feedback can be
given to the organization. The content creation team can address it.
One comment spoke to the departure of human capital from the organization where
Participant 12 stated, “I definitely over the past few years, I know patrollers retired because they
said to hell with this newfangled stuff online.” In addition, several participants used more
explicit terminology throughout the interview process to indicate their attitudes regarding a
perceived negative correlation between technology implementation and turnover rates within the
organization. This comment builds a case for stakeholder analysis before conducting technology
rollouts. Finally, participant 16 stated an opinion regarding the organization’s demographics:
So, I think the attitudes for the older people using new technology is a little less willing to
change, a little more skeptical of the new software and glitches that might be in that
software versus a pen and a piece of paper.
This skepticism and resistance to change will impact collective efficacy since they work together
as a team and share opinions on the use of technology.
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Participant 11 spoke about their peer’s efforts with technology and the difficulties they
perceive having: “They struggle when it’s time to do things online [and] when it’s time to do the
refresher online, that kind of thing.” Finally, Participant 17 offered an opinion on a root cause of
technology resistance: “Technologically, especially, because people don’t always embrace
technology out of fear or lack of knowledge.” The perception of the group struggling with
technology anxiety will lead to more extended implementations of technology solutions.
There was one comment that was supportive of collective efficacy regarding the LMS.
Participant 15 stated, “I think everybody tolerated it well. Again, annoying in some aspects, but I
think because this has been going on for a couple of years, I think people are getting more used
to it and less aggravating.” This comment speaks to the evolution of the organization’s attitude
toward leveraging technology. The organization seems to have a continuous improvement
mindset and mechanisms to address issues annually.
Lack of Training
Participant 7 summarized the most-mentioned item, the lack of training: “The biggest
barrier has been insufficient training.” All participants cited the lack of training. Participant 4
stated, “There’s no training at all. They assume you’re already computer literate.” With limited
funding, an assumption may be that staff members need to be accountable for their computer
literacy. Participant 14 stated, “My learning prerogative regarding my EMS work has been, from
the training that I’ve been provided, has been inadequate for me to do the job.” Participant 7
stated, “From my experience, using different things like Zoom and I’ve used Microsoft Teams,
the biggest barrier has been a lack of sufficient training.”
A positive response came in the form of a training strategy. Participant 13 stated,
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That preloading of the experience, the training of the experience, and the intuitive nature
of the experience are key factors in acceptance and utilization. It shortens the time where
it becomes the new norm because that’s really what you’re creating.
This type of experience will lead to positive change and further the evolution of technology.
Within the organizational-wide document search, several documents mentioned how to
complete a particular task to validate the participant’s views on the lack of training on
technology utilization. However, there were no observed documents on using the tools
holistically. For example, one organizational document stated, “Never forget the challenge of
technology. Leave time for getting it set upright [sic].”
Technology Success Stories
Although this study identifies areas for improvement, some comments were positive
regarding the technology implemented or the organization’s overarching strategy. One positive
observation is that the participants see the value in the technology implemented. As referenced
earlier, Participant 13 stated,
So, electronic medical records or electronic incident reports of accidents certainly have
an upside. For starters, you’re not trying to decipher somebody’s handwriting. So, in
theory, it’s all legible, and you can set it up so that you can’t not answer a question before
closing out a report demanding that the information be filled out completely. So, people
can’t miss something or skip something.
Another statement contributed by Participant 15 regarding the benefits of technology cost and
logistics shows an understanding of the impact of technology on the organization’s bottom line.
They stated,
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I think the benefits are clear that the technology is a cost saver. It wasn’t easy to hold in-
person training sessions with respect to logistics and getting a platform or a facility
gathering to [bring] people together that have to travel miles to attend the training and the
support that would go along with it. I think that the advent of the Zoom and everything is
probably more cost-effective for all parties involved. I think that every organization is
facing a crisis with respect to expense, reimbursement, and retention.
Participant 15 pointed out that the funding crisis mentioned by Kahn (2012) shows that budget
cuts and EMS compensation shortfalls impact all aspects of the organization, including its
technology.
Participant 11 mentioned another benefit to the technology implemented:
So, you can do your online modules or now that stuff that you used to have to do on
paper with pen and paper, so to speak, you can now do online, protect your certificates.
So, that seems to be very helpful.
From their observation, participant 8 stated that integrating multiple technologies were
successful: “They integrate fairly well. Because we can get the 911 dispatches that we get to our
pagers, to our cell phones. We can utilize the CAD system. Basically, all these things are fairly
connected and reliable, on a whole.” These two statements support the fact that technology
improves staff members’ ability to succeed in their roles and shows a line of site-to-patient
management process improvement, which translates to an increase in positive patient outcomes.
Summary
The most significant barrier to technology success within the EMS community is the lack
of resources, specifically training. Since training is a resource and costs money, EMS
organizations fund training in the technology areas. As Heggie and Heggie (2008) stated that
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EMS organizations are chronically underfunded, the assumption is that these chronically
underfunded organizations lack the financial means to fully bring their staff’s technology
competency to a level that can sustain the organization’s overall role-specific needs.
The EMS staff studied has a high level of self-efficacy. They mentioned several times
that they could learn new technologies and find information to help them even if the organization
has not provided it. Forty-seven percent of the participants identified as very confident in their
abilities to learn new technologies. None of the participants stated that they struggle with
technology within their EMS organization.
The participants had both positive and negative impacts on their productivity. They stated
that connectivity to Wi-Fi is one of the root causes of negative productivity. However, the
participants noted that increasing funding for technology infrastructure could solve this. The
participants also stated that there was increased productivity specifically in two areas, one in the
documentation of patience, EMRs, and training development, where time would be decreased
based on leveraging technology.
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Chapter Five: Recommendations
This chapter discusses three central components. The first is how the findings align with
the literature review. The second is practice recommendations, and the third is an integrated
implementation and evaluation plan. Also, the recommendation for future research and the
limitations of this study will be addressed.
Discussion of Findings
Data analysis revealed three key themes. First, training is the primary barrier to
participants’ technology success. The second is that there is not adequate funding for technology
and the resources to implement and maintain it. Participants mentioned that increased funding for
training is necessary. The third is that there needs to be an improvement in the interviewees’
collective efficacy. The findings conclude that there is an adequate level of self-efficacy. Still,
when collective efficacy has discussed the beliefs, the group exhibited several deltas.
Participant 7 best summed up the lack of training barrier when they stated, “The biggest
barrier has been insufficient training.” All participants mentioned the lack of training. Nilsson
and Engstrom (2015) noted that staff who lack skills should have better access to learning
opportunities. Nilsson and Engstrom also noted that a well-educated, experienced, and competent
staff is essential. Furthermore, organizational documents seldom referenced how to complete
particular technology-related tasks but did not address participants’ views on technology
utilization. This lack of technology support documentation is one area recommended for
improvement.
Funding contributed to the lack of competency in this organization. The participants
stated that the lack of funding is evident in the absence of essential training, physical technology
solutions, maintenance, and support processes. The participants noted an interrelationship
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between funding and education for technology. Moskos and Isherwood (2019) stated that
training funding at the organization level competes with financial priorities, specifically at the
client level, which directly impacts the worker’s skill and quality of service. This competition
sheds light on why there may not be enough funding dedicated to training. Competing priorities
may have funneled funding away from training efforts. Also, Moskos and Isherwood stated that
the lack of training impacts the technology competency of workers by not contributing to the
evolution of staff’s skills.
Concerning self-efficacy, most participants stated that they were comfortable with
technology in general terms. However, when collective efficacy was discussed, there were signs
of resistance to technology implementation that came in differing opinions towards different
organizational areas responsible for project management or performance. Bandura (2000) stated
that the higher the collective efficacy, the higher the group’s motivation would evolve.
Bandura’s statement relates to this study because a group’s perception of technology connects
directly to its level of competency. To add a lens of employee relations, Nilsson and Engstrom
(2015) stated that job satisfaction, self-empowerment, and position in the group would improve
employee growth in educational opportunities. This growth is significant because, ultimately, the
EMS organizations want their staff to be satisfied to reduce turnover rates. Nilsson and Engstrom
also inferred that the group’s improvement would increase motivation and directly impact
collective efficacy. Based on the previous research into Bandura’s collective efficacy concept, a
deficit in collective efficacy is one area the organization should focus on for improvement when
managing all aspects of technology to support its workforce.
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Recommendations for Practice
This research found three areas of focus. The first is training and communication of
technology. This was the most referenced topic in the interviews. The second is addressing
funding gaps. This recommendation will suggest bringing equity to funding across the EMS
organization. Finally, the third recommendation is a focus on collective efficacy.
Training and Communication Planning
The most referred topic during the interviews was training on the technology used
throughout the organization. This high-impact recommendation for the organization studied
would provide training opportunities for current technology and future implementations.
Training planning should be embedded into the project management strategy. A suggested
training session and evaluation plan will be outlined in length within this chapter’s integrated
implementation and evaluation plan.
Concerning the overall management of technology projects, project management should
be utilized more effectively to provide efficient implementation and use of technology. Project
management tools such as stakeholder analysis, dashboards, and communication plans are some
of the tools that need to be utilized. Adams (2009) stated that group or staff interactions
influence an organization’s IT requirements and implementation of technology solutions. This
idea speaks to collective efficacy and the need to document such interactions with staff utilizing
stakeholder or event analyses tools. These analyses will not govern the project correctly but give
much-needed data to develop training initiatives and communication plans.
In addition to stakeholder or event analyses, a more robust process for communication
planning should be embedded into every staging project management strategy to implement
technology-related projects. Communications plans should involve leadership and include all
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communication vectors sent out directly from their office. This would increase staff buy-in for
initiatives, thus improving collective efficacy.
Addressing Funding Gaps
This study’s financial inequities were not itemized, but a general need was established.
Unfortunately, staff had no suggestion on funding additional resources or gaining the required
monies for hardware gaps. Since the research site is a volunteer organization with limited
funding, additional funding would have to be appraised, as validated by Heggie and Heggie
(2008).). This appraisal can be achieved in several ways, such as grant writing, donations, and
fundraising. Damianov and Peeters (2018) stated that smaller organizations utilize incentive-
based mechanisms to raise funds. This type of fundraising would benefit local EMS
organizations.
Addressing financial inequity across the organization is needed so that its small, localized
parts can bridge the technology gap. One solution is targeted subsidization by the governing
organization. First, a gap analysis identifies the most impactful areas that technology funding
would benefit from and then provides financing. Dasgupta et al. (2022) stated that targeted
subsidization leads to the sustainability of development goals. As for pooling resources, several
local EMS providers can network to utilize the exact technology solutions or vendors to realize
cost benefits by leveraging their larger size as a group.
A Focus on Collective Efficacy
Bandura (2018) stated that ignoring consequences can lead to a victim state, phobias. If
an organization ignores its staff when implementing change within technology, it will lead to
fear. This fear will impact collective efficacy when the team discusses such change throughout
their workplace collaborations.
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A stakeholder analysis should be considered and embedded into the project management
strategy of technology-related projects. The benefits of conducting a stakeholder analysis will
gather information about organizational perception to manage stakeholder expectations. In
addition, it will show staff that leadership is engaged in proactive data gathering to be used to
create the most efficient and effective final solution. Adams (2009) stated that discussing IT road
maps through stakeholder analyses and other project management tools and processes will
stimulate discussion on how the system and context evolve. This stimulation of thought as a
group will add to the collective efficacy when the implementation reaches the fully implemented
phase, and users will interact with the technology full time. This will be achieved by allowing
staff to be a part of developing the technology solution that they will ultimately be utilizing.
Tools like a stakeholder analysis are also a mechanism for facilitating two-way
communication. Focus groups or committees provide input into IT-related project development.
This type of communication will engage the project teams with staff. It will allow them to have
formal discussions to offer insight into the final solution. These discussions will improve
collective efficacy through group interactions and expectations for technology solutions earlier.
Yelton and Schoener (2020) stated that being physically present strengthened networks and
facilitated better communication and performance. Based on this statement, conducting focus
groups and setting up committees will provide group interaction where collective efficacy will be
strengthened.
Integrated Implementation and Evaluation Plan
This study’s technology training recommendation leverages Kirkpatrick and
Kirkpatrick’s (2016) four levels of an evaluation framework. This framework is a method of
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implementing measurement methodically throughout the organization. This model is scalable
and can be applied to almost all organizations and technologies to gather measurements.
Reaction, Level 1
A Level 1 evaluation will measure a participant’s feelings toward training or event. It will
add insight into discovering if it is valuable. It will also calculate how engaged participants were.
The instructor is also evaluated during this level regarding perceptions of their performance. This
level is utilized mainly for training.
Learning, Level 2
A Level 2 evaluation will measure a participant’s knowledge acquisition, skill,
confidence, or commitment.
Behavior, Level 3
This level measures how the participant applies the learning when returning to their role.
This level is essential data to gather so that the organization can gauge if they have a continuous
learning culture towards technology. Learning from a Level 3 is vital and should be an ongoing
improvement process to improve technology competency. Level 3 measurement will be
incorporated into the learning plan and integrated into the implementation and evaluation plan.
Results, Level 4
Level 4 measures the extent to which outcomes occur due to the training, event, or
project. This level of measurement also incorporates leading indicators that keep initiatives on
track. It also facilitates accountability through both qualitative and quantitative analyses. Level 4
will be incorporated into learning and continuous improvement projects.
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Return on Investment, Level 5
Some alternate versions of the Kirkpatrick model identify an additional level, Level 5.
This level addresses return on investment (ROI) and return on expectations (ROE). Both ROI
and ROE will be leveraged within learning and continuous improvement projects. ROI and ROE
will show process improvement, stakeholder/ customer/learner expectations, and financial gains
or deltas. This level will not be applied to this evaluation plan.
Organizational Purpose, Needs, and Expectations
The organization aims to provide emergency care, rescue, and education services. There
is an expectation for technology usage based on their organizational pillars. The organization’s
leaders also articulate that they would like to become financially self-sustaining. Within their
technology and infrastructure pillar, they use best practices.
Data collection will be crucial to supporting this organization’s purpose throughout this
implementation and evaluation. This implementation and evaluation plan will focus on
technology training opportunities and leverage the existing learning measurement strategy.
Dubnick (2014) stated that a critical viewpoint could elevate questions and issues about accepted
practices. He went on to say that they can also underscore assumptions that describe why
accountability-based programs and policies fail.
The organization expects its staff to be technology competent before interacting with
their training offerings. Therefore, there will be several items within this implementation and
evaluation plan discussing the process. According to Tetlock et al. (2013), the organization has
difficult choices between process and outcomes. To leverage Tetlock’s statement, each process
examined will align with the outcome of educating their staff so that they are successful in their
roles.
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Stakeholder Description
The stakeholders for this plan are all EMS staff needing to utilize technology within their
role. Therefore, staff will measure impact using Kirkpatrick & Kirkpatrick’s (2016) Level 4
measurement. Additionally, the team will provide resources and data collection to aid with
implementation.
Stakeholder Accountability
The current accountability climate is similar to what is described by Tetlock (1992) in
that the leadership favors outcome-based metrics. The stakeholders closely resemble what is
defined by the Olsen (2014) study. Olsen described similar characteristics where objectives,
technology, and experience are unclear. The organizational leadership also created the
accountability of a system in the form of regulators. Vibert (2014) described system authority,
which this organization exhibits as an actor wielding power and a forum that monitors how it is
to be used. The system accountability is also present within the organization’s hierarchy by
which the EMS directors are the regulators.
Lindberg (2013) identified two types of accountabilities applied to this initiative: patron-
client and audit accountability. Audit accountability will be primarily used when implementing
the methods to achieve the outcomes of this initiative that will be later described. The patron is
the leader of patron-client responsibility, and the client is the EMS staff.
Level 4: Results and Leading Indicators
The application of Kirkpatrick and Kirkpatrick’s (2016) framework will start with Level
4, results and leading indicators, and work to Level 1, reaction, to introduce the outcomes first.
Table 4 shows the Level 4 metrics as internal and external outcomes. The metrics and methods
for each outcome are itemized within the table. If the internal outcome is achieved, there will be
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a positive impact on external outcomes. According to USAID (2010), “Institutionalizing a
performance monitoring and management system enables an organization to regularly monitor
its performance in critical areas that are leading indicators of its overall performance success” (p.
21). The results capture by leveraging the table are the first step in creating a performance
monitoring system.
Table 4
Outcomes, Metrics, and Methods for External and Internal Outcomes
Outcome Metrics Methods
Internal outcomes
Increase technology training
opportunities
Count of training
opportunities
Create a database of
metrics facilitated by
dashboards that are
updated monthly.
Increase communication to
staff regarding technology
and funding initiatives.
Count of communications Quarterly trend analysis of
KPIs to be determined.
Increase internal spending
on technology training and
resources.
Amount of spend per year Annual report
External outcomes
Decrease outside training in
technology
Total amount of vender
assisted spend per year.
Annual report
Increase fundraising
initiatives
Total amount of spend per
year.
Annual report
Increase patient satisfaction Four out of a seven-point
Likert scale rating on a
satisfaction survey.
Patient intake database
monitored monthly.
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Level 3: Behavior
Critical Behaviors
The required behaviors that need to be addressed are identifying collective efficacy
improvement opportunities, allocating funding for training, and technology enablement.
Throughout this process, the changing of critical behaviors will be assessed in various ways,
illustrated in Table 5. In addition, Appendix D provides an example of a Level 3 assessment.
Table 5
Critical Behaviors, Metrics, Methods, and Timing for Evaluation:
Critical behavior Metrics Methods Timing
Enable technology
competency
through training
events
Obtain a satisfaction
metric of 4.0 on a
7-point Likert scale
A. Online survey A. Report of
metrics will be
made monthly
B. Reports made by
training staff via
in-class discussions
B. Reports of
metrics will be
made monthly
Address funding
inequities
Increase the annual
spending on
technology
training, resources,
or fixed assets by
10%%
A. Reports made to
the leadership
A. Report of errors
will be made
annually
Increase collective
efficacy
Satisfaction metric of
4.0 on a 7-point
Likert scale
A. Focus groups A. Monthly reports
B. Online survey B. Report of
metrics will be
made monthly
C. Reports made by
training staff via
in-class discussions
C. Reports of
metrics will be
made monthly
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Required Drivers
Table 6 presents the drivers that will reinforce, encourage, reward, and monitor the
critical behaviors of EMS staff. These methods will need to be collaborated upon with sight
directors within the organization since they will own the delivery. Depending on leadership
hierarchies and the size of the local EMS organization, the leadership engagement will be varied.
Table 6
Required Drivers to Support Critical Behaviors
Methods Timing
Critical behaviors supported
1, 2, and 3
Reinforcing
Daily huddle meetings Daily 1 & 3
Leadership meetings Monthly 1, 2, & 3
Share site collaboration Ongoing 1, 2, & 3
Encouraging
Daily huddle meetings Daily 1 & 3
One-on-one
manager/staff meeting
Monthly 1, 2, & 3
Leadership
communication on
success stories.
Ongoing 1, 2, & 3
Rewarding
The performance-based
rewards
Annual 2 & 3
Leadership
acknowledgment of
self-reporting
Ongoing 1, 2, & 3
Monitoring
Senior leadership visits. Ongoing 1, 2, & 3
Daily huddle meetings,
discussion boards
Daily 1, 2, & 3
Metrics dashboard Monthly 1, 2, & 3
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Organizational Support
The organization should provide the following support to ensure the success of the
critical behaviors and drivers outlined above. The organization should also offer transparency to
its organizational goals, for which the reduction of errors is a priority. Finally, this EMS
organization should empower its staff to identify learning gaps through collaborative
communication sessions such as department meetings, one-on-ones, and huddle meetings.
Level 2: Learning
The proposed training event will empower the acquisition and sustainability of
technology competency. Also, it will provide a mechanism in which staff can discuss challenges
and propose solutions to site-specific technology needs. In addition to evolving the utilization of
technology within the organization, this training program will aim to reduce turnover rates due to
frustration that may occur when technology is implemented throughout an organization.
Learning Goals
Upon successful completion of the training, the learners will be able to do the following:
• Identify technology resources for just-in-time issue resolution.
• Apply root cause analysis to just-in-time error resolution.
• Articulate the reporting technology process.
Program
The training program purposed will address the learning goals itemized above via
instructor-led training (ILT) or virtual instructor-led training (vILT). This ILT or vILT event will
be conducted within 2 hours. It will be broken into four sections dedicating 30 minutes per
section. This training program will be held during the annual required session to maintain staff
members’ certifications. The first section will assess the learner’s current technology comfort
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and competency through a structured discussion. The following team will review the technology
needed to fulfill an EMS role, the available resources, and the location. Section three will
introduce root cause analysis and techniques for problem-solving technology issues with the
presentations of case studies. The fourth section of the class will be instruction on reporting
technology issues to the organization. This section will take 25 minutes, with time at the end
consisting of 10 minutes for the learners to complete a written Level 2 assessment.
Evaluation of the Components of Learning
Table 7 itemizes the Level 2 methods used to evaluate the program’s learning described
above. The five elements of the learning program are essential. They provide a well-rounded
approach to addressing the identified behavior change.
Table 7
Evaluation of the Components of Learning for the Program
Methods or activities Timing
Declarative knowledge “I know it.”
The organization’s learning management
system administers document assessments
After a designated online class or course
The synchronous breakout session will be
conducted to reinforce the technology topic.
A breakout session will be conducted during
the designated class or courses.
Procedural skills “I can do it right now.”
Group presentation assessment During class or course
Attitude “I believe this is worthwhile.”
Direct observation of learners during class During class or course
Focused discussions After class or course
Reflection on the final class test At the end of the class
Confidence “I think I can do it on the job.”
Focused interviews with class participants After class or course
Reflection on the final class test At the end of the class or course
Commitment “I will do it on the job.”
Focused interviews with class participants After class or course
Reflection on the final class test At the end of the class or course
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Level 1: Reaction
Table 8 outlines the methods of obtaining Level 1. Kirkpatrick and Kirkpatrick (2016)
stated that a Level 1 assessment will gauge the learners feeling toward a training event and
measure engagement. Therefore, it is essential to measure the learners’ perception of learning
events to create actionable items to improve the learning events supporting technology
implementation.
Table 8
Components to Measure Reactions to the Program
Methods or tools Timing
Engagement
Informal assessments (question and answer
sessions) to measure the engagement
During each class section, random learners
will be called on to answer two or three
questions on the topic.
Direct observation by the instructor of
participation
During each class, ongoing
Class roster review (Attendance) At the beginning of class
Course evaluation via an online survey such as
Survey Monkey
Three to 7 days after the class
Relevance
Focused interview with influencers within the
class
Three to 7 days after the class
Course evaluation via an online survey
(Survey Monkey)
Three to 7 days after the class
Customer satisfaction
Focused interview with influencers that
attended the class
Three to 7 days after the class
Course evaluation via an online survey such as
Survey Monkey
Three to 7 days after the class
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Evaluation Tools
Immediately following the training program’s implementation, a survey will be sent to
the learners who attended the training 3 to 7 days after the training event. The collection method
will be an online survey, such as Survey Monkey, comprised of a series of questions expressed
using a five-point Likert scale and open-ended questions. This information will be leveraged to
improve upon the satisfaction training and engagement of the course.
The instructor will determine Level 1 evaluation data by leveraging the informal
assessment technique of direct observation to measure engagement. Any corrective measures for
engagement will be addressed in real-time or documented for improvement after the session. In
addition to the in-class assessment, a survey will be sent to the learners. Appendix C presents a
sample of Level 1 survey questions.
An online follow-up survey will be sent within 6 to 9 weeks. This survey will provide
insight into Levels 3 and 4. The survey questions will focus on whether the learner could apply
the knowledge directly to their role (Appendices D and E) for question samples. In addition to
this survey, data also exists outside this learning event and will be leveraged. Metrics reported by
the organization’s leadership will be monitored to gauge the impact on technology competency
and other return on expectation indicators.
Data Analysis and Reporting
Once a month, the data will be collected in charts. They will then be condensed into a
graphical form to be presented via a presentation. Appendix F provides an example of a diagram
used for reporting. Also, other evaluation techniques described previously will be discussed
during the leadership meetings where process training within the organization is concerned. The
presentations will then be posted on a share site. This share site should be transparent to all EMS
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staff who belong to the organization and a central repository for training outcome information.
Any deltas recognized will be incorporated into the learning event or addressed with the area
identified.
Summary
Leveraging Kirkpatrick and Kirkpatrick’s (2016) levels of training evaluations will create
a robust data set that is qualitative and quantitative. Through this framework, the data will add
credibility to the stakeholders for which this approach was designed. Technology improvement
starts with data collection. This data will be used throughout the project management phases of
technology-related projects.
Levels 1 and 2 will be able to answer the question of whether the training event met the
participants’ expectations and learning needs, whereas Levels 3 and 4 measure behavior changes
and results. This framework provides a sound approach that maximizes outcomes and achieves
the organizational mission. Ultimately the accusation of technology competency will be
improved, and the financial inequity within the organization.
Strengths and Weaknesses of the Approach
The qualitative approach of this research was the most robust way to examine the
perceptions of EMS staff regarding technology competency and how it relates to finance.
Creswell and Creswell (2018) stated that qualitative research offers insight into participants’
perspectives. The strength of this approach was that the interview format provided a lens into a
deep and rich understanding of the participant’s perception of technology and finance relating to
the sample studied.
The weakness of this approach was that there was very little objective data that supported
current technology solutions and the decisions based on the financial limitations of the
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organization studied. The subjective data in the research questions provide one side of the story.
It provides the voice of the customer and leadership perspectives outlined within this research.
Still, it does not consider the organization’s financial limitations, technology limitations, or the
EMS’s current climate. Quantitative data analysis would have provided a way of looking at
subjective data and looking for trends to be used in the final recommendations of this research.
Limitations and Delimitations
The findings based on the research questions aligned well with most organizational goals
to investigate a snapshot in time of the healthcare staff’s measurable perceptions. This topic is
broad in scope and does not reflect the healthcare industry. The responses only focus on
healthcare organizations at one volunteer organization in the eastern United States. Most
participants were located in Pennsylvania. This study was conducted by a researcher who
maintains a leadership role and may influence how staff training and development programs are
run. Merriam and Tisdell (2016) stated that qualitative research within this study also has
limitations tied to the researcher’s positionality, impacting the analysis.
The qualitative approach to this study also has limitations. The limitation of the
qualitative analysis approach is that it can become too overgeneralized. Gibbs (2018) stated that
if qualitative research is not grounded in data, it may become overgeneralized. In addition to this,
qualitative data capturing is a snapshot in time that may evolve into something new.
Recommendations for Future Research
The role of equity in this research was restricted to individual self-efficacy and financial
resources’ impact on technology competency acquisition. Four areas in future research should be
considered. First, what should be investigated is leadership’s impact on managing finance
challenges, specifically within technology acquisition and competency. The participants
66
mentioned leadership’s role sparingly only by the participants, but enough to consider a deeper
dive into the impact. This future research needs to include project management strategies since
leadership influences how technology projects are implemented.
The second area that should be considered for further research is if gender inequality
within EMS organizations impacts the acquisition of technology competency. The organization
studied has a very low percentage of individuals identifying as female. This study interviewed
three females, which is 18% of the participants. The researcher has completed their due diligence
in seeking inclusive opinions with limited success. The third area to take a deeper dive into is the
impact of a staff member’s age on self-efficacy in acquiring technology competency. The study
only looks at the staff member’s tenure and not age. One topic that the participants mentioned
was the turnover of tenured staff. This would also need to be researched to see if the turnover
rate is impacted by self-efficacy concerning a staff member’s age. Finally, the last area to
explore is the perspectives of EMS staff members that are with the organization from 0 to 5
years. The least tenured person that participated in this study was an EMS member for five years.
This study does not represent new members of EMS, and this demographic should be taken into
consideration.
Conclusion
This study provided data and insight into financial inequities and how this impacts
technology competency. This is important because this topic directly connects to patient care.
Without understanding the barriers to staff regarding their role competency, there is no basis to
start improvement initiatives.
Participants discussed several barriers, mainly the lack of training. The lack of training
led to negative emotions and a lack of technology competency. Haji et al. (2015) stated that
67
negative emotions increase anxiety when it overwhelms cognitive resources and reduces
performance. Managing perceptions of technology within an organization is advantageous for all
stakeholders. A negative employee experience will lead to having less competency and a
negative patient impact. Bandura’s (2018) self-efficacy theory relative to collective efficacy
supported this problem of practice by providing a framework to understand the perceptions of
healthcare staff so that areas for improving technology can be identified.
The staff provided examples of unpleasant experiences due to partially implemented
technology solutions. In that case, this will negatively impact self-efficacy and affect collective
efficacy. Grimes (2019) stated that support, leadership, alignment, collaboration, and resource
barriers keep organizations fully engaged in the implementation and acquisition of technology
competency. Participants have also provided several examples of root causes of partially
implemented technology solutions. The participants noted that funding is a significant barrier to
technology competency. Funding must be increased for technology and training.
Three main recommendations were given to address the findings. Training and
communication planning, addressing funding gaps, and focusing on collective efficacy were the
primary areas the organization should consider as improvement initiatives. In addition, several
suggestions were made on research topics that would lead to further understanding of this topic.
68
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Appendix A: Interview Questions
The interview questions below were used within the interviews conducted within this
study. Each interview question is aligned with one or multiple research questions identified
within column RQ addressed. Each interview question was asked of each participant. In addition,
a potential follow-up question was asked if the primary interview question did not present
adequate data. Each of the questions was aligned with the research questions and the conceptual
framework used for this study.
Table A1
Interview Questions
Interview questions Potential probing
questions
RQ addressed Conceptual
framework alignment
Can you describe
your attitudes
towards learning
technology
implemented
within your
organization,
specifically with
the LMS?
Can you provide an
example of how
technology
improved your
ability to complete
your work?
RQ1 Personal/cognitive
factors
Think back to the
most recent
training technology
implemented
within your
organization; how
did your co-works
respond?
What opinions do
your co-workers
have regarding
utilizing
technology within
your organization?
Were there enough
resources available,
and if so, what
would be needed to
make it successful?
RQ1 Environmental
factors
79
Interview questions Potential probing
questions
RQ addressed Conceptual
framework alignment
Thinking back to the
example of the
most recent
software
implemented, what
are some barriers
to learning new
technology within
your role?
How did these
barriers affect your
work?
Did financial
resources create
barriers, and if so,
how?
RQ1 Personal/cognitive
factors
Describe your
experience
interacting with
several different
types of technology
within your daily
work.
What challenges did
you experience?
Are there better tools
you know of, and
can you list them?
RQ1 Personal/cognitive
factors
What is your
experience logging
into your computer
and software
application with
multiple
passwords?
What are your
challenges when
having various
passwords?
RQ1 Personal/cognitive
factors
Can you describe
examples of
technology devices
that did not
increase your
productivity?
Where the devices
within this example
cumbersome or
physically broken?
Was the funding
available to replace
any broken
technology?
RQ1 Personal/cognitive
factors
How well are you
trained on the
technology you use
within your role?
What is your opinion
on the overall
training strategy
within technology
implementation
within your
organization?
RQ2 Personal/cognitive
and behavioral
factors
80
Interview questions Potential probing
questions
RQ addressed Conceptual
framework alignment
Describe your
confidence level
when learning new
technology.
Provide an example
of your confidence
increasing or
decreasing after a
training event?
RQ2 Personal/cognitive
factors
How often do you
ask someone in the
office or refer to an
outside resource
for help with
technology?
Describe your
process when
seeking assistance.
Have you networked
with your peers to
solve a technology
issue?
RQ2 Environmental
factors
How often do you
call IT for
assistance?
What is your
experience when
interacting with IT
to address your
questions?
RQ2 Behavioral factors
Do your peers
interact with IT for
support issues, and
describe your
perception of their
experience?
Do you and your
peers interact to
solve IT-related
issues?
RQ2 Behavioral factors
81
Appendix B: Informed Consent Form
University of Southern California
USC Rossier School of Education
Waite Phillips Hall, 3470 Trousdale Parkway, Los Angeles, CA 90089
Phone: (213) 740-0224
Study Title: Financial Inequity and the Impact on the Acquiring of Technology Competency
within the EMS Community
Principal Investigator: Brian Lee DeFluri
Faculty Advisor: Emmy J. Min, Ph.D.
You are invited to participate in a research study. Your participation is voluntary. This
document explains information about this study. Please ask any questions about anything unclear
to you.
Purpose
This study examines the challenges with acquiring technology competency among
emergency medical service professionals and the influence funding has on staff self-efficacy. We
hope to learn healthcare staff’s perceptions concerning how their organization leverages
technology and if funding is an influencer. Also, this study will look at if self-efficacy plays a
role when implementing technology. You are invited as a possible participant because you are a
member of an ancillary EMS organization that will provide insight into the purpose of this study.
Participant Involvement
If you decide to participate, you will be asked within a confidential 11-question interview
that will provide the qualitative data needed for this study.
These interviews will take place as a one-on-one event with the principal investigator. If you
agree to be interviewed, please contact Brian DeFluri at XXX-XXX-XXX or defluri@usc.edu to
82
schedule your interview. The interviews will take place via telephone or Zoom meeting and
adhere to the CDC’s recommendations for Covid prevention.
During the interview process, you may request to end it and destroy the data captured.
Also, after the interview until May 1st, 2022, you may request that your interview data be used
within the study and all files be deleted.
Payment/Compensation for Participation
You will not be compensated for your participation.
Confidentiality
The research team members and the University of Southern California Institutional Review
Board may access the data. The IRB reviews and monitors research studies to protect the rights
and welfare of research subjects.
No identifiable information will be used when the research results are published or
discussed at conferences.
This study will be creating audio recordings of the interview process. All participants
have the right to review/edit the audio recordings or transcripts. There will be three parties that
have access to the interview materials, the principal investigator (Brian DeFluri), the faculty
advisor (Emmy J. Min, Ph.D.), and the transcription company (Rev.com).
All notes and recordings will be kept confidential. Any written messages will be
maintained within a locked cabinet at the residence of the primary investigator. Electronic files,
such as audio recordings and transcription, will be saved within an encrypted file folder stored on
the primary investigator’s home desktop computer. The transcriptions and audio recordings will
be deleted once the data are reviewed and used within this study’s findings. This deletion process
will take place on May 1
st,
2022.
83
If there is a breach of confidentiality, all interviewees will be contacted and provided an
explanation of the violation. Any breached confidential material will be excluded from this
study.
Investigator Contact Information
If you have any questions about this study, please contact Brian DeFluri at XXXXXX-XXX-
XXX or defluri@usc.edu.
IRB Contact Information
If you have any questions about your rights as a research participant, please get in touch
with the University of Southern California Institutional Review Board at (323) 442-0114 or
email irb@usc.edu.
Acknowledgement
I _______________________ (Print your name) acknowledge the content within this
document and my right as a participant to stop the interview at any time as well as that I can
request to be excluded from the study up until May 1
st
, 2022. Please sign below to attest to this
statement.
Signature: _______________________ Date: _______________________
84
Appendix C: Sample Level 1 Assessment Response Data Chart
Response table
Strongly
disagree
Disagree
Neither agree
nor disagree
Agree
Strongly
disagree
0.00% 0.00% 0.00% 100.00% 0.00%
Before the training
event, the trainer
or training
coordinator
provides you
with technology
resources.
0 0 0 1 0
– 0.00% 0.00% 100.00% 0.00% 0.00%
The instructor was
knowledgeable
about leveraging
technology
during the
training event.
0 0 1 0 0
– 0.00% 0.00% 0.00% 100.00% 0.00%
The instructor
guided how to
utilize the
technology used
during this class.
0 0 0 1 0
– 0.00% 0.00% 100.00% 0.00% 0.00%
The connectivity
during this
training event
was acceptable.
0 0 1 0 0
85
Appendix D: Sample Level 3 Survey Questions
Level 3 evaluation sample questions
Strongly
disagree Disagree
Neither agree
nor disagree Agree
Strongly
agree
I was able to use the
knowledge gained in
this course
immediately.
I can perform what was
covered during the
in-class session.
I have met with my
manager to discuss
this training and its
application to our
organization.
86
Appendix E: Sample Level 3 Instructor Lead Training Survey Questions
Level 3 evaluation
sample questions
Strongly
disagree
Disagree Neither
agree nor
disagree
Agree Strongly
agree
I was able to use the
knowledge gained in
this training event
immediately.
I can perform what was
covered during the
training event.
I have met with my
leadership to discuss
this training and its
application to our
organization.
87
Appendix F: Sample Level 1 Assessment Data Bar Chart for Reporting
Abstract (if available)
Abstract
Research has found that EMS organizations are chronically underfunded. Additionally, healthcare staff workers juggle multiple competing priorities with the increasing need to leverage technology. This qualitative study aimed to discover a relationship between technology barriers relating to organizational funding inequities through the lens of healthcare staff members’ perceptions of technology they use in their professional duties. Seventeen participants were interviewed from various locations within the organization studied. Also, documents like instructor directions and training materials were analyzed. The participants were staff members of a volunteer EMS organization. The outcomes show the extent to which funding is a barrier to the acquisition of technology competency. Therefore, the interventions for this study are to provide recommendations for EMS organizations to support the investment of technology with limited funding and resources. In addition, this research can provide insight into their technology work processes and implementations.
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Asset Metadata
Creator
DeFluri, Brian Lee
(author)
Core Title
Financial inequity and the impact of acquiring technology competency within the emergency medical service community
School
Rossier School of Education
Degree
Doctor of Education
Degree Program
Organizational Change and Leadership (On Line)
Degree Conferral Date
2022-05
Publication Date
05/02/2022
Defense Date
04/18/2022
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
collective efficacy,emergency medical services,Finance,healthcare,OAI-PMH Harvest,social cognitive theory,technology competency
Format
application/pdf
(imt)
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Min, Emmy J. (
committee chair
), Hyde, Corinne E. (
committee member
), Maddox, Anthony B. (
committee member
)
Creator Email
brian@defluri.us,defluri@usc.edu
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-oUC111159681
Unique identifier
UC111159681
Document Type
Dissertation
Format
application/pdf (imt)
Rights
DeFluri, Brian Lee
Type
texts
Source
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(batch),
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
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Tags
collective efficacy
emergency medical services
healthcare
social cognitive theory
technology competency