Northcentral Risk mitigation strategies: civil engineering projects in Nigeria

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this chapter should be 15 pages not including references. I have uploaded all the information you need and will upload more if i come across something i think you may need. before using the prospectus paper make correction with the comment my instructor

1 An Investigation of Circumstances Affecting Consumer Behavioral Intentions to Use Telemedicine Technology: An Interpretative Phenomenological Study Dissertation Manuscript Submitted to Northcentral University Graduate Faculty of the School of Business and Technology Management in Partial Fulfillment of the Requirements for the Degree of DOCTOR OF PHILOSOPHY by Haywood Cutts Prescott Valley, Arizona April 2017 2 Abstract Concerns related to the protection of personal identification information, graphic user interface, patient privacy, and consumer acceptance, to name a few, have plagued the implementation of telemedicine. Advocates of telemedicine have gained the interests of consumers but failed to recognize the true nature of consumer attitudes towards the use of telemedicine. This research was a significant step towards understanding consumer unwillingness to use telemedicine. Understanding and acknowledging what customers feel is detrimental to improving the telemedicine implementation process. The purpose of this qualitative study was to explore consumers who may have experienced cognitive dissonance between their interest and the use of wireless body area networks. The interpretative phenomenological method was employed to understand and contribute knowledge about the phenomenon. The research participants were randomly selected patients, physicians, nurses, paramedics, and healthcare professionals. The findings contribute to knowledge by exposing the relevance of understanding cognitive dissonance, and its underrated affiliations. Such alliances play a meaningful role when embracing or rejecting the use of telemedicine. Future research may consider aligning and employing use behavioral models, such as the social cognitive theory, or the social capital theory, to help increase knowledge and understanding of consumer cognitive dissonance towards the use of telemedicine Advocates planning to implement telemedicine in rural areas could use these findings to help diminish or subdue indigenous consumer anxiety towards the use of telemedicine 3 Acknowledgements Thank you, Mom, for birthing me life. Your quintessence and memory are paramount stimulus and driving force propelling my pursuit to higher academic endeavors. I am utterly grateful for the guidance, persistence, and willfulness of numerous esteemed scholars and scrupulous professionals. The honor and pleasure to learn from you resonates within my demeaner, and disposition. Predominantly assuring the existence of this manuscript were a prestigious NCU Chair and Committee, namely the monumental wisdoms of Dr. Brian McKay Allen, the rocksteady insightfulness of Dr. Scott Burrus, and the just darn inevitable austerity of Dr. Henry Luckel. Thank you Dr. Anne Kohnke and Dr. Eva Mika for invaluable encouragement, understanding, and guidance to and through the crossroads of this relentless, yet incredible journey. Thank you to close, and not so close, family, friends, and frenemies for keeping your distance and being there unexpectedly. Thank you for enduring my rambling on those rare moments I emerged from my academia cocoon. Heartfelt acknowledgement to Ellington, an awesome son and mentor- your ambitions boosted my efforts to seeing this soul searching and mind boggling journey through; this manuscript is devoted to you. The universe prevails! 4 Table of Contents Chapter 1: Embracing Modern Telemedicine ..................................................................... 8 Background ................................................................................................................. 10 Statement of the Problem ............................................................................................ 12 Purpose of the Study ................................................................................................... 14 Theoretical Framework ............................................................................................... 15 Research Questions ..................................................................................................... 16 Nature of the Study ..................................................................................................... 17 Significance of the Study ............................................................................................ 18 Definition of Key Terms ............................................................................................. 19 Summary ..................................................................................................................... 20 Chapter 2: Literature Review ............................................................................................ 22 Documentation ............................................................................................................ 22 Synthesis and Critical Analysis .................................................................................. 23 Research Design Considerations................................................................................. 25 Subject Deliberations: Attention Emphasis ................................................................ 28 Emergence of Healthcare Information Systems ......................................................... 30 Telemedicine Technology: Wireless Body Area Networks (WBANs) ...................... 31 Wireless Body Area Network Fundamentals. ............................................................. 32 Characteristics Unique to Wireless Body Area Networks .......................................... 33 Wireless Body Area Networks Technological Framework ........................................ 34 Wireless Body Area Networks Consumer Concerns .................................................. 35 Telemedicine Elusive Value: Repercussions .............................................................. 36 Societal Recognition of Telemedicine ........................................................................ 37 Telemedicine Usage Implications ............................................................................... 38 Psychological Effects .................................................................................................. 40 Theoretical Insinuations. ............................................................................................. 41 Impediments and Attributes of Cognitive Dissonance ............................................... 44 Leveling Occurrence of Cognition.............................................................................. 48 Qualitative Prospecting of a Dilemma ........................................................................ 51 Exploring Acceptance ................................................................................................. 55 Relevance of Acceptance and Factors ........................................................................ 57 Analyses Techniques Profiled..................................................................................... 61 Theory of Acceptance in Practice ............................................................................... 66 Relative Literature Specifics ....................................................................................... 71 Knowledge Gaps ......................................................................................................... 71 Recognized Limitations to Research. ......................................................................... 72 Summary ..................................................................................................................... 73 Chapter 3: Research Method ............................................................................................. 75 Research Methods and Design(s)................................................................................ 76 Population ................................................................................................................... 80 5 Sample......................................................................................................................... 81 Materials/Instruments ................................................................................................. 85 Data Collection, Processing, and Analysis ................................................................. 87 Assumptions................................................................................................................ 97 Limitations .................................................................................................................. 97 Delimitations ............................................................................................................... 99 Ethical Assurances ...................................................................................................... 99 Summary ................................................................................................................... 101 Chapter 4: Findings ......................................................................................................... 103 Trustworthiness of Data ............................................................................................ 103 Results ....................................................................................................................... 104 Synopsis of Research Inquiries ................................................................................. 109 Portrayal of Data ....................................................................................................... 112 Evaluation of Findings .............................................................................................. 113 Summary ................................................................................................................... 114 Chapter 5: Implications, Recommendations, and Conclusions ...................................... 116 Implications............................................................................................................... 117 Recommendations ..................................................................................................... 120 Conclusions ............................................................................................................... 122 References ....................................................................................................................... 124 Appendices...................................................................................................................... 154 Appendix A: Interview Protocol ..................................................................................... 155 Appendix B: Informed Consent Form ............................................................................ 157 Appendix B: Informed Consent Form Readability Report ............................................. 160 Appendix C: Recruiting Notice ...................................................................................... 161 Appendix C: Recruiting Notice Readability Report ....................................................... 162 Appendix D: Interview Questions .................................................................................. 163 Appendix D: Interview Questions Readability Report ................................................... 164 Appendix F: Informed Consent Signature Procedure ..................................................... 166 Appendix G: Research Activities Procedures ................................................................. 167 Appendix H: UVA IRB Inquiry...................................................................................... 170 6 Appendix I: UVA FB Representative Inquiry ................................................................ 174 Appendix J: UVA FB Rep IRB Inquiry.......................................................................... 176 Appendix K: FB Rep Notification .................................................................................. 177 Appendix L: Approval to Post on HIMSS Facebook Account ....................................... 178 Appendix M: Approval to Post on UVA Health System Facebook Account ................. 179 Appendix N: IRB Approval with Conditions Letter Haywood Cutts ............................. 180 Appendix O: Example Site Telemedicine Research ....................................................... 181 Appendix P: Example Site Readability Report ............................................................... 182 Appendix Q: IRB Modification Approval Letter Haywood Cutts.................................. 183 Appendix R: Code to Theme Cooccurrence Table ......................................................... 185 7 List of Tables Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Conceptual to Empirical Literature Review Comparison ................................. 25 Question 1 Weight of Themes ........................................................................ 110 Question 2 Weight of Themes ........................................................................ 111 Question 3 Weight of Themes ........................................................................ 111 Question 4 Weight of Themes ........................................................................ 112 Degree of Transcripts...................................................................................... 113 8 Chapter 1: Embracing Modern Telemedicine Throughout the history of civilizations, innovations in the practice of telemedicine and information technology prompted new opportunities in patient healthcare and contemporary medicine (Wills, Sarnikar, El-Gayar, & Deokar, 2010). Telemedicine programs and healthcare practices directly benefited from improvements in the practice of information technology (Latre, Braem, Moerman, Blondia, & Demeester, 2011). Patient healthcare represented an important sector of any nation's economy (Gupta & Sharda, 2013; Kohnke, Cole, & Bush, 2014). The United States Department of Health & Human Services reported healthcare spending comprises roughly 17% of United States Gross Domestic Product (Gupta & Sharda, 2013). Telemedicine is gradually becoming a sought-after information technology tool. Telemedicine is used to improve the quality, safety, and efficiency in healthcare treatment (Duan, Street, & Xu, 2011; Bardhan & Thouin, 2013; Winstein & Requejo, 2015). Telemedicine is the remote monitoring, realtime interactive services, and data capture of medical information (Hughes, Xinheng, & Tao, 2012; Kohnke et al., 2014). Efficient healthcare information technology and telemedicine programs are important to businesses and communities (Kohnke et al., 2014; Petter, DeLone, & McLean, 2012). The convergence of telemedicine programs and healthcare information technologies creates new opportunities for improving the quality of life (Alwahaishi & Snasel, 2013; Jovanov & Milenkovic, 2011). Telemedicine technology facilitates new health care processes, such as remote doctor-patient consultations, remote monitoring of vital signs and health education services (Tsai, 2014; Vowden, 2015). Understanding the attitudes, apprehensions, and experiences of consumers are important when introducing 9 modern technologies to healthcare practices (Fensli et al., 2010; Hughes et al., 2012). For example, Knoblock-Hahn and LeRouge (2014) emphasized more research on consumer use of telemedicine technology is needed (Knoblock-Hahn & LeRouge, 2014). Previous research focused predominately on the adoption of innovative technologies by medical practitioners (Duan et al., 2011; Fensli et al., 2010). Cognitive dissonance affects consumer acceptance of telemedicine (Shareef, Kumar, & Kumar, 2014; Yang, Kankanhalli, Ng, & Lim, 2015). Undertaking research to help understand the effects of cognitive dissonance may help increase knowledge about consumer behavior attentions towards the use of telemedicine (Shareef et al., 2014; Fensli et al., 2010; Yang, Kankanhalli, Ng, & Lim, 2015). In this study, effects of an emerging telemedicine technology on the decision temperament of consumers were investigated. Wireless body area network is an evolving telemedicine technology (Abbas, & Assar, 2014; Sandhu et al., 2015). It is a technology designed to enhance remote treatment of patient healthcare (Misra & Chatterjee, 2014; Wang, Agoulmine, Deen, & Zhao, 2014). Wireless body area networks consist of compact sensors placed around a patient's body to collect and transmit vital signs and anatomy for diagnosis (Chen & Pompili, 2011; Sandhu et al., 2015). Wireless body area networks facilitate real-time interactive data capture, and remote monitoring of various patients (Akhter et al., 2014; Latif, Abbas, & Assar, 2014). This study is in four sections. The first presents the central ideas and contexts of this document. It includes the research problem, the purpose of the study, research questions, and definitions of key terms. Certain aspects relevant to the study of the phenomena are highlighted. Inquiries and 10 suppositions to illustrate the relations between healthcare information technology and its usage are included. The Theoretical Framework section groups into themes pertinent thoughts and concepts about the research questions. It contains explanations linking the practice of new healthcare information technology and users of telemedicine programs (Corley & Giola, 2011; Hilberts & Gray, 2014). The Review of the Literature section illustrates relevant works authored by scholars and researchers essential to this study (Martelo, 2011). The concluding chapter, Research Method, highlights the criteria and techniques used to decipher the characteristics of the research. The features include design dimension and measurements applied in this study. A summary of the research ideas and contexts, and a proposed plan to contribute to the practice of telemedicine technology is provided. Background The fundamental principles of telemedicine have evolved alongside the evolution of communication, healthcare, and information technology (Shareef et al., 2014; Whitten, 2006). The practice of remote healthcare involved either the medical practitioner visiting the patient, or a layman through written instruction, manuscript, or memory (Miladinovic et al., 2013; Schwabl & Vennos, 2015). The arrival of modern technology helped usher in newer, faster, and more efficient ways to provide healthcare to patients in remote areas or difficult to reach places, such as a ship or distant land mass (Miladinovic et al., 2013; Rizzo, 1997). Modern day advocates and practitioners of patient healthcare, who agree on the benefits of telemedicine, are eager to bring about grandiose implementations of telemedicine (Breen & Matusitz, 2010; LeRouge & Garfield, 2013). 11 Telemedicine is fast becoming a choice tool for healthcare professionals, as well as for patients, but not without encountering resistance by those who are less enthusiastic about it (Cooper, 2015; Dewsbury & Ballard, 2015; Yang et al., 2015). Healthcare professionals and patients, as well as other consumers, such as home care facilities and emergency technicians, have varied reasons for agreeing or not agreeing to use telemedicine (Hilberts & Gray, 2014; O'Fallon & Butterfield, 2012). Advocates and enthusiasts typically promote the benefits of using telemedicine, assuming people will eagerly use telemedicine because of the benefits alone (Achelrod, 2014; Nuq & Aubert, 2013). Kohnke, Cole, and Bush (2014) suggest the benefits of using telemedicine do not convenience people to use it. When the use of telemedicine is unwelcomed, advocates and enthusiasts are baffled. The implementation of telemedicine has slowed because the behavior of consumers who are less enthusiastic about using it is not understood (Buck, 2009; Prasanna & Huggins, 2016). Consumer intentions research has helped researchers understand more about consumer behavior, which focus primarily on understanding consumer intentions of consumers to use telemedicine (Escobar-Rodríguez & Carvajal-Trujillo, 2014; KnoblockHahn & LeRouge, 2014). Researchers suggested understanding the behavioral intentions of consumers would help improve consumer adoption and use of telemedicine (Attuquayefio & Addo, 2014; Winstein & Requejo, 2015). Different theories, such as the unified theory of acceptance and use of technology model, and the social cognitive theory, were used by researchers as theoretical frameworks to help understand consumer behavioral intentions (Cheng & Chu, 2014; Kohnke, Cole, & Bush, 2014; Sun & Rau, 2015). Review of research findings about consumer behavioral intentions have helped 12 understand the perceptions of consumers towards the use of telemedicine but failed to recognize or understand consumer attitudes affiliated with the decision to use or not use telemedicine (Kohnke, Cole, & Bush, 2014; Martins, Oliveira, Popovic, 2014). Other researchers suggested that consumers naturally strive to ensure there is consistency in their individual beliefs and behaviors. Otherwise, conflict and contrary views cause problems that most people hope to avoid (Festinger, 1957; Harmon-Jones, 2012). It is essential to the practice of telemedicine to understand not just consumer behavior intentions, but consumer attitudes and beliefs associated with the decision to use or not use telemedicine (Antoniou et al., 2013; Young, 2011). Introducing recent technologies to consumers instigates unforeseen or unknown problems, particularly when it involves a change in habit or routine and individual beliefs are taken for granted (Cegarra-Navarro & Carrion, 2013; Shealy et al., 2015). This research focused on exposing consumer attitudes surrounding the decision to use or not use telemedicine (Cho, Park, & Lee, 2014; Rideaux, 2015; Setta & Shemie, 2015). This study was necessary to enhance knowledge about the effects of consumer cognitive dissonance on decisions towards the use of telemedicine (Cegarra-Navarro & Carrion, 2013; Craig & Patterson, 2005; Karagozoglu, 2014). This research was practical because it helped facilitate illuminating consumer experiences with cognitive dissonance associated with decisions that impact the use of telemedicine (Cho, Park, & Lee, 2014; Koller & Salzberger, 2012; Wang et al., 2014). Statement of the Problem The general problem this study addressed was the unwillingness of consumers to use telemedicine (Al Ameen, Liu, & Kwak, 2012; Kohnke, Cole, & Bush, 2014). 13 Consumers understand telemedicine is designed to augment the livelihood of people and minimize patient healthcare expenses, but remain unenthusiastic towards its use (Dewsbury & Ballard, 2015; May, 2015). Researchers have suggested this dilemma might have an adverse impact on plans to introduce telemedicine technology (Phichitchaisopa & Naenna, 2013; Teoa & Noyesb, 2014). Researchers have posited it may be difficult for healthcare advocates to promote telemedicine when consumers show little interest in using it (Baig, Gholamhosseini, & Connolly, 2013; Kohnke, Cole, & Bush, 2014). Researchers advised this issue might affect patients, doctors, nurses, and emergency workforces; it obstructs the efforts of telemedicine supporters, manufacturers, and software developers (Alwahaishi & Snasel, 2013; Vowden, 2015). The particular problem this study focused on is consumer experiences with cognitive dissonance towards the use of telemedicine (Baig et al., 2013; Solling, Caroe, & Mathiesen, 2014). Consumers cordially embrace telemedicine until using it trespasses delicate principals (Baig et al., 2013; Winstein & Requejo, 2015). Cognitive dissonance emerges when consumer beliefs and attitudes conflict (Attuquayefio & Addo, 2014; Martins, Oliveira, Popovic, 2014). For example, wearing a wireless device may conflict with consumer cultural and religious beliefs (Hunter & Scott, 2010; Kaliyadan, Amin, Kuruvilla, & Ali, 2013). The barriers that inhibit consumer enthusiasm are a widely understated and undervalued phenomenon (Muehlan & Schmidt, 2013; Sorensen, Dyb, Rygh, Salvesen, & Thomassen, 2014). A review of the literature concludes gaps exists about consumer cognitive dissonance towards the use of telemedicine (Antoniou, Doukas, & Subrahmanyam, 2013; Jovanov & Milenkovic, 2011). The ability to extend health care to remote patients may diminish if the source of cognitive dissonance remains 14 unidentified and unchallenged (Abdul Karim, 2013; Levine, Richardson, Granieri, & Reid, 2014). Purpose of the Study The purpose of this qualitative study was to investigate consumers of telemedicine who experienced cognitive dissonance between their interest about telemedicine and their decision to use or not use it. The results of this phenomenological study facilitated a profound understanding of consumer cognitions towards the use of telemedicine (Karagozoglu, 2014; Rho, Choi, & Lee, 2014). In this study, inquiries into experiences with cognitive dissonance were used to explore consumer interactions with telemedicine (Pietkiewicz & Smith, 2014; Pi-Yueh & Ping-Kun, 2012). This approach helped identify schemes to lessen the effects of cognitive dissonance towards the use of telemedicine (Pietkiewicz & Smith, 2014; Roberts, 2013). Open-ended questions were used to investigate lived experiences of consumers influenced by incompatible beliefs, attitudes, and behaviors (Chapman & Clucas, 2014; Roberts & Clare, 2013). The interview was the primary instrument to collect research data (Bloomberg & Volpe, 2012; Seidman, 2013). Research questions and literature reviews were used to collect data (Bansal & Corley, 2012; Grossoehme, 2014). Data triangulation was employed to compare data illuminated during planned interview sessions (Bekhet & Zauszniewski, 2012; Houghton, Casey, Shaw, & Murphy, 2013). The study population consisted of purposively selected patients, physicians, nurses, paramedics, and healthcare professionals who have knowledge of or experience with wireless body area networks. The research sample size is n = 9 participants (Bertaux, 1981; Mason, 2010). This research sample size facilitated acquiring manageable data, and was sufficient for 15 narrowing the collection of participant perceptions articulated during interviews (Penner & McClement, 2008; Pietkiewicz & Smith, 2014; Mason, 2010). The research data sources were responses to open-ended questions, focus group discussions, and semistructured interviews. The research locations were web pages hosted on the Facebook Internet social media sites (n = 3). Theoretical Framework In modern first world societies, telemedicine technology is designed and developed to facilitate effective and efficient management of healthcare treatment and sustainment (Crenshaw, Hale, & Harper, 2011; Dewsbury & Ballard, 2015). The overall intention of this interpretative phenomenological research was to interpret the lived experiences of consumers to understand their cognitive interactions towards the use of telemedicine technology. Cognitive dissonance occurs when elevated inconsistencies in consumer cognitions surface (Hernandez, Haidet, Gill, & Teal, 2013; Yu-Lun & ChingJui, 2014). Inconsistent elevations could lead to unfavorable behavioral intentions towards the use of telemedicine technology (Kumar, Seay, & Karabenick, 2015; Sandvoll, 2014). Festinger’s (1957) original cognitive dissonance theory and HarmonJones’ (2012) theoretical reinterpretation will be used to illuminate the relevance of consumer cognitive dissonance (Festinger, 1957; Harmon-Jones, 2012). The theory was used to assess whether inconsistent beliefs and attitudes will arouse consumer cognitive dissonance (Festinger, 1957; Harmon-Jones, 2012). The theoretical framework for this analysis contributed to the cognitive dissonance theory by exploring the lived experiences of consumer cognitive while interacting with telemedicine technology (Karagozoglu, 2014; Cheng & Hsu, 2012). Examining the foundations of consumer cognitive 16 dissonance was essential to understanding how consumers encounter inconsistent beliefs and attitudes (Antoniou et al., 2013; Barker, 2003). The cognitive dissonance theory exposes consumer sentiments affecting decisions towards the perspective of an artifact, such as stocks or adverse publicity (Antoniou et al., 2013; Young, 2011). This theoretical framework was purposeful for delineating consumer insights towards the use of wireless body area network technology. For example, this structure can be used to recognize the consonant choices and attitudes of paramedics towards a new Sensitivity Array Test System. The cognitive dissonance theory posits conflict between consumer consonant and dissonant cognition could alter decisions to use telemedicine (Koller & Salzberger, 2012; Wang et al., 2013). Telemedicine technology is fast becoming an integral alternative for patient healthcare treatment, sustainment, and management (Levine et al., 2014; Winstein & Requejo, 2015). A broader understanding of consumer cognitions and the personal specifics impacting consumer behavior is crucial to the future of telemedicine (Dewsbury & Ballard, 2015; Sandvoll, 2014). The research findings will increase the awareness of consumer cognition and behavioral intentions towards the usage of wireless body area networks (Cincera, 2013; Thomas et al., 2013). Research Questions In this qualitative study, four research questions were used to explore the basis of consumer experience with telemedicine (Cincera, 2013; Wang et al., 2013). Q1. How do consumers describe experiences with individual beliefs and attitudes towards the use of telemedicine? 17 Q2. In what settings do consumers experience individual beliefs and attitudes towards the use of telemedicine? Q3. How do consumers approach uncertainty to change individual beliefs and attitudes towards the use of telemedicine? Q4. What challenges do consumers experience when personal beliefs and attitudes conflict with the use of telemedicine? Nature of the Study In this study, the qualitative method was utilized (Bloomberg & Volpe, 2012; Moustakas, 1994; Pietkiewicz & Smith, 2014; Roberts, 2013). The qualitative phenomenological design is appropriate to the exploration of the lived experiences of consumers’ encounter with cognitive dissonance and telemedicine (Moustakas, 1994; Pietkiewicz & Smith, 2014). In this study, phenomenology was used to focus research activities on the fundamental nature of consumer experience with cognitive dissonance (Pringle, Hendry, & McLafferty, 2011; Roberts, 2013). The interpretative phenomenological approach was used to facilitate the exploration and understanding of consumer cognitive dissonance (Moustakas, 1994; Smith, Flowers, & Larkin, 2009). This approach was employed to assess consumer beliefs and attitudes affecting consumer cognition (Moustakas, 1994; Pietkiewicz & Smith, 2014; Smith, Flowers, & Larkin, 2009). The interpretative phenomenological approach underscored the exploration of consumer experiences and principles because they are crucial to the future of telemedicine technology (Gill, 2014; Moustakas, 1994). Within the framework of qualitative methodology, this study was appropriate for a phenomenological study. The 18 qualitative approach facilitated discovery of consumer cognitive dilemmas and perspectives, and an optimum avenue to contribute to knowledge. The interpretative phenomenological approach is unique to the purpose of informing on the experiences and perspectives of consumers towards the use to wireless body area networks (Moustakas, 1994; Pietkiewicz & Smith, 2014). The research questions petitioned the utility of factors affecting consumer beliefs and opinions towards the use of wireless body area networks. Researchers demonstrated certain factors affect consumer behavior intention and acceptance towards the use of telemedicine (KabakcıYurdakul et al., 2013; Saravani & Haddow, 2011). Researchers’ findings highlight consumer cognitive aspects towards the use of wireless body area networks is limited or nonexistent (Hung & Jen, 2012; Jovanov & Milenkovic, 2011). Undertaking this interpretative phenomenological analysis facilitated an opportunity to increase knowledge of consumer cognitive dispositions towards the use of wireless body area networks. The central research activities of this research included review of works contributing to consumer cognitive and behavioral intentions towards telemedicine, and review of qualitative data collection and analysis techniques. The research activities included a plan to recruit research participants, a focus group and semi-structured interview plan, and permissions from Institutional Review Board (IRB) authorities to conduct the study. Significance of the Study Businesses, organizations and governments rely on the innovations in information technology. They employ these techniques to accommodate individual needs and to strategize the execution of commercial and organizational endeavors (Blobel et al., 2012; Heselmans et al., 2012). Understanding the factors influencing consumer acceptance of 19 telemedicine technology is vital to societal communities and corporate leaders (Wills et al., 2010). The objectives of these entities are accomplished through the execution of an established blueprint designed to expose and illuminate consumer decision and behavioral intention (Koller & Salzberger, 2012; Scheck et al., 2013). This study employed the cognitive dissonance theory. This technique served as a blueprint to detecting and deciphering obstacles affecting consumer choices and acceptance (Karagozoglu, 2014; Taiwo & Downe, 2013). This framework facilitated research necessary to broaden knowledge of those elements impacting consumer decision and behavioral intention (Kohnke et al., 2014; Wang et al., 2013). Definition of Key Terms Consumers. Consumers are doctors, nurses, remote healthcare professionals, medical staff, patients, emergency management technicians, and paramedics (Wills et al., 2010). Healthcare Professionals. Healthcare professionals are clinicians, doctors, nurses, remote healthcare professionals, emergency management technicians, and paramedics (Wills et al., 2010). Medical Treatment. The activity of healthcare professionals and patients to sustain or improve the healthcare of a patient (Wang et al., 2014). Patients. Patients are male and female adults who are treated for medical conditions (Wills et al., 2010). Procedures. Procedures are the clinical practices used to remotely monitor, store, organize, and retrieve patient treatment information (Wills et al., 2010). 20 Remote Location. Remote location is the place patients are treated and monitored for a medical condition away from the physical location of a healthcare professional (Khan, Yuce, Bulger, & Harding, 2012). Telemedicine Programs. Telemedicine programs are the technology, procedures, data, information, and equipment used to make effective and efficient decisions (Oman, 2011). Wireless Body Area Networks. Wireless body area networks are the electronic sensors, coordinator, computers, and mobile devices used to monitor and treat patients remotely (Wang et al., 2014). Summary Telemedicine technology continues to be a phenomenon at the forefront of strategic resources in the fight against human suffering and untimely demise. Technological capabilities such as wireless communication influence the practice of modern medicine (Hughes et al., 2012; Vowden, 2015). Telemedicine technology is gradually being integrated into the infrastructures of medical facilities and emergency units (Winstein & Requejo, 2015). Increasing consumer interests depends on telemedicine technology adopting a more significant role in the decision making of patient healthcare (Jovanov & Milenkovic, 2011; Levine et al., 2014). As telemedicine technology matures, the potential for wireless body area networks will see a tremendous increase in demand (Dewsbury & Ballard, 2015; Moeckli et al., 2013). Mobile wireless technology is already providing valuable services to consumers, particularly with the treatment of chronic illnesses (Kohnke, Cole, & Bush, 2014; May, 2015). Accessibility to telemedicine technology after an introduction and the sustainment of telemedicine 21 technology beyond implementation are overlooked factors (Kirbas & Bayilmis, 2012; Vowden, 2015). Achieving a broader understanding of consumer cognition and behavioral intentions is crucial to the implementation of wireless body area network technology (Baig et al., 2013; Misra & Chatterjee, 2014). 22 Chapter 2: Literature Review The objective of this literature review was to project an extended synopsis of theoretical works that corroborates the important characteristics of the research questions that probe consumer experience with telemedicine. Telemedicine is emerging as a hightech healthcare tool for improving the livelihood of people (Rideaux, 2015). The mental and physical well-being of people is essential to the growth, sustainment, and stability of communities and societies worldwide (Viers et al., 2015). Healthcare consumers are intrigued by the capabilities and practicality of telemedicine (Xuea et al., 2015). However, telemedicine consumers may not be so eager to accept telemedicine as part of a lifestyle (Ali & Khan, 2014). In this qualitative study, consumers of telemedicine who experience cognitive dissonance between their interest about telemedicine and their decision towards its use will be investigated. This review is in thirteen themes. The opening themes synopsize the gradual induction of telemedicine into societies and communities, preceded by themes that delve into human physiognomies that collaborate telemedicine usage and acceptance. The closing themes highlights perspectives appropriate to the study, followed by a summary of business acumen that aligns cognitive dissonance theory, research ideas and contexts, to telemedicine technology research. Documentation The primary source of the journals used for this study is the Northcentral University library while keywords were telemedicine, cognitive dissonance, psychological gap, analysis, and practice. Research activities consisted of reviewing journals analysis, and appraising the framework of telemedicine consumption and the cognitive dissonance theory. The literature review portrays an analysis of research 23 findings and discussions derived from the theoretical framework of scholarly writings (Pontes, Clement, & Rollason, 2014). The literature review highlights residual benefit and practical application of theoretical concepts and types of philosophies that attribute to credibility of the author, and the authors’ works. These examinations highlight real life situations motivated by social, cultural, and ethical issues that contribute to practical application of empirical research. The analysis and illustrated methodologies of these journals did not adhere to a singular theoretical framework. Synthesis and Critical Analysis The emphasis of this thematic literature review was to illuminate scholarly works about circumstances affecting consumer behavioral intentions and experiences towards the use of telemedicine technology (Ali, Zhou, Miller, & Ieromonachou, 2016). Research strategy of scholarly journals and articles was initiated to gather, access, and analyze subjects, findings, and conclusions pertinent to this research topic, the purpose and problem statements, and the research questions (Cornell, 2015). Keywords and terminologies served as search indicators for this literature review. The source of keywords and languages came from research results determined during the concept paper development phase and subsequent research activities (Maguire & Clarke, 2014). Keywords and terminologies included cognitive dissonance, wireless body area networks, telemedicine, healthcare information technology, healthcare technology, interpretative phenomenological, interview, qualitative methods, consumer acceptance, consumer behavior, consumer intentions, technology acceptance theories, technology acceptance models, and technology acceptance frameworks. Those keywords were critical to 24 identifying content that was applicable and relevant to the research parameters (Oliver, 2015). Research of those keywords and terminologies were not in any particular order or precedence. This integrative analysis integrates and synthesizes classical literature relevant to the research a topic (Bloomberg & Volpe, 2012). This assessment of literature was used to conjure central conceptual and empirical themes (Pontes, Clement, & Rollason, 2014). These ideas helped form the groundwork of the research proper (Cornell, 2015). This review provides clear and balanced depictions of current theories, concepts, and findings of the investigated themes (Constantinides, Chiasson, & Introna, 2012). Table 1 illustrates the diverse and weighed emphasis of empirical and conceptual journals and articles that were researched and analyzed (Maguire & Clarke, 2014). This illustration depicts rations between conceptual and empirical literature analyzed, the quantity, and balance (Douglas, 2013). The balance does not imply any bias towards any particular research methodology. 25 Table 1 Conceptual to Empirical Literature Review Comparison Theme Quantity Conceptual Empirical Cognitive 140 49% 51% Dissonance WBAN 105 27% 73% UTAUT 160 48% 52% Model TAM Model 137 46% 54% Social Cognitive 88 38% 63% Theory Telemedicine 220 45% 55% Design 179 45% 55% Other 323 47% 53% Total Works 1352 Weighted Cumulative 44% 56% Note: WBAN means wireless body area network; UTAUT means theory of acceptance and use of technology; TAM means technology acceptance model; and other means methodologies, frameworks, and concepts. Research Design Considerations. The research design role varied for each article that appears to align relative to the unique ethical challenges surrounding consumer acceptance of telemedicine (Ataria, 2014). Scholarly articles reviewed for this study reflect a heavier reliance on the fixed mixed methods research design over the qualitative research design and the quantitative design. This observation does not coincide with the design approach used for this study, which is a qualitative methods design. Qualitative methods are unique to exposing a deeper outlook towards the behavior of people, and the underlying factors inducing such behavior (Creswell & Clark, 2011; Fouad et al., 2012; Grossoehme, 2014). To date, more than one thousand journals have either been considered or reviewed for this study, with 26 roughly half of them cited as references. Sixty-eight percent of those articles employ the mixed methods designed, with the qualitative and quantitative methods being relatively even. In a qualitative study of social aspects, the authors have used a descriptive review of the literature to investigate the phenomenon (Muehlan & Schmidt, 2013). Several qualitative studies reflected summarized interpretative phenomenological analysis to illustrate conclusions about consumer choices and behavioral intentions (Dutta & Singh, 2014; Solling et al., 2014). A qualitative grounded theory study on the lens of evolutionary psychology demonstrated scholars are not sensitized towards evolved psychological mechanisms (Abraham et al., 2013). Examining psychological implications relative to cognitive dissonance may be helpful understanding consumer attitudes (Freijy & Kothe, 2013; Guazzini, Yoneki, & Gronchi, 2015). In a telemedicine case study, the researchers presented a unique illustration of methods of data collection used in the study (LeRouge, Garfield, & Collins, 2012). The approach was exceptional considering research questions required individual analysis processes, which attributed depth to each issue (LeRouge, Garfield, & Collins, 2012). Researchers using the quantitative design encountered language obstacles with survey questionnaires initially developed in English (Achelrod, 2014; Martins, Oliveira, Popovic, 2014). The authors employed the services of a professional translator with the definitive version of the questionnaire (Achelrod, 2014; Martins, Oliveira, Popovic, 2014). A vast amount of informative data and illustrations presented in a wireless body area networks study left this reader feeling rather overwhelmed (Misra & Chatterjee, 2014). It’s as if the authors produced a technical manual instead of a scholarly journal. 27 In summating the research findings and conclusions, Sikka & Barash (2012) presented an extraordinary case, reflecting on three challenges to health care: access, quality of care, and cost-effective care (Sikka & Barash, 2012). The suggestion was interesting, but the absence of any supporting data or data analysis appears to render the researchers’ findings somewhat insignificant. In a separate study, the researcher used the qualitative research approach, while employing the descriptive statistics, and the nonexperiment design approach to analyze and condense research data (Camlek, 2011). The author suggested as telemedicine matures there is potential for an enormous amount of workflow content to become available, which is a major concern for telemedicine consumers (Camlek, 2011). Conducting research is necessary to expose essential particulars of controversial problems associated with consumer acceptance of telemedicine. Investigators examined how to improve access to health care for large population bases following the mixed method approach. The authors used a quantitative approach to analyze comparatively perceptions and experiences of various user groups, and a qualitative approach to the illuminate reasoning behind user attitudes toward system automation (Cline & Luiz, 2013). Structured interviews were conducted, using a combination of closed-ended and open-ended questions (Cline & Luiz, 2013). Researchers of a qualitative study about telemedicine applied the ethnographic method (Solling, Caroe, & Mathiesen, 2014). The approach allowed the investigators to have informal conversations in the private homes of telemedicine consumers (Solling, Caroe, & Mathiesen, 2014). The researchers employed the ethnographic method to obtain a thorough understanding of the everyday life of the research participants (Solling et al., 2014). The research design role varied for each article, which was particular to the unique 28 ethical challenges surrounding consumer acceptance of telemedicine. Focus group and structured interview methods held a significant presence in qualitative research, and limited usage in quantitative studies (Levine et al., 2014). Researchers used both a survey instrument and the interview techniques in a qualitative study of consumer telemedicine acceptance (Sorensen et al., 2014). It is reasonable to conclude survey instruments play a significant and helpful role when researching the telemedicine consumer acceptance dilemma (Viers et al., 2015). Subject Deliberations: Attention Emphasis The employment of telemedicine technology, notwithstanding its promised benefits, has drastically slowed due to consumer reluctance to embrace it. Researchers and advocates of telemedicine have sought to understand what is causing this dilemma. American health insurance brokers such as Cigna Incorporated and Oscar Health have promoted consumer insurance plans that accommodate telemedicine services for the past five years (Gumpert, 2015). The Agency for Healthcare Research and Quality and The Leapfrog Group are among several consumer groups advocating the use of telemedicine, signifying telemedicine technology could significantly benefit healthcare consumers and the healthcare industry (Zhang et al., 2013). Gumpert (2015) concluded 15 million consumers were the beneficiaries of telemedicine since 2013, which reflects a fifty percent increase (Gumpert, 2015). Despite telemedicine activists realizing significant gains in consumer advocacy of telemedicine, certain factors continue to obstruct a wider acceptance in actual healthcare settings (Rideaux, 2015). Instigated by the concerns of advocates and the lack of knowledge about this phenomenon, government reforms, and investigative studies were set in motion (Cooper, 2015). 29 The 2009 American Recovery and Reinvestment Act sought to stimulate development, boasting $22 billion in government appropriations towards telemedicine modernization efforts (LeRouge & Garfield, 2013). Researchers aimed to increase knowledge surrounding the consumer acceptance predicament focusing investigative efforts on exposing and deciphering determinants that adversely impact telemedicine adoption (Alaiad & Zhou, 2014). The practice of identifying factors that induce behavioral intentions to use telemedicine emerged as a dominant approach to understanding the consumer acceptance predicament (Venkatesh, Thong, Chan, Hu, & Brown, 2011). Researchers converged on theoretical models about technology acceptance to understand consumer intentions (Alwahaishi & Snasel, 2013). Researchers employed theoretical models such as the unified theory of acceptance and use of technology, and the technology acceptance model in their investigations (Attuquayefio & Addo, 2014). Researchers used these models to probe possible reactions to temporal factors (Nistor, Gogus, & Lerche, 2013). These theoretical models emulate psychology, which postulates that consumer behavior portrays strong intentions to perform a behavior (Taiwo & Downe, 2013). Kohnke, Cole, and Bush applied this approach hypothesizing the factors that made up a model helped predict consumer behavioral intentions (2014). Research findings were encouraging but vaguely conclusive (Lee & Song, 2013). The effects of the model antecedents explained variances in consumer behavioral intention to use hospital information (Sharifian, Askarian, Nematolahi, & Farhadi, 2014). Research efforts to predict consumer behavior resulted in additional uncontested voids, further widening the gap in understanding consumer reluctance to embrace healthcare information technology (Kim, Lee, Hwang, & Yoo, 2016). Kohnke, Cole, and Bush 30 further suggested a focus on understanding why telemedicine consumers inhibit their use of the telemedicine was lacking (2014). Emergence of Healthcare Information Systems The role of information systems is increasingly becoming critical to patients and healthcare professionals, particularly in the areas of data capture and transfer (Attuquayefio & Addo, 2014). The interests and uses of wireless sensor networks in the treatment of patients are accelerating (Al Ameen et al., 2012). In a qualitative study, Fensli et al. (2010) found that the adoption and utilization of wireless technologies are growing rapidly (Fensli et al., 2010). The author concluded hospitals and medical equipment firms realize the potential benefits (Fensli et al., 2010). Lai, Lin, and Tseng have indicated an appropriate adoption of information technology significantly improves medical services and operations (2014). In a similar study, Lai et al. (2014) employed the Technology– Organization–Environment framework to illustrate the significance of emerging healthcare technology (2014). Innovative new medicine, medical treatment, therapeutic techniques, and information technology drive the rapid evolutions of telemedicine systems (Mays & Pope, 2000; Sikka & Barash, 2012). As a result, wireless networks and other relevant technologies have become pervasive in recent years (Chen & Bennet, 2013). This research phenomenon is exemplified in research conducted by Zhang et al. (2013). In that study, a descriptive statistics analysis of 586 participants was used to interpret differences in the characteristics of medical facilities opting to adopt or not adopt telemedicine technology (Zhang et al., 2013). In a qualitative study, Camlek found interoperability, data standardization, and user adoption challenges exist impacting the 31 deployment of telemedicine services (2011). The research findings of Glaser and Overhage (2013) found consumers trust a learning organization (Glaser & Overhage, 2013). Glaser and Overhage also noted the efficient use of telemedicine technology benefits the transition of hospitals and health systems (2013). Gururajan and Hafeez-Baig posited that researchers should align with patient healthcare environments to develop suitable methods for addressing research questions (Gururajan & Hafeez-Baig, 2014). Telemedicine Technology: Wireless Body Area Networks (WBANs) Telemedicine comprises information technology configured as communications platforms, designed to accommodate management of patient healthcare in remote environments (Dewsbury & Ballard, 2015). Attributes of telemedicine enable healthcare professionals to administrate patient health care between distant stations or locations, such as a residence and hospital (Allan, 2006; Butcher, 2015). Telemedicine configurations accommodate specifications about the nature of a therapeutic service and design capacity (Rideaux, 2015). Vowden (2015) found telemedicine consumers faced with challenging medical situations adjust by adopting strategies (Vowden, 2015). Telemedicine technology aligns medical treatment, monitoring, and management capabilities during emergent and catastrophic events (Hung & Jen, 2012). Telemedicine is designed and used to resolve remote clinical challenges and barriers about mobility limitations of isolated or rural populations (Miladinovic et al., 2013). Peripheral components to telemedicine are composed of hardware and software that provision realtime two-way communications (Sorensen et al., 2014). LeRouge, Garfield, and Collins (2012) concluded service interactions between service providers and telemedicine consumers, would improve immensely through 32 mediating healthcare information technology (LeRouge et al., 2012). Telemedicine facilitates information exchange during emergency and non-emergency situations that involves medical facilities, patients, and healthcare professionals (Winstein & Requejo, 2015). Telemedicine capabilities include video and audio conferencing, echocardiograms, human anatomy measurement, etcetera (Levine et al., 2014). The type of telemedicine employed is distinguished by the medical disposition of a patient, and the type of treatment administered (Vowden, 2015). Wireless body area networks are a unique telemedicine component, specifically designed to augment monitoring, diagnostic, and treatment (Wang et al., 2014). Wireless Body Area Network Fundamentals. Wireless body area networks are revolutionizing medical therapy and specialist care of patients (Baig, Gholamhosseini, & Connolly, 2013). The wireless body area networks ostentatious value lay predominantly in suitability, accommodating telemedicine consumers with enhanced diagnoses and therapeutics monitoring capability (Sandhu et al., 2015). This form of telemedicine compliments healthcare patients and professionals by averting physical visits, and streamlining time constraints (Wang et al., 2014). Wireless body area networks afford the extension of remote medical capability, such physiological observations, appraisal of vital signs, and stress measurement of human body parts (Khan, Yuce, Bulger, & Harding, 2012). Patients are no longer restricted to a hospital bed while recovering from procedures, and healthcare professionals have increased flexibility in managing healthcare (Kirbas & Bayilmis, 2012). Wireless body area networks are crucial to accommodating aging populations, particularly patients stricken with immobility issues 33 (Latre et al., 2011). Wireless body area networks eliminate cumbersome wiring and heavy instruments that limit patient comfort and independence (Jovanov & Milenkovic, 2011). Wireless body area networks provision an array of electrographic functions, such as electrocardiography, electroencephalography, and electromyography (Zhou et al., 2015). Before wireless body area systems, patient monitoring required wired connections to signal processing components (Khan et al., 2012). These components tethered patients to beds or were either carried or affixed to a wheeled carrier (Ullah & Alamri, 2013). Wireless body area networks accommodate ease of mobility, impose small conservation costs, and cause minimal deployment restraints on telemedicine consumers (Hughes et al., 2012). Characteristics Unique to Wireless Body Area Networks. Wireless body area networks are patient wearable networked sensors that monitor the activities of the human anatomy, accumulate real-time medical statistics and track healthcare treatment and progress (Zhao, 2014). A composition of wireless body area networks consists of multifaceted medical bands that integrate biosensors designed to obtain physiological data. Sensor nodes are strategically placed to chart biosensors within designated regions of the human body (Kumar, Sivalingam, & Kumar, 2013). These sensor nodes are electronically interconnected and affixed to or nearby a targeted body point or zone (Ullah & Alamri, 2013). Implant versions of these sensors modules are statically located to enable physiological data collection (Touati & Tabish, 2013). These formations of biosensors facilitate continuous monitoring regardless the location of the patient or healthcare professional (Jovanov & Milenkovic, 2011). 34 Data parameters such as blood pressure, respiratory, temperature, glucose levels are aggregated and transmitted using wireless body area networks to specific receiving devices (Felisberto, Laza, Fdez-Riverola, & Pereira, 2015). Data collected are delivered to base stations located in hospitals, designated reviewing areas, or medical facility receiving centers (Felisberto et al., 2015). Healthcare professions use these centers to monitor or interface with wireless body area networks to process, visualize, and analyze patient data (Dewsbury & Ballard, 2015). Wireless body area networks biosensors are also capable of delivering therapeutic service to various regions of the body, such as muscle or nerve systems (Fortino, Di Fatta, Pathan, & Vasilakos, 2014). Wireless Body Area Networks Technological Framework. Broadband Internet technology is harnessed for connectivity to the infrastructure of telemedicine services (Shivaprakasha, Kulkarni, & Joshi, 2013). Internet technology is used to concentrate wireless sensors networks and wireless body area networks capabilities (Felisberto et al., 2015). These capabilities accommodate treatment and monitoring of patients in remote areas (Kim & Lee, 2014). Internet infrastructures comprise data bandwidth management, power consumption measurements, wireless communication protocols, encryption, frequency bands, broadcast remoteness, and verification devices and methodology (Khan, Yuce, Bulger, & Harding, 2012). Communication functions of sensors are configured to exchange data with coordinator devices that are worn by patients (Zedong et al., 2015). Coordinator devices collect and process the data transmitted by biomedical sensors, which sends the data to an Internet gateway (Sandhu et al., 2015). Wireless body area networks operate within an architecture that contains mobile computing network, sensor network, and remote monitoring network levels (Bhutta, 35 Cruickshank, & Sun, 2014). These levels facilitate extended communication range, high data rates, and exceptional positioning capability (Sandhu et al., 2015). Medical bands are components of wireless body area networks, used to reduce interference allowing data transfer to distant locations (Han, Han, Tuan, In, & Jo, 2014). Multi-hopping is a physical layer technique that facilitates broadcasting wireless body area networks efficiently (Diallo, Rodrigues, Sene, & Niu, 2014). Multi-hopping provides sensory nodes the ability to receive and transmit data simultaneously (Quwaider & Jararweh, 2015). Data receiving stations incorporate node technology to establish Internet connections to biosensor nodes (Sudha, Karthik, & Kumar, 2014). Local area networks, such as those supporting hospitals, use the same node technology for Internet connectivity (Shivaprakasha et al., 2013). Sensory node technology schemas facilitate access to patient physiological signals within a certain radius inside or outside a medical facility (Diallo et al., 2014). Wireless Body Area Networks Consumer Concerns. Wireless body area networks provide continuous detection, collection, transmission, and storage of pertinent patient data (Al Ameen et al., 2012). Security of patient data traversing the Internet, local networks, communication devices, and storage apparatuses stimulate social implications (Zhou et al., 2015). Safeguard and security of patient data occupy the judgments and cognition of telemedicine consumers (Pathania & Bilandi, 2014). The applicability and capability of wireless body area networks further exasperate telemedicine consumer uneasiness (Fortino et al., 2014). Telemedicine consumers are not all technologically savvy, but many understand the importance of privacy (Pathania & Bilandi, 2014). Safekeeping of personal information, particularly healthcare data captured, transmitted, 36 and stored using wireless body area networks, is the foremost priority of telemedicine consumers (Felisberto et al., 2015). Wireless body area networks are vulnerable to malicious, and intrusion cybercriminal attacks the same as the Internet and local area networks (Latif, Abbas, & Assar, 2014). The prospects of cybercriminal activity compromising personal or healthcare data managed through wireless body area networks causes a great deal of uneasiness with telemedicine consumers (Han et al., 2014). Cyber-criminal activities such as eavesdropping, passive and active attacks and denial of service threats adversely affect telemedicine consumer confidence in wireless body area networks (Latif, Abbas, & Assar, 2014). Telemedicine consumers understand eavesdropping exposes wireless body area networks to serious security vulnerabilities since remote healthcare relies heavily on information technologies (Quwaider & Jararweh, 2015). Telemedicine consumers expect reassurance patient healthcare data are securely stored and securely transmitted during usage of wireless body area networks (Illiano & Lupu, 2015). Telemedicine Elusive Value: Repercussions Improving patient healthcare is driving changes in medical practices at a phenomenal pace, surpassed perhaps only by rapid innovations in information technology (Dewsbury & Ballard, 2015). Telemedicine is one such technology affected by these changes (Abrahams & Singh, 2013). Telemedicine embodies communication, technology, equipment, and services used to function together to improve or sustain the health of people (American Telemedicine Association, 2012; Winstein & Requejo, 2015). Advocates describe telemedicine as a method used to increase access to the treatment, sustainment, and monitoring of patient healthcare (Moeckli et al., 2013). Researchers 37 suggested personal beliefs, cultural habits, opinions, and religious practices may influence the daily lives of people (Butcher, 2015). Research in regard to knowledge is limited whether these factors affect the use of telemedicine (Rho, Choi, & Lee, 2014). At the epicenter of this phenomenon are smart wearable components of telemedicine (Wingham et al., 2014). Smart wearable components are electronic devices designed to capture, transmit, and monitor the anatomy and healthcare treatment of patients (Shah et al., 2013). The wireless body area network is a smart wearable apparatus impacted by the dynamic changes in technology, which further compound limited knowledge of consumer use of telemedicine (Misra & Chatterjee, 2014). Societal Recognition of Telemedicine Healthcare systems comprise a broad spectrum of advanced diagnostic tools, information systems, computer networks, databases, and people (Winstein & Requejo, 2015). The attributions of information technology are immense, particularly when used to advance the field of healthcare (American Telemedicine Association, 2012). Telemedicine technology is gaining recognition as a solution to delivering healthcare services to metropolitan and other less-served areas (Tsai, 2014). Jovanov and Milenkovic (2011) conducted similar research, finding an obscure dilemma in the impact user behavior has on the acceptance of a healthcare information technology (Jovanov & Milenkovic, 2011). Weigel, Rainer, Hazen, Cegielski, and Ford (2013) conducted a historical study of relevant literature to understand the social effects of telemedicine technology (Weigel et al., 2013). The authors used a quantitative analysis approach to systematically search 2,188 periodicals (Weigel et al., 2013). Weigel et al produced ten research themes, or gaps in knowledge relevant to understanding the societal impact of 38 patient healthcare information technology (2013). The researcher’s findings indicate a much-overlooked issue in consumer behavior towards the use of telemedicine technology (Al Ameen et al., 2012). Social acceptance and finding a wider application of its use are vital to the progress of patient healthcare information technology (Latre et al., 2011). Any concept or assumption that people are openly eager and willing to use health care information technology without question are absurd and undoubtedly perilous (Martins et al., 2014). Misra and Chatterjee (2014) used the Theory of Social Choice in a mixed methods study. The authors applied descriptive statistical analysis to examine patient healthcare information technology used for post-disaster healthcare problems (Misra & Chatterjee, 2014). Investigating end-user perceptions and intention to use of patient healthcare information technology are fundamental to understanding this predicament (Thomas et al., 2013). The approach demonstrated by Rajagopal (2013) in a phenomenology study, used a conceptual model and a standardized coefficient to understand the predictability of tested independent variables within healthcare technology (Rajagopal, 2013). The author exemplified societal recognition of healthcare systems, indicating gains in efficiency resulted from the use of telemedicine technology (Rajagopal, 2013). Patients, doctors, nurses, and healthcare providers, have different perspectives on how, when, and why the use of telemedicine technology is necessary (Dabbs et al., 2013). Telemedicine Usage Implications The application of information technology for healthcare has received substantial attention, gaining acknowledgment of healthcare professionals, patients, and advocates (Butcher, 2015). Consequential variations across healthcare practices and consumer 39 based differences between medical facilities involve various types of technologies (Vowden, 2015). The primary objective of healthcare technology is to improve human welfare and sustain life (Dewsbury & Ballard, 2015). Technological innovations directly attribute to that goal, introducing new healthcare practices and procedures (Winstein & Requejo, 2015). Telemedicine is a technological innovation designed to accommodate healthcare treatment of patients located in remote locations (LeRouge, Garfield, & Collins, 2012). Telemedicine is used to help meet patient healthcare objectives, which may be used to help free up time for routine tasks (Mun & Turner, 1999). Telemedicine functions serve predominately as a communications and monitoring platform, deployed in remote areas to increase efficiency and patient independence (Rideaux, 2015). Convenience and proficiency are significant attributes of telemedicine advocates, healthcare professionals, and patients find appealing (Moeckli et al., 2013). Understanding the economic benefits of using telemedicine is important, but recognizing the relevance of telemedicine on consumer behavior is essential (Sandhu et al., 2015). Capitalizing on the benefits of telemedicine has yet to outpace the enthusiasm of advocates, with user acceptance destabilizing telemedicine implementations (Kohnke, Cole, & Bush, 2014). Researchers suggested predicting behavioral intentions sheds light on illuminating consumer acceptance towards the use of telemedicine (Knoblock-Hahn & LeRouge, 20140. Researchers have employed theoretical frameworks that consisted of models to decipher user acceptance of telemedicine (Sun & Rau, 2015). The theory of reasoned action, the technology acceptance model, the theory of planned behavior, and the innovation diffusion theory are all models used to predict consumer behavioral intentions (Tsai, 2014). Consumer behavior intentions towards the use of telemedicine 40 motivate implications of consumer psychological reactions (Shareef, Kumar, & Kumar, 2014). Analysis of consumer regards towards telemedicine may help instigate logical insinuations that may be associated with predictive factors that impact behavior intentions (Chugani, Irwin, & Redden, 2015). Inferences resulting from logical and comparative psychological effects of consumer concerns may help understand the depth of behavior intentions towards the use of telemedicine (Abraham et al., 2013). Psychological and theoretical implications are integral to understanding circumstances affecting consumer behavioral intentions towards the use of telemedicine (Cooper & Neal, 2015). Psychological Effects. Evolutions in information technology help broaden the competencies of people to process information, which inevitably contributes to an increased awareness of individual social and cognitive reasoning (Abraham et al., 2013). People respond with varying responses to different situations and predicaments, particularly when it involves certain factors related to emotions and perceived comfort and ease (Breen & Matusitz, 2010). (Xuea et al. posited factors such as comfort, discomfort, fear, joy, desire, or dislike, to name a few, are well-known inhibitors to repelling or welcoming the use of telemedicine (2015). Djamasbi, Fruhling, and Loiacono (2009) concluded cognitive psychology impacts cognition and behavior (Djamasbi et al., 2009). Throughout the course of a day, a person may confront factors that are inconsistent with expectations or cognition (Choi, & Lee, 2014). Rideaux (2015) concluded possible misdiagnosis or equipment malfunctions while using telemedicine causes fear among some patients and practitioners (Rideaux, 2015). On the contrary, research illustrates patients and practitioners appreciate not having to travel to a medical 41 facility for healthcare, thus are willing to use telemedicine (Viers et al., 2015). Whether a consumer chooses to use or not use telemedicine, psychological ramifications arise when making ultimate decisions (Cooper & Neal, 2015). Psychological implications result from a mental or emotional state of a person’s mind when confronted with a complex decision (Mordini, 2014; Murakami et al., 2013). For example, a psychological ramification could involve frustration over the choice to use artificial insemination, or appease religious beliefs by not doing so (Abraham et al., 2013). Psychological ramifications are unavoidable when undertaking a conviction to resolve an inconsistency between an attitude or behavior (Adams, Shakespeare-Finch, & Armstrong, 2015; Setta & Shemie, 2015). In situations where sentiment towards a particular action involves unrelated reasons, psychological ramifications may include excessive optimism or pessimism (Antoniou, Doukas, & Subrahmanyam, 2013; Bjorvatn & Tungodden, 2015). Psychological consequences may occur before and after making a complex decision, such as deciding to use telemedicine and feeling relief for not having to travel to a medical facility (Sandvoll, 2014). Psychological ramifications may have a favorable or unfavorable impact on a decisionmaking process (Karagozoglu, 2014). Consumers may avoid telemedicine simply because of the psychological implications associated with the decision to use or not use it (Barker, 2003). Situations where discrepancies between attitudes and behavior occur, psychological ramifications will more than likely change to accommodate the behavior (Abraham et al., 2013; Karagozoglu, 2014). Theoretical Insinuations. Understanding what behavioral intentions impact consumers towards the use of information systems is essential to the ambitions of 42 corporate and societal leaders. Cheng & Chu used Social Cognitive Theory in a study of course enrollment, to examine factors influencing the behavioral intentions of students (2014). In a separate study, trust and commitment were identified as social behaviors affecting user’s perceptions and intentions (Tsai, 2014). Hsu, Tseng, and Chuang (2011) found individual factors impact consumer plans to use healthcare technology. Hsu, et al. established that a hypothesis factor analysis yielded a positive and significant effect on users' intentions, or p < .01, p < .001 (2011). The hypothesis illustrates certain behavioral and societal factors either positively or negatively influences the acceptance of telemedicine technology. Nistor, Gogus, and Lerche (2013) demonstrated this in a mixed method study, where use behavior positively correlated with variable IDV (t = 0.67, p < 0.05) and negatively with variable MAS (t = -0.56, p < 0.05) (Nistor et al., 2013). Martins et al. (2014) used structural equation modeling in a mixed method study to test and estimate causal relations between behavioral constructs. Martins et al. further found behaviors, such as intention influence consumer perceptions to use of telemedicine technology (2014). As users gain the first-hand experience with information technology usage, they evaluate their initial cognition with experience, and revise their cognition to lessen the dissonance (Wang, Oh, Wang, & Yuan, 2013). The theory of planned behavior hypothesizes consumer behavioral intentions drive usage plans, focusing on enactments of consumer behavior. This approach is used to summate consumer views on the consequence of choices and decisions versus cognitive relationships (Dutta & Singh, 2014; Omodior, Pennington-Gray, & Donohoe, 2015). Ajzen (1985) originated the constructs for this theory as behavioral intention, behavior, attitude toward behavior, subjective norm, and perceived behavioral control 43 (Ajzen, 1985). The constructs of cognitive dissonance theory are relative, but they are different. Festinger (1957) inscribed the constructs as user satisfaction, performance, perception, behavior, usage, expectations, disconfirmation, attitude, and belief (Festinger, 1957; Yu-Lun & Ching-Jui, 2014). This theory draws on the conflict existing among the constructs affecting consumer choices and decisions (Randles et. al., 2015). The unified theory of acceptance model is designed and used to explain consumer acceptance of information technology (Dulle & Minishi-Majanja, 2011; Venkatesh, Thong, & Xu, 2012). The model consists of eight distinct philosophies (Nuq & Aubert, 2013; Thomas et al., 2013). The model is useful for predicting the impact of technology utilization by users (Knoblock-Hahn & LeRouge, 2014; Taiwo & Downe, 2013). Throughout the regular course of a day, people may be faced with making decisions that may conflict with what they consider reasonable or safe. Such a predicament may challenge people to choose between several inappropriate actions or beliefs (Cincera, 2013; Sandvoll, 2014). For example, going to visit the doctor could be considered normal, while using telemedicine could be regarded as abnormal. The cognitive dissonance theory is used to focus emphases relationships among cognitions (Coker, 2015; Festinger (1957). The cognitive dissonance theory suggests people seek consistency among cognitions, particularly when personal beliefs clash with subjective opinions (Festinger, 1957; Yu-Lun & Ching-Jui, 2014). Information may play a crucial role in resolving the inconsistency between cognitions, which may or may not support a final decision (Yap & Gaur, 2014; Yousaf & Gobet, 2013). When faced with the possibility of making a wrong decision, dissonant towards intentions and discomforting feelings arise (Elinder, 2012). To relieve dissonance, a person may instead change 44 preferences or filter information to be better than it is (Kim, 2011; Madsen, 2015). The cognitive dissonance theory is an important model for understanding relationships among psychological and cognitive barriers that potentially stimulate people to use or not use telemedicine (Cho, Park, & Lee, 2014; Koller & Salzberger, 2012). Impediments and Attributes of Cognitive Dissonance Cognitive dissonance can be a source of distress or hopelessness when faced with psychological conflict, but it is not always a challenging ordeal (Chapman & Clucas, 2014). There are situations where dissonance is necessary, particularly when it strengthens consumer personality (Czaja, 2015). The ability to manage cognitive dissonance through mental mediation or compromise helps relinquish discomfort (Xuea et al., 2015). Mentally negotiating or weighing the benefits for or against using telemedicine helps guard against making a reckless decision (Cooper, 2015). Maintaining consistent control of mental emotions attributes to a balanced temperament (Yousaf & Gobet, 2013). A controlled approach may help achieve an advantageous decision towards the use of telemedicine (Sandvoll, 2014). On the contrary, a strong personality does not automatically guarantee control of emotions during cognitive dissonance (Roberts & Clare, 2013). Assuming so comes with unpredictable risks (Harmon-Jones, 2012). Over confident decision making could lead to swift actions, apprehensive assumptions, or passionate responses (Coker, 2015). Cognitive dissonance affords consumers opportunities to consider clearly the benefits and consequences of using telemedicine and exercise the ability to handle tight situations (Chapman & Clucas, 2014). Telemedicine consumers with reclusive or assertive behaviors can benefit from cognitive dissonance, particularly when consumer uneasiness 45 affects relationships with other telemedicine users (D'Arcy, Herath, & Shoss, 2014). Discussions or exchange of ideas towards the use of telemedicine could contribute to a gradual resolution of cognitive dissonance (Lajoie & Lu, 2012). Forcing telemedicine on patients or promoting its use as a form of punishment may cause an aggressive approach (Hsieh, 2015). Telling a patient to accept the use of telemedicine or receive no monitoring does not contribute to the use of telemedicine (Gregory-Smith, Smith, & Winklhofer, 2013). An aggressive approach may worsen chances of resolving cognitive dissonance (Breen, Daniels, & Tomlinson, 2015). Telemedicine patients exposed to reckless encouragement or threats may unintentionally seek a haphazard strategy to resolve conflict dissonance (Paley, 2014). Cognitive dissonance may be used to change reliance on a habit or behavior (Freijy & Kothe, 2013). For example, proposing telemedicine to replace home caregiver monitoring may cause cognitive dissonance (Chugani et al., 2015). Patients who grow accustomed to home caregiver services may be reluctant to lose the human interaction (D'Arcy et al., 2014). Cognitive dissonance may help encourage in-depth consideration to use telemedicine (Hernandez, Haidet, Gill, & Teal, 2013). The opportune to weigh the benefits of telemedicine may improve when cognitive dissonance occurs (Helmus, O Ciardha, & Seto, 2015). Problems arise in cognitive dissonance when an approach to resolve it involves something that is not true (Mai, Tuan, & Yoshi, 2013). Attempting to resolve cognitive dissonance through blatant or concealed lies may result in dire consequences (Chugani et al., 2015). Convincing oneself or others to believe the false propaganda about telemedicine as true may cause more harm than good (Roberts & Clare, 2013). The mental damage resulting from engaging these harmful attitudes, or 46 harboring negative behavior may be irreversible (Gregory-Smith et al., 2013). Untrue or misguided inferences towards telemedicine that are accepted as true help form psychological barriers that may contradict the benefits of using telemedicine (Subramanian, Hopp, Lowery, Woodbridge, & Smith, 2004). Mannerisms of this type destroy the opportunity to resolve cognitive dissonance associated with the use of telemedicine (Antoniou, Doukas, & Subrahmanyam, 2013). Cognitive dissonance causes awkwardness in some situations, whereas mental separation from the current environment may occur (Freijy & Kothe, 2013). Taking a few moments to sort and organize thoughts, beliefs, or attitudes that conflict is a natural reaction to cognitive dissonance (D'Arcy et al., 2014). A quick resolution to cognitive is possible but taking a few more moments to consider the ramifications of a decision may be more beneficial (Harmon-Jones, 2012). Thoughtless decisions to resolve cognitive dissonance reinforce future questionable decisions (Levine et al., 2014). Dismissing benefits associated with telemedicine simply because a home healthcare professional is attractive will not help resolve cognitive dissonance (Hernandez et al., 2013). If replacement of the healthcare professional were to occur, cognitive dissonance might intensify (Antoniou et al., 2013). On the contrary, agreeing to use telemedicine because of discord with a home healthcare professional will not resolve cognitive dissonance (Madsen, 2015). Cognitive dissonance involves a compromise between conflicting beliefs and attitudes, to achieve consistency and certainty of the resulting decision (Nunnerley, Hay-Smith, & Dean, 2013). Cognitive dissonance is essential when pondering the use of telemedicine (Gregory-Smith et al., 2013). Usage of telemedicine may impact the daily routine of a consumer, and may compromise the privacy and 47 comfort of a consumer. Taking individual beliefs and attitudes into account towards the use of telemedicine is important (Xuea et al., 2015). Telemedicine consumers are typically confident the decisive approach to resolving cognitive dissonance is unmistakably correct (Xuea et al., 2015). Reevaluating a decision, whether for or against using telemedicine, is either avoided or dismissed when confident decisive decision making occurs at the onset. Remaining flexible when resolving cognitive dissonance helps ensure pertinent facts and benefits are considered (D'Arcy et al., 2014). Imposed time constraints, either mentally or otherwise, are not necessarily influential factors unless there is a medical emergency (Randles, Inzlicht, Proulx, Tullett, & Heine, 2015). Self-imposed restraints, such as conjuring up a manufactured crisis, or determining to limit interest in using telemedicine harms resolving cognitive dissonance (Madsen, 2015). Telemedicine is designed to enhance patient health care, so limiting time and capacity to resolve cognitive dissonance could lead to a bad conclusion (Hernandez et al., 2013). Ultimately, timely and fair resolutions of cognitive dissonance help subdue or remove discomfort and avoid regret (Gregory-Smith et al., 2013). Changing one’s belief to align with negative actions creates an unhealthy resolution to cognitive dissonance, which may eventually increase discomfort, or a wrong decision (Coker, 2015). It is imperative telemedicine consumers avoid rationalizing negative behavior to bring about a quick resolution of cognitive dissonance (Helmus et al., 2015). Condoning negative cognition, then attempting to disarm the behavior may lead to more discomfort, and possibly more intense cognitive dissonance (Mai et al., 2013). 48 Leveling Occurrence of Cognition Telemedicine consumers experience cognitive dissonance in predicaments when decisions involve conflicting attitudes, beliefs, or behaviors (Sandvoll, 2014). The practice and use of telemedicine are no exceptions (Butcher, 2015). Technological innovations met by advocates with too much enthusiasm, but may cause user acceptance of telemedicine to go unnoticed (Guazzini, Yoneki, & Gronchi, 2015). During development of new telemedicine applications, a great deal of attention is given to technical aspects of telemedicine (Chugani et al., 2015). Telemedicine is rapidly changing healthcare practices for patients and healthcare professionals (Dewsbury & Ballard, 2015). These constant changes in telemedicine are likely to produce some levels of discomfort, or dissonance (Carter & Grover, 2015). When consumers confront cognitive impairments, this will happen (Guazzini et al., 2015). Having to change a routine may not come quickly, particularly when the consumer is comfortable with the routine (Abraham et al., 2013). Telemedicine consumers attempt to lessen or eliminate discomfort associated with dissonance by altering an attitude, behavior, or belief (Yi & Gyoungho, 2013). This tactic is used merely to restore balance to what may be obstructing a decision (Meladze & Brown, 2015). Consumers may dismiss the cognition altogether and make a rushed decision, choosing to deal with the consequences later (Murray, Wood, & Lilienfeld, 2012). If developers and advocates of telemedicine increase their concentration on problems related to user cognitive or conscious state, user acceptance may improve (Chugani et al., 2015). Promoters and designers of telemedicine circumvent consumer dissatisfaction by understanding the conceptual significance of cognitive dissonance (Koller & Salzberger, 49 2012). Understanding these factors drive the use of telemedicine, dismissing consumer cognitive dissonance aside is reckless (Buck, 2009). Cho, Park, and Lee, 2014 posit knowledge is limited to cognitive and motivational factors that influence the use of telemedicine. The researchers studied the effects of several cognitive factors while exploring the significance of using different patterns (Cho et al., 2014). Cho et al. noted little research exists about emotional motivators that stimulate consumer use of telemedicine (2014). Such provocations are pertinent to personal psychological circumstances (Hernandez et al., 2013). The magnitude and power of consumer dissonance are subjective to factors present before or during an uncomfortable predicament (Freijy & Kothe, 2013). The more personal the cognition is, such as an individual belief, the greater the dissonance (Madsen, 2015). The level of value towards a particular belief, and the degree that a belief is inconsistent impacts the extent of consumer dissonance experience (Guazzini, Yoneki, & Gronchi, 2015). People pursue consistency in personal views and philosophies, and subconsciously dread when a conflict occurs (Samaras, Real, Curtis, & Meunier, 2012. When views conflict with previously held beliefs, the existence of two conflicting ideas causes a mental state of discomfort (Meladze & Brown, 2015). Cognitive dissonance describes consumer predicament in which internal conflicts arise (Lee & Yi, 2013). A choice or change must occur to lessen or eradicate the inconsistency. Yu-Lun and Ching-Jui (2014) concluded self-persuasion helps moderate conflict but does not eliminate internal conflict, particularly during cognitive dissonance early stages (YuLun & Ching-Jui, 2014). 50 Djamasbi, Fruhling, and Loiacono (2009) suggested cognitive psychology has a significant impact on cognition and behavior (Djamasbi et al., 2009). Cognitive dissonance affects consumer personality, mannerism and responsiveness to change (Yap & Gaur, 2014). Concentrating exclusively on self-encouragement has benefits but could cause oversight of crucial factors that promote the use of telemedicine (Abraham et al., 2013). Abruptly convincing one-self not to use telemedicine because it’s something new, dismissing the benefits telemedicine has to offer can be risky (Cho, Park, & Lee, 2014). Brisk decisions could lead to dire consequences (Sandvoll, 2014). Mental encouragement helps avoid unwanted consequences, opening an avenue to suppress being too eager (Karagozoglu, 2014). Mental motivation is challenging considering the higher the value a belief or opinion, the stronger the dissonance (Cho, Park, & Lee, 2014). Such action could lead to greater resistance to change. Coker posited that encouraging one-self to remain calm helps ease discomfort caused by cognitive dissonance (2015). The role of cognitive dissonance is crucial to interacting with telemedicine consumers (Guazzini et al., 2015). Cognitive dissonance can occur anytime telemedicine becomes a topic (Yu-Lun & Ching-Jui, 2014). Privacy is a concern for many people, therefore maintaining a calm disposition when discussing the use of telemedicine is important. It can happen when introduced by a healthcare professional, or reading relevant literature (Hernandez et al., 2013). Negative moods affect coping with cognitive dissonance, which may hypothetically increase anxiety towards using telemedicine (Djamasbi et al., 2009). Focusing on cognitive dissonance the moment it occurs, and controlling negative views, is crucial to a beneficial resolution to using telemedicine (Kim, 2011). 51 Resolving cognitive dissonance is mentally taxing and physically intensive, and is further compounded when cognitive vulnerabilities go unnoticed (Shah et al., 2013). Neglecting to recognize cognitive weaknesses further increases inconsistency between attitudes or behaviors towards the use of telemedicine (Allahyani, 2012). Acknowledging mental vulnerabilities increases the ability to change, and helps seek a meaningful resolution to cognitive dissonance (Wingham et al., 2014). Cognitive impairment impacts communications ability, which may impede the capacity to acknowledge it (Chugani et al., 2015). Mental impairments such as memory loss or acute anxiety need to be dealt with delicately. In these situations, cognitive dissonance requires extensive analysis, regardless how onerous or difficult (Cooper & Neal, 2015). Behavioral change lends to motivate change, thus casting aside or dismissing cognitive impairments as irrelevant and thus hinders resolving cognitive dissonance (Freijy & Kothe, 2013). Cognitive appraisals determine resistance to telemedicine (Lee & Yi, 2013). These evaluations may result in perceiving telemedicine as a threat; further intensifying cognitive dissonance (Shah et al., 2013). Presenting examples or other consumer experience with telemedicine are important mechanisms (Meladze & Brown, 2015). This approach helps consumers cope with cognitive dissonance, and adjust to the perspective of using telemedicine (Paley, 2014). A favorable interpretation of environmental contingencies tends to summon motivational and cognitive resources to adapt to changes (Xuea et al., 2015). Qualitative Prospecting of a Dilemma Consumer reluctance to use telemedicine adversely impacts its implementation, wreaking havoc on the enthusiasm of advocates (Al-Qeisi, Dennis, Alamanos, & 52 Jayawardhena, 2014). Researchers concluded the prime suspect of this dilemma were predictive factors that affect consumer behavior intentions (Heselmans et al., 2012). Escobar-Rodriguez and Carvajal-Trujillo (2014) suggested statistical analysis of such factors may help understand consumer behavior intentions to use telemedicine. Researchers that employed the quantitative research method hypothesized that predictive factors varied among relational variables (Venkatesh, Thong, & Xu, 2012). Statistical analysis facilitates researcher dissection, interpretation, and assessment to measure the impact of predictive factors affecting the use of telemedicine (D'Abundo et al., 2014). Quantitative data analysis reflects significant dispositions about healthcare information technology usage but does not account for consumer experiences towards using such technology (Jones & Hawkins, 2015). Qualitative research divulges a variety of consumer behavior and sensitivities that may relate to particular problems or subjects (Workman, 2014). Qualitative investigations facilitate the use of various interview techniques and superior exploration tactics to construct hypotheses. Qualitative data analysis research reflects descriptive rather than predictive dispositions of a usage dilemma, which may account for consumer experiences (Lai, Lin, & Tseng, 2014). Kohnke, Cole, and Bush (2014) suggested increasing awareness of consumer attitudes towards the use of telemedicine might identify acceptance impediments (Kohnke, Cole, & Bush, 2014). Illuminating consumer attitudes towards a particular predicament may help understand consumer reluctance to do something (Blake et al., 2015). Qualitative investigation and analyzes enabled researchers to reach beyond cautious reactions and reluctant motivations (Ataria, 2014). 53 Douglas (2013) sought to understand the attitude towards a managerial approach adopted by a company takeover by an owner-entrepreneur. The author illustrated the perceptual differences that current, and impending stakeholders embrace regarding the future of the new organization (Douglas, 2013). Qualitative research focusing on organizational change may expose extenuating factors, such as management style, rational cognitions, and behavioral reactions (Douglas, 2013). Liebhart (2013) investigated the influence and impact of energy flowing between people in this type of predicament (Liebhart, 2013). The research purpose was to provide a unique qualitative examination of developmental processes in mentoring relationships (Liebhart, 2013). In both studies, the researchers sought a deeper ontological and epistemological understanding of consumer cognition and attitude towards an individual predicament (Breen, Daniels, & Tomlinson, 2015). In a case-based qualitative design methodology, Mcalearney, Reiter, Weiner, Minasian, and Song have identified consumer participation in the National Cancer Institute's Community Clinical Oncology Program as a research problem (2013). Challenges, such as administrative, financial, and organizational prerequisites adversely impacted the participation of healthcare professionals (Mcalearney et al., 2013). In a separate study, Tuason (2013) investigated the psychological experiences of poverty among two groups of economically disadvantaged Filipino citizens, categorizing those who's predicament had not changed, and those who eventually became successful (Tuason, 2013). In the studies, mentioned earlier, the researchers employed the interview or group discussion process, actively engaging respondents to expose perceived cognitions, coping mechanisms, and cultural characteristics (Bansal & Corley, 2012). 54 Qualitative research affords the opportunity to observe synergy among research participants, record and interpret non-verbal communication, and engage consumers in projective practices (Chen & Bennet, 2013). For example, Liebhart (2013) observed study participants categorized as high or average work performers, who differed in organizational mentoring affiliation. The members continuously challenged and tested personality limits. Cognitive observations concluded study subjects conveyed active and negative emotions, with participants inadvertently or naturally asserting opinions to the predicament (Liebhart, 2013). Sun and Rau (2015) observed body languages, voice modulations, and the like as part of participant feedback. Interviews, discussions, and analyzes may produce qualitative data of this nature (Knoblock-Hahn & LeRouge, 2014). Such data may represent in-depth insight into consumer reluctance towards to a particular predicament, such as towards the use of telemedicine (Lai, Lin, & Tseng, 2014). Originating from human sciences, such as behavioral, social, psychology, qualitative research methodology useful for exploring the content and complexity participant experiences (Chapman & Clucas, 2014). Qualitative methodological research techniques facilitate researchers with a systematic approach to examining lived experiences of telemedicine consumers (Guazzini et al., 2015). The qualitative methodology afforded researchers an opportunity to uncover influences of cognitions not easily recognized (Friedman et al., 2015). Qualitative research of consumer attitudes accommodates a subjective perspective about cognitive dissonance, which may increase knowledge of consumer behavior intentions towards the use of telemedicine (Rodger, Neill, & Nugent, 2015). 55 Exploring Acceptance Healthcare information systems and technologies are vital to supporting healthcare business operations, patient needs, and executive strategies (Blobel et al., 2012). These are part of an essential strategy to understanding what fundamental factors attributable to user acceptance of patient healthcare information technology (Chen & Chang, 2013). In-depth exploration of those factors is critical to understanding user acceptance (Saravani & Haddow, 2011). In a study on cross-cultural validation, researchers examined educational technology users (Nistor, Gogus, & Lerche, 2013). The theoretical framework consisted of combining culture and unified theory of acceptance and use of technology model (Nistor et al., 2013). The research objective focused on finding significant differences in acceptance between user groups (Nistor et al., 2013). Brown, Dennis, and Venkatesh (2010) conducted a two-part investigation study in Finland that focused on factors characteristics of collaboration technology. The researchers combined collaboration technology and the unified theory of acceptance and use of technology model to form the theoretical framework (Brown et al., 2010). Escobar-Rodríguez and Carvajal-Trujillo (2014) used an extended version of the unified theory of acceptance and use of technology model to explain user purchase intention (Escobar-Rodríguez & Carvajal-Trujillo, 2014). Attuquayefio and Addo (2014) sought to understand issues surrounding acceptance of information and communication technology in a case (Attuquayefio & Addo, 2014). Employing the same unified model, Attuquayefio and Addo (2014) exposed the intentions of communication technology. Subjects of the study were college students from Ghana (Attuquayefio & Addo, 2014). 56 The researchers’ findings suggested behavioral intention to use information technology significantly influenced effort expectancy (Attuquayefio & Addo, 2014). Gogus et al. (2012) sought to extend the applicability of the unified theory of acceptance and use of technology model to understand user acceptance towards educational technology (Gogus et al., 2012). The authors conducted a correlation study on users of Turkish learning technology, exploring regional cross-cultural differences in Turkey (Gogus et al., 2012). Dulle and Minishi-Majanja (2011) sought to formulate a research model of technology acceptance (Dulle & Minishi-Majanja, 2011). The researchers applied a similar pattern to explore the adoption of open access in a research environment (Dulle & Minishi-Majanja, 2011). In a similar study, questionnaires were collected from two hundred and forty-nine participants with the intention of understanding the determinants of Internet banking adoption (Martins, Oliveira, & Popovic, 2014). Unlike Martins et al. (2014), the research conducted by Gogus et al. (2012) used a questionnaire to collect responses from one thousand seven hundred and twenty-three participants (Gogus et al., 2012). In this study, structural equation modeling was employed to analyze data while both studies used the application Statistical Package for Social Science (SPSS) for data analysis (Gogus et al., 2012; Martins et al., 2014). The authors Gogus et al. (2012) found definitions of culture apply in the context of educational technology acceptance while Martins et al. (2014) revealed perceived risk as a principal factor affecting user intention (Martins et al., 2014). Research tools such as the unified theory of acceptance and cognitive models are practical for exploring acceptance of healthcare technology (Dulle and Minishi-Majanja, 2011). Studies have shown using theoretical models help decipher and detect constructs 57 and moderating factors affecting user acceptance (Escobar-Rodríguez & CarvajalTrujillo, 2014). Researchers have effectively combined theoretical models to explain the intention and usage behavior towards information technology, such as healthcare system (Attuquayefio & Addo, 2014). Martins et al. (2014) applied structural equation modeling in explorations to test and estimate causal relations. Combinations of statistical data and qualitative causal assumptions were also useful in these explorations to understand user acceptance of healthcare information technology (Chen & Chang, 2013; Martins et al., 2014). The theoretical blueprint applied to an exploration is fundamental in exposing moderating factors that affect user acceptance (Jeng & Tzeng, 2012). Moran, Hawkes, and El Gayar (2010) emphasized the significance of hypothesizing integration of theoretical models for exploring and predicting acceptance of healthcare technology (Moran et al., 2010). Practice and application of theoretical models to yield pertinent research results is imperative to achieving a meaning exploration, as well as the objectives and goals of the researcher. Relevance of Acceptance and Factors One of eight models of the unified theory of acceptance and use of the technology design, the technology acceptance model, is popular and used frequently (Vanneste, Vermeulen, & Declercq, 2013). Alwahaishi and Snasel (2013) researched the relative impact of factors which contribute to technology acceptance of mobile Internet (Alwahaishi & Snasel, 2013). Alwahaishi and Snasel (2013) composed a new hybrid theoretical framework for identifying the factors affecting the acceptance and use of mobile Internet as the means of information and communications technology acceptance. Asua, Orruno, Reviriego, and Gagnon (2012) examined the psychosocial factors related 58 to the acceptance and use of a telemonitoring system (Asua et al., 2012). Chung-Hung (2014) investigated the determinants of behavioral intentions toward the use of telehealth technology by elderly residents in Nantou County, Central Taiwan (Chung-Hung, 2014). Asua et al. (2012) developed a parsimonious logistic regression model that was in predicting the intentions of the healthcare professionals. Early predictions are useful, but fitting the best theoretical model to the survey is essential to obtaining a useful research sample (Asua et al., 2012). In a separate study, data was collected and tested against the unified theory of acceptance and use of technology and flow methods, using the structural equation modeling approach to analyze the hypothesized relationships (Alwahaishi & Snasel, 2013). Asua et al. (2012) in their study found showed perceived usefulness, compatibility, and facilitators were the significant predictors of user intention to use the telemonitoring. Observable factors affecting user acceptance of healthcare technology are detectable through extensive research (Dulle & Minishi-Majanja, 2011). Unnoticeable factors can be elusive prompting the need for intensive exploration beyond obvious factors (Gogus, Nistor, Riley, & Lerche, 2012). Chen and Chang (2013) investigated behavioral factors impacting user recognition of near-field communication mobile phone applications (Chen & Chang, 2013). The researchers adopted the unified theory of acceptance and use of technology model for exploring factors affecting user acceptance of communication capability (Chen & Chang, 2013). Saravani and Haddow (2011) mirrored the same pattern for understanding the acceptance aspect of capability development within an academic library setting (Saravani & Haddow, 2011). In this study, a semi-structured questionnaire of twelve open-ended questions was administered 59 to interviewees (Saravani & Haddow, 2011). Saravani and Haddow (2011) conducted a study in Australia and New Zealand using the grounded theory to analyze open-data coding to reveal factor relationships. The study had seventy-six participants (Saravani & Haddow, 2011). The researchers’ results indicated potential for predicting user acceptance of mobile services. The authors noted discovered findings at levels greater than deconstructed themes (Saravani & Haddow, 2011). This approach enabled an unique perspective of how constructs can influence user acceptance of healthcare technology (Wills et al., 2010). Alwahaishi & Snasel (2013) revealed the need for a thorough understanding of user attitudes and preferences towards information and communications technology acceptance. Chung-Hung (2014) further applied an integration of social capital theory and the technology acceptance model constructs. The study examined the relationships between social capital factors, technological factors, and system self-efficacy in telehealth (Chung-Hung, 2014). Understanding constructs provides the opportunity to explore which actions might be carried out to boost use (Escobar-Rodríguez, MongeLozano, & Romero-Alonso, 2012). Chung-Hung (2014) findings imply social capital factors have a significant role in perceived ease of use and perceived usefulness in supporting the proposed behavioral model. Dunnebeil, Sunyaev, Blohm, Leimeister, and Krcmar, 2012) extended existing technology acceptance models for electronic health in ambulatory care settings in research. Dunnebeil et al. (2012) explored constructs such as the opinions, attitudes, and knowledge of physicians to find drivers for technology acceptance. Egea and Gonzalez (2011) examined the behavioral intentions of doctors in a study on individual acceptance 60 of electronic health care record systems (Egea & Gonzalez, 2011). Egea and Gonzalez (2011) based research their design on the original technology acceptance model to establish relationships between constructs (2011). The model can be used in evaluating the additional predictive value and relative importance of trust and risk factors, such as institutional trust, perceived risk, and information integrity (Egea & Gonzalez, 2011). Dunnebeil et al. (2012) indicated the perceived importance of standardization and current information technology utilization were significant drivers for accepting electronic health services. Granlien and Hertzum (2012) investigated the adoption and use of an electronic medication record system by clinicians (Granlien & Hertzum, 2012). Specifically, they examined barriers to adopting the electronic medication record system, and the ease of its use (Granlien & Hertzum, 2012). Escobar-Rodríguez et al. (2012) investigated the intentions of physicians and nurses to use e-prescriptions and an automated medication management system (Escobar-Rodríguez et al., 2012). The technology acceptance model and the theory of reasoned action formed the theoretical grounding (Escobar-Rodríguez et al., 2012). Escobar-Rodríguez et al. (2012) used a technology acceptance model framework to identify the causal relationships between constructs. Hendrikx et al. (2013) investigated users’ intentions, to determine if potential adoption of the system was possible. A previous version of the technology acceptance model was adapted to explore users’ intentions located in the Netherlands (Hendrikx et al., 2013). Asua et al. (2012) used an extension of the technology acceptance model. Hendrikx, Pippel, van de Wetering, and Batenburg (2013) sought to measure the interest of consumers of a Dutch online healthcare system. 61 Granlien and Hertzum (2012) found a considerable difference between the mandated and actual adoption of electronic medication record systems (Granlien & Hertzum, 2012). They concluded practitioners should consider systematic implementation of systems (Granlien & Hertzum, 2012). Moores (2012) examined an integrated model of information technology in healthcare based on the technology acceptance model (Moores, 2012). Moores concluded retained the technology acceptance model constructs as fundamental determinants (Moores, 2012). The theoretical framework consisted of a pair of second-order constructs, and three measures of acceptance (Moores, 2012). Vanneste, Vermeulen, and Declercq (2013) researched the applicability of the unified theory of acceptance and use of technology model (Vanneste et al., 2013). Kuang-Ming et al. (2013) aimed to determine the technology readiness and intentions of nurses to use mobile electronic medical record systems. The technology acceptance model was chosen to segregate the impact of other factors (Kuang-Ming et al., 2013). Researcher findings illustrated study participants were optimistic, innovative, and secure but uncomfortable about the technology. Finally, Vanneste et al. (2013) research results indicated superior quality software, and other critical factors stimulate user behavioral intention to use innovative technology. Analyses Techniques Profiled Cranen et al. conducted research with the goal to explore patient perceptions of telerehabilitation, another term for telemedicine, services and factors that facilitated or impeded intentions to use the services (2012). The researchers collected data via interviews with study participants (Cranen et al., 2012). The sample of twenty-five chronic pain patients was selected from a rehabilitation facility. Cranen et al. (2012) used 62 inductive analysis to analyze data (2012). The study population consisted of twenty-five chronic pain patients from the Netherlands (Cranen et al., 2012). Participants ranged in age from twenty-two to seventy-seven years, with a mean age of forty years (Cranen et al., 2012). The researchers applied the unified theory of acceptance and use of technology to measure the pros and cons of telerehabilitation services (Cranen et al., 2012). Data for each component were analyzed and arranged into subthemes using an inductive process. Cranen et al. (2012) concluded the effect of telerehabilitation on healthcare strongly depends on patients’ willingness acceptance of use (2012). The researchers’ findings indicated chronic pain patients valued the benefits of telerehabilitation but hesitate to use it as an autonomous treatment (Cranen et al., 2012). The researchers established that participants considered telerehabilitation helpful as a complementary or follow-up treatment (Cranen et al., 2012). Dunnebeil, Sunyaev, Blohm, Leimeister, & Krcmar (2012) extended existing technology acceptance models to research electronic health in ambulatory care settings. The researchers explored the opinions, attitudes, and knowledge of physicians to identify drivers for technology acceptance (Dunnebeil et al., 2012). The researchers focused on information technology, use, process and security orientation, standardization, communication, documentation and general working patterns (Dunnebeil et al., 2012). The researchers distributed five hundred questionnaires by mail to ambulatory care physicians in the Bavaria (Dunnebeil et al., 2012). One hundred and seventeen participants participated by completing the questionnaire, which the researchers acknowledged represented a small sampling (Dunnebeil et al., 2012). The researchers employed the partial least squares regression model to analyze the data (Dunnebeil et al., 63 2012). The research sample consisted of one hundred and seventeen participants (Dunnebeil et al., 2012). The researchers posited that the weak response suggested more effort was needed to improve participation in the survey. The researchers found the data demonstrated the perceived importance of standardization and current information technology utilization were significant drivers for accepting electronic health services (Dunnebeil et al., 2012). The researchers used the study in deriving implications for the design and introduction of e-health services (Dunnebeil et al., 2012). Egea and Gonzalez (2011) examined the behavioral intentions of physicians in a study on individual acceptance of electronic health care record systems. The researchers based the research model on the original technology acceptance model to establish relationships between perceived usefulness, perceived ease of use, usage attitude, and usage intentions. Egea and Gonzalez (2011) used the research model to evaluate the additional predictive value and relative importance of trust and risk factors, such as institutional trust, perceived risk, and information integrity (Egea & Gonzalez, 2011). In related studies, this approach was used to explain the acceptance of health care information technology by medical professionals. In this study, a sample of one thousand and five hundred physicians was extracted from the initial list through systematic sampling (Egea & Gonzalez, 2011). The sample consisted of physicians with private medical practices located in Southern Spain. After two different mail campaigns, two hundred and fifty-four people completed the questionnaire (Egea & Gonzalez, 2011). Egea and Gonzalez (2011) applied the confirmatory factor analysis and structural equation modeling to examine the psychometric properties of the scale and test the hypotheses of the research model (Egea & Gonzalez, 2011). The researchers’ findings 64 illustrated this study adds to the growing literature on the complex and important issue of technology acceptance in health care (Egea & Gonzalez, 2011). In their study, Escobar-Rodríguez et al. (2012) investigated the intention of physicians and nurses to use e-prescriptions and automated medication management systems (Escobar-Rodríguez et al., 2012). The technology acceptance model and the theory of reasoned action were used by the researchers in forming the theoretical grounding for this research (Escobar-Rodríguez et al., 2012). The authors used this framework to specify the causal relationships between perceived usefulness, perceived ease of use, and actual usage behavior (Escobar-Rodríguez et al., 2012). The authors extended the technology acceptance model through the addition of four external variables. The variables were perceived compatibility, perceived usefulness to enhance control systems, training, and perceived risks. The proposed model consisted of seven constructs, with the researchers generating eleven hypotheses from connections among the seven constructs. The study was conducted in the Infanta Elena Hospital located in Spain. The researchers distributed a questionnaire for collection of data, with a total of two hundred and nine valid responses received. Of these, ninety-one were physicians, and one hundred and eighteen were nurses. The researchers concluded understanding the influential factors offers opportunities to explore which actions might be carried out to increase the use of the systems (Escobar-Rodríguez et al., 2012). Hendrikx, Pippel, van de Wetering, & Batenburg (2013) sought to measure the interest of consumers of a Dutch online healthcare system called eHealth. The researchers investigated the intentions of the consumers of products and services, to determine if the adoption of the system was a breakthrough. The researchers adapted a previous version 65 of the technology acceptance model, to explore the attitude of citizens and patients. The authors distributed a survey among patients and providers of private healthcare organizations in the Netherlands. Sixty-eight participants completed and returned the questionnaire. The researchers recognized the limitation of this research considering its small sample size. The limited number of respondents caused the authors to employ factor analysis with the standard error of the mean. Hendrikx et al. (2013) suggested future research focus on increasing the sample size and validating the model. Ketikidis, Dimitrovski, Lazuras, & Bath (2012) sought to assess the predictors of health information technology among nurses and medical doctors. In this study Ketikidis et al. (2012) applied a modified version of the revised technology acceptance model. The researchers assessed the relevant beliefs and acceptance of health information technology systems in a sample of health professionals. For this study, the researchers used an anonymous questionnaire and cross-sectional design. The analysis of variances method was employed to examine differences in technology acceptance model related variables between nurses and medical doctors. The authors used a structured questionnaire included measures of demographic characteristics, age, and gender. Of the two hundred questionnaires, one hundred and sixty-nine were returned. One hundred and thirty-three was eligible for further analysis. The research participants lived in Skopje, the capital city of the Republic of Macedonia. The authors applied the multiple linear regression analysis to assess the predictors of usage intentions. The researchers’ findings supported the study hypothesis, with perceived ease of use significantly predicting usage intentions. Ketikidis et al. (2012) found a modified version of the technology acceptance model is 66 needed to understand healthcare professionals’ acceptance of health information technology systems. Vanneste, Vermeulen, and Declercq (2013) researched the applicability of the unified theory of acceptance and use of technology theoretical model. The researchers analyzed the receipt of the BelRAI web application by nursing healthcare professionals. The health care professionals specialized in home health care, and acute hospital care. The authors used the unified theory of acceptance and use of technology theoretical model as a framework for this study. A structured questionnaire containing constructs from a previous survey was distributed to six hundred and sixty-one caregivers located in Flemish, Belgium. The participants were a heterogeneous group of Flemish licensed or qualified caregivers. The researchers analyzed data from two hundred and eighty-two questionnaires to obtain information on behavioral intentions to use the BelRAI web application. The findings show superior quality software, and other critical factors, stimulates end-user behavioral intention to use modern technology. The authors indicated their study findings could be utilized by policy makers to maximize the acceptance and the success of modern technologies (Vanneste et al., 2013). Theory of Acceptance in Practice Bhandari and Snowdon (2012) conducted a study to assess the impact of service design elements user acceptance and usage of a web-based health care navigation tool. The authors hypothesized an active relationship between the technology acceptance model and service design principles existed. The researchers used a service ontology questionnaire to collect data from local health integration networks funded member organizations located in South-western Ontario, Canada. Eighty-eight member companies 67 participated in this survey. These data were examined to identify the underlying service delivery concepts in the region. The authors used service interface designs with the research model. The researchers used five propositions to examine the impact service design elements and environments on the antecedents of the unified theory of acceptance and use of technology model. Bhandari & Snowdon (2012) findings indicate a possible linkage between service design principles and the unified theory of acceptance and use of technology model exists. Blobel, Pharow, Sousa, and Monteiro (2012) researched the expectation of value and results created by the Ambient Assisted Living system. The researchers sought to understand the intention of its use. The researchers explored the pertinence of adding an extension to a theory in order capture quality of life improvements expectations. The authors applied the unified theory of acceptance and use of technology to do this research. The researchers used a questionnaire survey to assess individuals' perceptions. There were no study participants for this research. To capture value and results obtained by the systems, measure the Quality of Life before the use of the system or technology and after. The authors indicated the Quality of Life can be measured by different time frames to achieve Quality of Life improvements. The researchers applied different indicators to measure Quality of Life variable. Those indicators are aggregated by Quality of Life components. The researchers concluded the variance in Quality of Life provided by the use of systems or technologies describes how much value the system can provide. Blobel et al. (2012) findings illustrate this information can be the foundation for a competition based on value and results. 68 In their study, Chien-Lung, Tseng, and Yu-Hao (2011) applied the unified theory of user acceptance and use of technology to construct five variables. The aim of this study was to examine user acceptance of intelligent vital monitoring products by people aged over fifty years. The authors used this approach to form the basis of performance expectancy. The researchers used questionnaires were divided into three parts. The study participants consisted of two nursing homes in Tucheng and Sinjhuang, Taiwan. One hundred and twenty-five surveys we collected in the space of one month. The authors applied the one-way analysis of variance to measure whether gender and level of education influenced the results. Using factor analysis, the researchers extracted factors needed to test the validity of the proposed model. The authors conducted a confirmatory factor analysis using structural equation modeling to analyze the proposed hypotheses. The findings showed a meaningful relationship between effort expectancy and user intention did not exist Chien-Lung et al. (2011) found the data does not correlate due to a biased sample, which did not support the hypothesis. Heselmans et al. (2012) sought to understand the assessment of user perceptions towards the recently implemented EBMeDS system. The technology acceptance model of the unified theory of acceptance and use of technology was used as a structural model. The authors developed and used a questionnaire to identify factors may account for acceptance and use of the EBMeDS system. The survey was administered online to three hundred and thirty-four Dutch-speaking family physicians. Thirty-nine participants completed the questionnaire. Respondent’s opinions represented real-world perspectives towards the system. Quantitative analysis of computer recorded user interactions was done by the researchers over a period of three months. The qualitative and quantitative 69 analyses were then linked. Descriptive statistics with corresponding graphical displays were conducted to describe the sample population and the data. The results showed the questionnaire clarified a need for better communication and support when the system launches. The researchers concluded most EBMeDS users had a positive attitude towards the system. They discovered the respondents would recommend the use of the scheme to others to some extent. A major drawback was low response rates which suggest caution be taken when generalizing the results. The study findings did not reflect staunch support for the weak response (Heselmans et al., 2012). Lee and Song (2013) sought to extend the unified theory of acceptance and use of technology model for exploring the relationship between trust and perceived risk. The authors applied the unified theory of acceptance and use of technology to the certified edocument authority service. The authors sought to validate the model, and aimed to deepen the understanding of relationships between different sets of variables. The researchers used IBM SPSS software to perform exploratory factor analysis and sample characteristics analysis. The researchers conducted a survey in the Republic of Korea, and used a questionnaire that was developed with the help of the Korea Research Institute. Of the three thousand two hundred and ten participants, the researchers used one hundred and forty-six selected questionnaires for conducting data analysis. The authors tested the research model using structural equation modeling techniques utilizing AMOS 20. The researchers investigated the overall structural model fit and the strengths of the hypothesized paths, and concluded structural equation modeling supported the research hypotheses. Lee and Song (2013) found the model demonstrated good predictive powers and indicated behavioral intentions. The authors concluded this study contributes 70 to the careful exploration of trust and perceived risk act on the core constructs of the unified theory of acceptance and use of technology model (Lee & Song, 2013). Knoblock-Hahn and LeRouge (2014) sought to determine parental views on how technology can support previously learned behaviors. The authors aimed to use the unified theory of acceptance and use of technology to inform on the design of a usercentered design application. The unified theory of acceptance and use of technology was used in providing theoretical parental constructs interactions within several socioecological contexts. Twenty participants from St Louis, Missouri participated in this study with a questionnaire used to conduct interviews. The authors used the unified theory of acceptance and use of technology as a theoretical foundation to guide the development of questions. The researchers employed the model to assess perceived usefulness of technology and user intent to use the user-centered design application. The researchers applied Dedoose qualitative data management software to analyze research data. The researchers’ results indicate participants’ perceived motivation to be more useful. The researchers concluded a limitation to the study was the selected research population (Knoblock-Hahn & LeRouge, 2014). Wang and Wang (2010) investigated determinants of mobile Internet acceptance to understand what motivates individuals to use mobile Internet. The researchers aimed to identify factors underlying the process leading to adopting this technology. The authors applied the unified theory of acceptance and use of technology model as the theoretical framework. Three additional constructs were added to the unified theory of acceptance and use of technology model to explore mobile Internet acceptance. Data used to test the research model came from an online sample in Taiwan, which consisted of three hundred 71 and forty-three participants. The researchers’ findings found three constructs had a significant positive influence on behavioral intention to use mobile Internet. The authors found perceived value and social influence on behavioral intention were significant, but found no gender differences (Wang & Wang, 2010). Relative Literature Specifics Knowledge Gaps. Baig et al. (2013) found very few studies reported a high percentage of acceptances towards wearable monitoring system and indicated this was mainly because of the low-invasive nature. Information regarding consumer disclosure of problems experienced with telemedicine and countermeasures to deal with such problems is limited (Cegarra-Navarro & Cepeda Carrion, 2013). Significant gaps exist in the literature on consumer work experiences, opportunities to identify marketable skills, and consumer sensitivities (Fouad et al., 2012; Moeckli, Cram, Cunningham, & Reisinger, 2013). Additional consumer antecedents towards the intention to use telemedicine service and consumer health in everyday life experiences are lacking knowledge (Rho et al., 2014; Solling et al., 2014). Researchers suggest cognitive dissonance and integration of conflicting cognitions be given further exploration to understand the process of reducing cognitive dissonance (Hernandez et al., 2013; Meladze & Brown, 2015). Karagozoglu (2014) and Yap and Gaur (2014) indicated the need for future research addressing the emergence of cognitive dissonance in a mathematical framework. Karagozoglu (2014) and Kim (2011) posited that future quantitative analysis may present useful findings for helping to understand cognitive dissonance. 72 Delving into divergent ideas or interpretations may help yield an increased understanding of cognitive dissonance (Guazzini et al., 2015; Madsen, 2015). Abraham et al. (2013) proposed of evolutionary psychology usage as a harmonizing perspective to investigate technology. They concluded psychology studies focused on technology acceptance is limited. Chui, Titman, and Wei (2010) suggested momentum of technology acceptance psychology is more pronounced in individualistic cultures (Chui, Titman, & Wei, 2010). However, questions still exist whether the irregular momentum patterns associated with individualistic attitudes are higher in other cultures than compared to the United States (Antoniou, Doukas, & Subrahmanyam, 2013). Ching-Jui (2014) indicated research involving psychological, behavioral, and organizational perspectives is lacking. The author posits knowledge gaps exist about technology acceptance, which is an unexplored phenomenon (Ching-Jui, 2014). Muehlan and Schmidt (2013) suggested research about psychosocial issues impacting patient home monitoring devices is necessary. They noted neglecting ongoing and emerged technological innovations as a limitation. Meladze & Brown (2015) found integration of conflicting cognitions is hidden in population subgroups, such as same-sex attracted people, necessitating cognitive dissonance research. In a separate study, Lee and Yi (2013) proposed the structure of creating cognitive conflict helps formulate a comprehensive and integrated perspective towards understanding the effectiveness of cognitive conflict. Recognized Limitations to Research. Research techniques, such as small sample size and focus groups, are limitations mentioned in previous studies (Al-Qeisi et al., 2014; Fillion, Braham, & Ekionea, 2012). Other studies illustrated relevant literature as 73 proxies to the study phenomenon, and the legality of telemedicine country (CegarraNavarro & Cepeda Carrion, 2013; Rho, Choi, & Lee, 2014). Preventive measures, such as literature and peer review will be done to avoid weakening the quality of the study. Prior research limitations will be examined and compared to prevent reoccurrences in this study (Brown, Venkatesh, & Goyal, 2012; Yang et al., 2012). Shareef, Kumar, and Kumar (2014) researched remote diabetic healthcare management, using wearable devices connected through smartphones. The authors concluded study findings rooted in the perception, instead of experience had limited value. A broader recruitment of research respondents was a restriction because of the study was conducted in a developing country (Shareef et al., 2014). The researchers noted developed and developing countries held differences in compatibility perception (Shareef et al., 2014). Summary Businesses, organizations and governments rely on the innovations in information technology. They employ these techniques to accommodate individual needs and to strategize the execution of commercial and organizational endeavors (Blobel et al., 2012; Heselmans et al., 2012). Understanding the factors influencing consumer acceptance of telemedicine technology is vital to societal communities and corporate leaders (Wills et al., 2010). The objectives of these entities are accomplished through the execution of an established blueprint designed to expose and illuminate consumer decision and behavioral intention (Koller & Salzberger, 2012; Scheck et al., 2013). Telemedicine consumers and advocates oppose counterarguments, especially when cognitive dissonance perpetuates and eliminates conflict (Cho, Park, & Lee, 2014). Cognitive dissonance predicaments aggravate and lessen the physiology conflict (Hsieh, 2015. 74 Cognitive dissonance experiences are dealt with in diverse ways (Xuea et al., 2015). Telemedicine consumers either cope with new facts; integrate various particulars, or choose suitable data to change behavioral intentions (Moody, Kostohryz, & Vereen, 2014). Advocates of telemedicine must recognize large-scale conflicts, such as ethnic conflicts since cognitive dissonance perpetuate struggles of this nature (Kumar, Seay, & Karabenick, 2015). To restore consonance, telemedicine consumers objectively tend to alter one of two cognitions in dissonance predicaments (Rodger, Neill, & Nugent, 2015). Comparable cognitions reinforce occurrences of negative perceptions (Czaja, 2015). Thoughts that contradict go ignored or may be avoided altogether (Freijy & Kothe, 2013). The unpleasantness associated with cognitive dissonance may cause closemindedness (Chapman & Clucas, 2014). Telemedicine consumers may prefer to go uninformed rather than face the consequences of cognitive dissonance (Hsieh, 2015). It is essential for telemedicine advocates to recognize the prevalence of barriers complicated by cognitive impairments within populations (Yap & Gaur, 2014). To do otherwise may further exasperate complications detrimental to telemedicine implementation (Abraham et al., 2013). This study employs cognitive dissonance theory. This unique technique serves as a blueprint to detecting and deciphering obstacles affecting consumer choices and acceptance (Karagozoglu, 2014; Taiwo & Downe, 2013). This framework will facilitate research necessary to broaden knowledge of those elements impacting consumer decision and behavioral intention (Kohnke et al., 2014; Wang et al., 2013). 75 Chapter 3: Research Method Continuous treatment and monitoring of patients are core capabilities of telemedicine (Cooper, 2015; LeRouge & Garfield, 2013). Telemedicine practices are enabled by wireless electronic devices designed to facilitate rapid responses to emergency situations and accommodate remote healthcare (Viers et al., 2015; Xue et al., 2015). The general problem this study addressed is the unwillingness of consumers to use telemedicine (Al Ameen et al., 2012; Kohnke et al., 2014). Consumers understand telemedicine is designed to augment the livelihood of people and minimize healthcare expenses, but remain unenthusiastic towards its use (Dewsbury & Ballard, 2015; May, 2015). The particular problem this study focused on is consumer experiences with cognitive dissonance towards the use of telemedicine (Baig et al., 2013; Solling et al., 2014). Consumers cordially embrace telemedicine until using it trespasses delicate principals and provokes dissonance (Baig et al., 2013; Winstein & Requejo, 2015). Cognitive dissonance emerges when consumer beliefs and attitudes conflict (Attuquayefio & Addo, 2014; Martins et al., 2014). For example, wearing a wireless device may conflict with consumer cultural or religious beliefs (Hunter & Scott, 2010; Kaliyadan et al., 2013). The purpose of this qualitative study is to investigate users who experience cognitive dissonance between their interests about telemedicine and their decision towards using it. Inquiries into consumer experiences with cognitive dissonance was used to explore consumer interactions with telemedicine (Pietkiewicz & Smith, 2014; Pi-Yueh & Ping-Kun, 2012). In this qualitative study, four research questions will be used to explore the basis of consumer experience with telemedicine: (1) How do consumers describe 76 experiences with individual beliefs and attitudes towards the use of telemedicine? (2) In what settings do consumers experience personal beliefs and attitudes towards the use of telemedicine? (3) How do consumers approach uncertainty to change individual beliefs and attitudes towards the use of telemedicine? (4) What challenges do consumers experience when personal beliefs and attitudes conflict with the use of telemedicine? These research questions reflect the utility of factors affecting consumer views and opinions towards the use of telemedicine (Cincera, 2013; Wang, Oh, Wang, & Yuan, 2013). Chapter Three describes the methodology that will be employed for this study. This section is comprised of deliberations about these themes: (a) synopsis of research design, and the rationale for the research design approach; (b) summary of information needed; (c) descriptions of population and research sample; (d) description of materials and instruments; (d) data collection methods, analysis, and synthesis; (e) methodological assumptions; (f) study limitations and delimitations; and (g) ethical considerations. A brief summary will be included to culminate Chapter Three. Research Methods and Design(s) Obstructions that inhibit consumer enthusiasm are a widely understated and undervalued phenomenon (Muehlan & Schmidt, 2013; Sorensen et al., 2014). Researchers have demonstrated certain factors affect consumer behavior intention and acceptance towards the use of telemedicine (Kabakcı-Yurdakul et al., 2013; Saravani & Haddow, 2011). Other researchers have suggested this dilemma might have an adverse impact on plans in introducing telemedicine (Phichitchaisopa & Naenna, 2013; Teoa & Noyesb, 2014). Fusch and Ness (2015) use of the quantitative method focused on systematic comparisons of data to predict and generalize consumer behavior. In this 77 study, the qualitative method will be utilized patterned after exiting research (Bloomberg & Volpe, 2012; Moustakas, 1994; Pietkiewicz & Smith, 2014; Roberts, 2013). The use of the qualitative method over quantitative approach will afford exploration of consumer behavioral nuances, such as motive, meaning, and perspective towards the use of telemedicine (Singh, 2015; Snelgrove, 2014). Research highlighting consumer cognitive aspects towards the use of telemedicine is limited or nonexistent (Hung & Jen, 2012; Jovanov & Milenkovic, 2011). The interpretative phenomenological approach is unique for the purpose of informing on the experiences and perspectives of consumers towards the use telemedicine (Moustakas, 1994; Pietkiewicz & Smith, 2014). Literature Review The literature review was continued as an ongoing process throughout this study preceded the bulk of the research activities. The initial and continued review involved analysis of the contents of journals and articles, such as findings and conclusions pertinent to consumer behavior towards the use of telemedicine. Several key words such as intentions, behavioral, and cognition were employed to narrow the efforts of the analysis, and correlate the significance of the reviewed works with the objectives of this research. Qualitative Research Design Rationale In this study, phenomenology was used to focus the activities of this research on the fundamental nature of consumer experience with cognitive dissonance (Pringle, Hendry, & McLafferty, 2011; Roberts, 2013). Undertaking an interpretative phenomenological analysis facilitated opportunity to increase knowledge of consumer cognitive dispositions towards the use of wireless body area networks. Chapter Three 78 central research activities included exemplifying the qualitative paradigm and interpretative phenomenological analysis methodology that was used to conduct and augment the research. Those activities involved illustrating plans detailing recruitment and selection processes of potential research participants, and presenting materials and instruments necessary to assert and orchestrate the study. The research events comprised data collection, processing, and analysis (Nunnerley, Hay-Smith, & Dean, 2013). This study incorporated protocols that are relevant to holding and conducting a focus group and semi-structured interviews. It included plans and forms used to recruit participant perspectives and obtainment of government and healthcare authority permissions. The qualitative phenomenological design was appropriate for the exploration of the lived experiences of consumer encounters with cognitive dissonance and telemedicine (Moustakas, 1994; Pietkiewicz & Smith, 2014). The qualitative approach helped facilitate an unbiased discovery of consumer emotional dilemmas and perspectives and provide an excellent avenue to contribute to the existing body of knowledge. The interpretative phenomenological approach was used to promote the exploration and understanding of consumer cognitive dissonance (Moustakas, 1994; Smith, Flowers, & Larkin, 2009). Qualitative research techniques were employed to expose and assess consumer beliefs and attitudes affecting consumer cognition (Moustakas, 1994; Pietkiewicz & Smith, 2014; Smith, Flowers, & Larkin, 2009). The interpretative phenomenological approach underscored the exploration of consumer experiences and principles (Gill, 2014; Moustakas, 1994). Understanding these user attributes are crucial to the future of telemedicine technology (Gill, 2014; Kohnke et al., 2014). Within the framework of qualitative methodology, this study was appropriate 79 for a phenomenological study (Moustakas, 1994; Pietkiewicz & Smith, 2014). The results of this phenomenological study facilitate the development of a profound understanding of consumer cognitions towards the use of telemedicine (Karagozoglu, 2014; Rho et al., 2014). Qualitative Research Design Blueprint Conducting this qualitative research involved using a practical methodology that illustrates what, where, and how impending work activities are planned. Adoption of research questions, which were formulated to explore the basis of consumer experience with telemedicine, preceded the study procedures outlined in this plan. The research questions were used to ensure focus of the activities in this study, particularly any new discoveries. They helped frame findings meaningful towards those discoveries and any other results incidental to this study. Before inviting contributors to participate in the research data collection process, assurances were taken to ensure research subjects completed a consent form. The assurances: (1) explained and discussed the contents and purpose of the consent form; (2) verified participant signatures were affixed to consent forms, and (3) verified participants and researcher have consent forms with original signatures. This study employed three data collection techniques: (a) interview; (b) focus group discussion; and (c) researcher field notes. Researcher field notes were used to record behavioral observations of participants (Abraham et al., 2013; Mulhall, 2003). The structured observation method was used to record: (1) body language; (2) head nods; (3) passionate comments; (4) eye contact amongst participants; (5) physical enthusiasm; and (6) non-verbal activity (Cohen & Crabtree, 2006a). 80 The unstructured observation method was used to record possible follow-up questions, notable quotes, other statements that illustrate participant point of view, new concepts, key points, and themes relative to each research question (Tutton, Seers, Langstaff, & Westwood, 2012; van Rooyen, Pretorius, Tembani, & ten Ham, 2015). These observational approaches were used to minimize researcher self-report bias (Tutton, Seers, Langstaff, & Westwood, 2012: van Rooyen et al., 2015). Data collection was done in three phases: (1) semi-structured interview; (2) focus groups discussion; and (3) data analysis and synthesis. Data analysis and data synthesis were conducted simultaneously. Phenomenological bracketing was used in the data analysis process (Pietkiewicz & Smith, 2014; Snelgrove, 2014). The data analysis consisted of coding fragmented field notes, interviews, and focus group discussions into distinct categories. The synthesis process was used to merge those fragments to reconstruct holistic and integrated accounts of participant perspectives (Levine et al., 2014; Shah et al., 2013). This research design was employed to corroborate and substantiate data acquired, to make sense of data, identify patterns, and construct a theme outline. This approach was used to avoid repetitious, unfocused, and erroneous data. Prior to implementing the proposed research design, the final draft dissertation proposal, which included final versions of Chapter One, Chapter Two, and Chapter Three were successfully defended, and subsequently approved by the reigning NCU Dissertation Chair. Population The target population were patients and healthcare professionals who have knowledge of or experience with telemedicine (LeRouge & Garfield, 2013). The population characteristics are: (1) patients who are male and female adults who have or 81 will receive medical treatment, and (2) clinicians, doctors, nurses, remote healthcare professionals, emergency management technicians, and paramedics who practice healthcare treatment (Petitte et al., 2014; Veith, Chisholm, Novicoff, Rheuban, & Cohn, 2014). The locations of the targeted population were within the United States. Researchers posited it may prove difficult for healthcare advocates to promote telemedicine when consumers show little interest in using said technologies (Baig, Gholamhosseini, & Connolly, 2013; Kohnke, Cole, & Bush, 2014). Researchers advised this issue might affect patients, doctors, nurses, and emergency workforces as it obstructs the efforts of telemedicine supporters, manufacturers, and software developers (Alwahaishi & Snasel, 2013; Vowden, 2015). Although access and availability of telemedicine are well established in many states, interests and usage continues to inhibit a broader implementation (Grady & Singleton, 2011; Levine & Goldschlag, 2015; MHCC, 2016). Researchers identified a population consisting of 6 to 15 participants would be sufficient for an interpretative phenomenological analysis research (Chapman & Clucas, 2014; Grossoehme, 2014; Moustakas, 1994). The population used for this study was used to produce an in-depth examination of the research phenomena, and not be used for generalization, and not used to generate theory (Pietkiewicz & Smith, 2014; Roy, et al., 2015). Sample The interpretative phenomenological approach was used to explore cognitions influencing consumer choices towards the use of telemedicine technology (Grossoehme, 2014; Pringle et al., 2011). In this study, the homogenous purposive technique was used to select a research sample and realize themes from diverse groups of people with shared 82 individual experiences (Hefferon & Gil-Rodriguez, 2011; Roberts, 2013). Purposive samples were based on the research population characteristics and selection criteria established by this researcher (Grossoehme, 2014; Lee-Jen Wu, Hui-Man, & Hao-Hsien, 2012). The purposive sampling technique was used to realize homogeneity and heterogeneity concepts (Cleary, Horsfall, & Hayter, 2014; Robinson, 2014). Homogenous notion was used to refer to having knowledge of or experience with telemedicine, and the heterogeneous idea was used to refer to having to participate in healthcare treatment at a medical facility (Barratt, Ferris, Lenton, 2015; Stanley & Nayar, 2014). This approach was used to minimize focus on sample size, and increase sample sufficiency (Barratt et al., 2015; Lee-Jen et al., 2012). The recruitment or selection strategy process for this study was in five phases: (1) establish gatekeeper relationship, (2) participant recruiting strategy, (3) inclusion criteria, (4), exclusion criteria, and (5) participant pool. Sample Size The sample size consisted of two purposive homogeneous samples; women, n = 3, and men, n = 6 (Grossoehme, 2014; Snelgrove, 2014). The works of Deegan and Terry (2013), Dworkin (2012), and Grossoehme (2014) were used to determine the sample size for this study (Deegan & Terry, 2013; Dworkin, 2012; Grossoehme, 2014). The sample size is considered sufficient to examine the characteristics of the research questions (Crozara et al., 2014; Dworkin, 2012). The research sample size was used to realize data saturation (O’Reilly & Parker, 2013; Marshall et al., 2013; Mason, 2010). Establish Gatekeepers Relationship This step involved establishing contact with representatives of Facebook or Internet websites that advocate the use of telemedicine, and introduce and explain the 83 intent of the research (Seidman, 2013). Compliance, acknowledgement, and conformance to website security and Institutional Review Board policies and guidelines relative to the Health Insurance Portability and Accountability Act, and the Privacy Act of 1974 was fulfilled (Shay & Gosfield, 2013). This phase will consist of coordinating the appropriate permissions to do the study. This step will involve soliciting the population to recruit prospective participants, determine appropriate means of communicating with potential members, recruit a designated website administrator or IRB coordinator, gain access to potential informants, and determine locations to conduct semi-structured interviews (Bloomberg & Volpe, 2012; Seidman, 2013). Participant Recruitment Strategy During this step, the designated website administrator or IRB coordinator were contacted to publish a recruitment announcement of the research to prospective participants. This initial contact was necessary to explain participant screening, assess appropriateness of potential participants, and provide a brief synopsis of the research. Interested participants contacted the researcher to confirm interest in participating (Blake et al., 2015; Cleary, Horsfall, & Hayter, 2014). Inclusion Criteria The researcher worked with designated website administrators or IRB coordinators to ensure applicable policies or guidance were met to protect the interests of the organization and consumers using the inclusion criteria (Griffith, 2013; Latif et al., 2014). The criteria were (a) current or previous patient who used telemedicine, (b) current or previous healthcare provider who used telemedicine, (c) experience with the use of telemedicine. The experience could come from being a patient, a healthcare 84 provider, or a relationship with a patient or healthcare provided who used telemedicine, (d) be able to communicate in English without the use of a translator, and (e) between the ages of 18 and 65 years old (Player, Mackenzie, Willis, & Loh, 2014; Sydor, 2013). At this step, the researcher advised the participants their privacy and confidentiality were critical components of this study, and participation were by invitation only (Wilkes, 2014). Exclusion Criteria The researcher used inclusion list and screen for exclusion using these criteria: (a) no consent, and why (b) no interest, and why (c) not eligible, and why not. This approach includes: (d) scheduling conflict (Breen, Daniels, & Tomlinson, 2015; Cleary et al., 2014). Participants that do not meet the exclusion criteria were invited to participate in this study. This process was used to explain the purpose of the study, present a definition of cognitive dissonance, reaffirm participant interests, and process consent forms. Participant Population Pool During this step, individuals that accepted invitations were placed in a participant population pool (Draper & Swift, 2011; Seidman, 2013). The pool size consisted of no more than forty eligible participants. A number affixed to each consent form was used to determine the order in which to issue invitations (Draper & Swift, 2011; Roberts, 2013). For example, the participant receiving the consent form labeled number one gets the first invitation and so forth until the desired research sample size is reached. At this stage, participants were informed of interview options face-to-face, via telephone, or Internet collaboration application, such as Skype, or GoToMeeting. The audio capture application 85 of the Apply iPad 2 was used to record interviews via non-secure communication, such as Skype, or GoToMeeting. Interviews conducted via an Internet application or telephone were done in enclosed area, such as the researchers’ home or car (Kam, 2015). These approaches were used to ensure the privacy and confidentially of participant data is not compromised (Libert, 2015). Materials/Instruments The semi-structured interview and focus group discussion were used to collect data (Murray & Holmes, 2014; Opdenakker, 2006; Seidman, 2013). Inquiries used during the conduct of the non-directed semi-structured interview and focus group discussion were open-ended questions (Deegan & Terry, 2013; Vaismoradi, Turunen, & Bondas, 2013). The interview guide illustrated at Appendix B, and the interview question illustrated at Appendix D was used to do semi-structured interviews and focus group discussions (Deegan & Terry, 2013; Seidman, 2013). The works of Bloomberg and Volpe’s (2012) and Jacob and Furgerson (2012) were used to influence the development and usage of this manual to pontificate interview protocol (Bloomberg & Volpe, 2012; Jacob & Furgerson, 2012). The interview questions were used to make phenomenological inquiry (Galletta, 2013; Jacob & Furgerson, 2012). The interview guide was designed to encourage an interactive process, and used to help alleviate concerns that arose regarding confidentiality (Bloomberg & Volpe, 2012; Jacob & Furgerson, 2012; Moustakas, 1994). The interview recruitment protocol illustrated at Appendix A was used to confirm interests of prospective participants (Bloomberg & Volpe, 2012; Jacob & Furgerson, 2012). The informed consent form illustrated at Appendix C was used confirm consent to partake in the study. 86 The researcher conducted a small field test of the interview guide and the interview questions (Bloomberg & Volpe, 2012; Northcentral University, 2016a). The approach was used to expose unforeseen obstacles or concerns (Jacob & Furgerson, 2012; Vaismoradi, Turunen, & Bondas, 2013). The field test of the interview guide and the interview questions were done before the research. Two or three telemedicine advocates were solicited to participate in the field test as volunteer informants. These informants were not participants in the research study. The field test was recorded, transcribed, and interpreted from the perspective of phenomenological objectives. The field test was done and used to inform on the process of extracted meaningful themes from the mock interview data. The researcher, field notes, observations, and digital audio recorders were the instruments used to conduct the research and field test (Bloomberg & Volpe, 2012; Moustakas, 1994; Northcentral University, 2016a). The digital recording apparatus was an Apple iPad Air 2 model. The recording apparatus comes equipped with a built-in microphone and sound/voice recording application that was used to capture audio recordings of the interview and focus group discussion sessions. Even though the feature exists, there were no video recording for this study. Research data will not be saved, stored, or transferred via the Internet, such as a Cloud storage service (Ramanathan, Schmit, Menon, & Fox, 2015). Access to interview data and transcripts were restricted to the researcher only (APA, 2010). Interview data and transcripts were stored on an 8-gigabit removable micro hard drive, or thumb drive that was encrypted and password protected (Kam, 2015). Access to the thumb drive were restricted to the researcher, and were stored in a fire-retardant metal safe for 5 years. The safe is located at the researcher’s residence, and will only be accessible by the researcher. 87 Data Collection, Processing, and Analysis This data analysis process was used simultaneously the data synthesis process to organize, decipher, and interpret consumer experiences and perceptions verbatim, rather a word for word approach (Chapman & Clucas, 2014; Fouad et al., 2012). This data analysis process was comprised of seven components: (1) data analysis; (2) data capture tools; (3) data source triangulation; (4) data triangulation; (5) data saturation; (6) sampling saturation; and (7) researcher role (Bloomberg & Volpe, 2012; Pietkiewicz & Smith, 2014; Roberts, 2013). This data analysis process was used to obtain information that was used to contribute to understanding consumer opinions, attitudes, and behavioral intentions towards the use of telemedicine (Brown et al., 2015; Fusch & Ness, 2015). Data Collection Phase I – Semi-structured Interview This step involved eliciting context-rich personal interpretations of the consumer in a natural setting (Murray & Holmes, 2014; Opdenakker, 2006). Over a one-week period, each semi-structured interview consisted of no more 360-minute sessions, or less (Gill et al., 2008; Kumar et al., 2015). Subsequent or follow-up interviews were arranged when necessary. The interviews were recorded in their entirety, and did not contain broken, or paused recording. The informal meetings entailed presenting the open-ended research questions, eliciting unstructured feedback, and unearthing or explanation of information (Chapman & Clucas, 2014; Dworkin, 2012). Participants were invited to provide follow-up statements via probes for clarifications and richer data to maximize saturation of common themes across interviews (Gill et al., 2008; Grossoehme, 2014; Kumar et al., 2015). These probes were conducted in person or via telephone, and last 15 minutes, or less. The researcher was the instrument used to conduct interviews. The 88 researcher used digital audio recordings, and field note taking to capture research data (Warwick-Booth, 2014). Semi-structured interview data composed of viewpoints from the perspective of the participant. The semi-structured interview format afforded the researcher the flexibility to use themes generated from focus group discussions (Bloomberg & Volpe, 2012; Marshall & Rossman, 2016). The interview process nurtured in-depth personal exchanges with the informants. The semi-structured interview approach facilitated more in-depth exploration of the experiences of the participants (Marshall & Rossman, 2016; Seidman, 2013). For example, participants could focus their philosophical perspectives about cognitive dissonances, experiences, beliefs, and attitudes (Cohen & Crabtree, 2006b; Gill et al., 2008). The proposed locations were medical facilities, residences, and hospitals. Consideration did go to other preferred locations. Within the research framework, the semi-structured interview method used in this study facilitated capturing consumer perspectives, perceptions, explanations, and descriptions of the research phenomenon. Data Collection Phase II - Focus Groups Discussions This step involved eliciting context-rich own interpretations of the participant in focus group discussions setting (Murray & Holmes, 2014; Opdenakker, 2006). Over a one-week period, each focus group discussion was done in 180-minute sessions, or less (Marshall & Rossman, 2016; Seidman, 2013). Subsequent or follow-up interviews to focus group discussions were arranged when necessary. The format of the focus group discussion was semi-structured discussion. The focus group discussions were recorded in its entirety and did not contain broken or paused during recording. The focus group 89 discussion consisted of presenting the open-ended research questions, and eliciting unstructured feedback (Cohen & Crabtree, 2006a; Chapman & Clucas, 2014; Dworkin, 2012). Focus group participants were invited to participate in semi-structured interviews. Participants with unusual or complex experiences were encouraged to take part in semistructured interviews. This study used one focus group discussions session which was conducted via Skype. The focus group discussion consisted of one purposive homogeneous sample; men, n = 2 (Cleary et al., 2014; Marshall, Cardon, Poddar, & Fontenot, 2013). One additional focus group session was proposed but not held. Additional focus group sessions depended on allocated time, need, and the results of the data saturation process. Unlike semi-structured interview data, focus group discussion data used facts based on common views and examples (Gill, Stewart, Treasure, & Chadwick, 2008; Seidman, 2013). The data included meanings associated with those views. The focus group discussion format afforded the researcher more flexibility to explore any unexpected issues (Marshall & Rossman, 2016; Seidman, 2013). The interview was the main instrument used to conduct focus group discussion. The data was captured by the researcher using digital audio recordings and via personal note taking. The locations of the informants were Facebook and Internet sites that promoted the interests of telemedicine. Within the research framework, the focus group method used for this study facilitated capturing consumer perspectives, perceptions, explanations, and descriptions of the research phenomenon. In this study, the focus discussion group method allowed for nurturing dialog and reciprocal exchanges among the informants that were appropriate for this type of phenomenological study. 90 Data Collection Phase III – Data Synthesis The research data synthesis process occurred in conjunction with data analysis process (Breen, Daniels, & Tomlinson, 2015; Catling, Dahlen, & Homer, 2014). Multiple triangulation methods were used to synthesize data (Moody, Kostohryz, & Vereen, 2014; Trotter, 2012). This approach was used to help establish rigor, comprehensiveness, and further an in-depth understanding of the research phenomenon (Bekhe & Zauszniewski, 2012; Houghton, Casey, Shaw, & Murphy, 2013). This study employed two triangulation approaches: (a) methodological, and (b) data sources. Methodological triangulation was used to check the consistency of results produced by using the three data collection methods (Brown et al., 2015; Moody et al., 2014). Identification of points where participant perspectives converge or deviate was used to affirm triangulation findings (Carter et al., 2014; Venkatesh, Brown, & Bala, 2013). Data triangulation of sources were used to examine and compare the consistency of participant perspectives. The point at which these perceptions intersect were used to represent authenticity of the research phenomenon. The data analysis and synthesis process involved reading: (1) individual transcripts; (2) extracting significant phrases; (3) identify emergent themes; (4) assessing and verifying transcripts with support participant perspectives; (5) group and note theme connections; and (6) assigning alphanumeric codes. The raw data consisted of field notes, recorded interviews, and emails, which were organized and loaded into the Atlas.ti software. Interview recordings were loaded and transcribed to Microsoft Word text-based format using the Trint transcription software, with transcription error corrections conducted by the researcher. The Atlas.ti application was used to conduct data synthesis to look for and affirm similarity, difference, frequency and themes or patterns to the 91 research data (Saldana, 2013). These methods of data synthesis were used to discover clusters, patterns, or themes that were similarly or divergently linked to analyze collectively research evidence (Weigel et al. 2013; Yang et al., 2015). Data Analysis This interpretative phenomenological study was used to focus on consenting research participants. In pursuing to understand consumer reluctance to use telemedicine, four research questions were explored to collect relevant information. The theoretical research framework was the basis of the information gathered and categorized. This process consisted of coding interview and focus group data line by line to observe, develop, interpret, and arranged in emerging and diverging themes (Pietkiewicz & Smith, 2014; Roberts, 2013; Smith & Osborn, 2003). These themes were assimilated to produce an explanation of the data (Chapman & Clucas, 2014; Hefferon & Gil-Rodriguez, 2011). Phenomenological bracketing was used to demonstrate validity of the data collection and analysis process (Chan, Fung, & Chien, 2013; Pringle et al., 2011). Descriptors and categories through thematic coding were used and aligned with the theoretical framework. Each descriptor and class had an alphanumerical code (Blake et al., 2015; Vaismoradi, Turunen, & Bondas, 2013). The digital audio recordings and researcher notes were transcribed immediately after each interview or group discussion. The transcriptions were verbatim and aligned with a descriptor and category. This data analysis process employed Interpretative Phenomenological Analysis guides (Pietkiewicz & Smith, 2014; Roberts, 2013; Smith & Osborn, 2003). Data Capture Tools 92 In this study, digital audio recording and researcher field notes were used (Levine et al., 2014; Morden, Jinks, Ong, Porcheret, & Dziedzic, 2014). The Apple iPad digital recording application was used to capture and record audio of the focus group discussion and interviews (Breen, Daniels, & Tomlinson, 2015; Catling, Dahlen, & Homer, 2014). In this study, a holistic approach was used to conduct an analysis and synthesis of the data collected, and to summate characteristics and concepts about cognitive dissonance. Data Source Triangulation This study employed methodology triangulation and the data source triangulation methods (Bloomberg & Volpe, 2012; Carter, Bryant-Lukosius, DiCenso, Blythe, & Neville, 2014). Data were collected from researcher field notes, audio recordings of focus groups discussions, and audio recordings of semi-structured interviews to identify factors that contributed to consumer behavior towards the use of telemedicine (Carter et al., 2014; Trotter, 2012). Data Triangulation: Methodology Three constructs from Festinger’s (1957) original cognitive dissonance theory were focused on (Festinger, 1957). The constructs belief and attitude are corresponding elements affecting the construct behavior (Festinger, 1957; Randles, Inzlicht, Proulx, Tullett, & Heine, 2015). The methodology triangulation of interviews and focus groups data was used to establish and code data sets (Baig et al., 2013; Walsh, 2014). Focus group discussion participants were invited to semi-structured interviews to clarify or enrich data. Focus group discussion and semi-structured methods was used to produce different participant responses (Cohen & Crabtree, 2006a; Seidman, 2013). Focus group data consisted of open dialog of consumer experiences, and specific topics that were 93 socialized. Semi-structured data resulted from personal issues, and in-depth experiences of the interviewee (Cohen & Crabtree, 2006b; Brown et al., 2015). Convergence and divergence of these data were done to achieve data triangulation (Grossoehme, 2014; LeRouge, Garfield, & Collins, 2012). These data sets helped support the validity and credibility of the constructs. The methodology triangulation helped capture various magnitudes about consumer experiences with cognitive dissonance towards the use of telemedicine (Bekhet & Zauszniewski, 2012; Houghton, Casey, Shaw, & Murphy, 2013). These data sets were used to help understand consumer unwillingness towards the use of wireless body area networks. Data Triangulation: Strategy The within-method triangulation, between-method triangulation, and memberchecking was a combined strategy used to achieve data and methodological triangulation (Yeasmin & Rahman, 2012). This strategy was used to accomplish convergence and divergence of research data captured from instances of an interview, focus group, and researcher notes (Grossoehme, 2014; LeRouge, Garfield, & Collins, 2012). This strategy facilitated analysis of participant experiences, and validation of data through cross verification from two or more sources (Goldberg & Allen, 2015). This approach involved the researcher observing and analyzing differences between sets of data, and using different vantage points (Carter, Bryant-Lukosius, DiCenso, Blythe, & Neville, 2014). This strategy was used to perform convergence of data collection methods used to capture research data during instances of cases of an interview, focus group, and researcher notes (Cope, 2014). This strategy included but did not involve member-check of transcriptions resulting from an interview, focus group discussion, and researcher 94 notes (Harvey, 2015). Member-checking facilitates sharing ideas, checking the accuracy of data, collaborating data categories, and confirming research data, descriptions, and final interpretations (Gadoud, Taylor, & Hussain, 2013). Member-checking was available to all participants, particularly those members that acknowledge and agree to the intent of practice (McConnell-Henry, Chapman, & Francis, 2011). The within-method triangulation, between-method triangulation, and member-checking strategy were used to increase the level of knowledge about the phenomenon and strengthen the researcher's view of empirical research from various aspects (Yuksel & Yildirim, 2015). Data Saturation Data saturation concepts were utilized to capture an abundance of converging current information (Cleary et al., 2014; Marshall et al., 2013). Qualitative data was holistically scrutinized and coded to establish emerging themes (Carman, Clark, Wolf, & Moon, 2015; Fusch & Ness, 2015). Research questions were thoroughly explored, analyzed, and exhausted to produce new concepts or ideas to realize data saturation (Cleary et al., 2014; Smith & Osborn, 2003). Once research data became redundant, and there were no new data, the process was stopped (Mason, 2010; O’Reilly & Parker, 2013). The Atlas (ti) software was used to illuminate and establish patterns and themes of the qualitative data (Changhoon, Caesar, & Rexford, 2011). Upload of the interview and focus group discussion transcriptions to the Atlas (ti) software were done (Friedman, Foster, Bergeron, Tanner, & Sei-Hill, 2015; Grossoehme, 2014). Several approaches were used to ensure data saturation (Kisely & Kendall, 2011). Focusing on the redundancy of data was an approach that involved undertaking following interviews until new concepts were repeated numerous times (Cleary, Horsfall, & Hayter, 95 2014). In this method, data saturation was obtained when sufficient data supported emerging codes, categories, and themes, and no additional information revealed (Abraham et al., 2013). Another approach involved conducting subsequent interviews until patterns and themes from the collected data were stabilized (Adams, ShakespeareFinch, & Armstrong, 2015). Cleary et al. (2014) suggested to achieve data saturation research questions are thoroughly explored, and no additional concepts or themes emerge. Triangulation is an approach involving building on the conceptualization of topics and patterns that was used to extract significance from the original data (Wisdom, Cavaleri, Onwuegbuzie, & Green, 2012). When triangulation of themes and patterns appears to be robust, with no gaps or unexplained occurrences, saturation has been achieved (Homburg, Klarmann, Reimann, & Schilke, 2012). Sampling Saturation Purposeful sampling saturation concepts was used to produce new information (Carman et al., 2015; Perkins, Columna, Lieberman, & Bailey, 2013). The recruitment process continued until information about the study phenomenon became redundant (Coyne, 1997; Roy, Zvonkovic, Goldberg, Sharp, & LaRossa, 2015). The recruitment process was stopped when there were no new themes, or no further occurrence of data saturation (Cleary et al., 2014; Marshall et al., 2013). Researcher Role The researcher was the primary and sole investigator for this study. The researcher was solely responsible for collecting, synthesizing, and reporting contextspecific perspective data so that it can be understood and considered (Genus & Theobald, 2015; Warwick-Booth, 2014). The researcher was solely responsible for all work activity 96 associated with this study, particularly presenting interview questions during the data collection process (Nelson, London, & Strobe, 2015; Smith & Ward, 2015). The researcher was solely responsible for generating or inductively developing meaning from the data collected. The researcher participated in this study as a passionate participant, and was solely responsible for facilitating an ontological positivism multi-voice disposition during the data collection and synergizing process (Bloomberg & Volpe, 2012; Kennedy-Lewis, 2012). Critical Constraint: Epoché Phenomenological processing of data was an essential activity in this study (Murray & Holmes, 2014). It was used to examine and illustrate research the experiences of participants with cognitive dissonance towards the use of telemedicine (Chapman & Clucas, 2014). Interviews, focus group discussions, and research questions were research techniques used to influence participants to share their experiences (Pietkiewicz & Smith, 2014). These research methods were used to probe intervals and occurrences of memories, thoughts, and behaviors residing in the consciousness of participants about the research phenomenon (Moustakas, 1994). The researcher used bracketing as a strategy to mitigate risks of data being tainted before, during, and after data capturing and analysis processes (Overgaard, 2015). Random perceptions and sentiments about the phenomenon such as, researcher bias, presuppositions, and judgments risks ruining research data, and were alleviated, or eliminated (Yuksel & Yildirim, 2015). The experiences of people, such as research participants, no matter how dramatic, could have a profound impact on the emotions of an observer (Daubman, 2014). For this study, the researcher set aside knowledge about 97 and experiences with the research phenomenon when engaging research participants, research data, and data collection and analysis processes (Bevan, 2014). The researcher suppressed thoughts and feelings that could incite reacting to emotions that may be about the experiences of research participants (Hewitson, 2014; Moustakas, 1994). The researcher employed these strategies until the end of study (Hewitson, 2014; Tufford & Newman, 2010). Only then did the researcher un-bracket and thoroughly process internal perspectives if there was a need (Finlay, 2012). Assumptions This phenomenological study was based on the supposition the population did not contemplate the impact of cognitive dissonances with experiences towards the use of telemedicine (Abraham et al., 2013; Carter & Grover, 2015). Studies have shown telemedicine consumers usually do not openly express or convey dissonance when contemplating decisions towards the use of telemedicine (Cegarra-Navarro & Carrion, 2013; Kohnke, Cole, & Bush, 2014). The research assumed the population was willing to communicate lived experiences with telemedicine (Chabrak & Craig, 2013; Yu-Lun & Ching-Jui, 2014). Previous research conclude telemedicine consumer were willing to discuss openly and elaborate on features and usage of telemedicine (Levine & Goldschlag, 2015; Veith et al., 2014). Limitations There were credibility and dependability threats to this research that was mitigated to safeguard a credible phenomenological research study (Cegarra-Navarro & Carrion, 2013). Researcher bias was a prominent threat to the credibility of this investigation (Bloomberg & Volpe, 2012; Kennedy-Lewis, 2012). Measures were 98 established to ensure biases were accurately bracketed and coincide with philosophical tenets of phenomenology and holistic examination of participant experiences (LeRouge, Garfield, & Collins, 2012; Moeckli et al., 2013). Inaccurate data recording was a potential threat to the validity of this research. Measures to adequately and accurately document research evidence were practiced and used before the research. Measures were established and used to ensure researcher observations and research participant perspectives were appropriately annotated (Cegarra-Navarro & Carrion, 2013). These measures consisted of using the research instruments, and the declared data analysis software. The researcher used a journal to annotate preconceptions, as well as feelings or conflicts, before, during and after the data collection and synthesis processes. This approach was used to ensure the researcher not impose individual perspectives on participant experiences (Yuen-ling, Zenobia, & Wai-tong, 2013). Solicited clarifications from participants were used to help mitigate threats to validity and credibility. This approach was used to maintain detailed field notes and digital transcripts. A threat to research credibility and dependability existed. The Atlas.ti and Trint transcription software were used to ensure data contextually transferrable properly gleaned from the research. A critical measure used was to set aside assumptions about, and interpretations of, the research phenomenon (Cegarra-Navarro & Carrion, 2013). This safeguard was used to ensure such assumptions were not considered or voiced, mistakenly or otherwise, to influence research participants describing their experience with telemedicine. Another measure used was the researchers’ acknowledgement of difficulties in compartmentalize knowledge with the potential to influence researcher bias and data analysis (LeRouge, Garfield, & Collins, 2012). 99 Delimitations The scope of this study was intentionally delimited to recruiting participants through Facebook and Internet websites. This delimitation was predominantly attributed to the proximity and familiarity of the researcher to this approach. This approach was supported by information illustrated in recent publications regarding regional telemedicine implementation efforts (Levine & Goldschlag, 2015; Tanio & Steffen, 2014). Researches have demonstrated growing and living longer populations in various locations within the United States increased the likelihood that telemedicine needs were inevitable (Eric De Jonge, et al., 2014: Gottlieb, 2015). To reach beyond the scope delimitation would represent an incomprehensible challenge of scale for this qualitative phenomenological study. Even though the results may apply to locations within the United States, the results may not be generalized to populations and regions not considered nor included in this study. Nonetheless, the results of the research could be used to help increase knowledge or deemed useful to further telemedicine implementation. Ethical Assurances Basic ethical principles were followed in the conduct of this qualitative research: the principles of respect for persons, beneficence and justice (Belmont Report, 1979). These principals are relevant to ethics about human subjects involved in research (Ignacio, & Taylor, 2013; Schelbe, 2015). These fundamental ethical issues were employed to ensure participant: (a) informed consent, (b) privacy, and (c) confidentiality (APA, 2010; Schelbe, 2015). Informed consent was obtained from research participants before initiating the data collection process. Research participants and researcher signed 100 two consent forms. This method was used to ensure member and researcher had personal consent form with original signatures affixed. Arbitrary pseudonyms and unique identification codes were assigned to each consent form, so the researcher was able to identify an individual participant to maintain confidentiality (Bloomberg & Volpe, 2012; Delost & Nadder, 2014). Research participants were advised of the precautions that were taken to maintain confidentiality, the purpose of the research study, and participant right to privacy (Sanjari et al., 2014; Wolf et al., 2015). A research attaché case was used to transport signed consent forms, researcher field notes, and the digital recording apparatus where necessary. These instruments were secured in a safe deposit at a location designated by the researcher, and are assessable only to the researcher to maintain confidentiality (Sanjari, Bahramnezhad, Fomani, Shoghi, & Cheraghi, 2014; Wolf et al., 2015). Institutional Review Board (IRB) Approval The IRB application available at the Northcentral University (NCU) Dissertation Center was downloaded and processed (Bloomberg & Volpe, 2012; Northcentral University, 2015). After that, the completed document was submitted to the reigning NCU Dissertation Chair for review. Once approved, the assigned NCU Dissertation Chair loaded the completed version of the application to the NCU Dissertation Tracking System for IRB review. Once approved by the IRB, electronic notifications of the granted date were made available to the researcher and NCU Dissertation Chair. Research data such as recordings, transcripts, and field notes were destroyed after the results of the research study are published (Bloomberg & Volpe, 2012; Northcentral University, 2015). 101 Summary Telemedicine technology continues to be a phenomenon at the forefront of strategic resources in the fight against human suffering and untimely demise. Technological capabilities such as wireless communication is influencing the practice of modern medicine (Hughes, Xinheng, & Tao, 2012; Vowden, 2015). Telemedicine technology is gradually being integrated into the infrastructures of medical facilities and emergency units (Winstein & Requejo, 2015). Increasing consumer interests depends on telemedicine technology adopting a more significant role in the decision making of patient healthcare (Jovanov & Milenkovic, 2011; Levine et al., 2014). As telemedicine technology matures, the potential for wireless body area networks will see a tremendous increase in demand (Dewsbury & Ballard, 2015; Moeckli et al., 2013). Mobile wireless technology is already providing valuable services to consumers, particularly with the treatment of chronic illnesses (Kohnke, Cole, & Bush, 2014; May, 2015). Accessibility to telemedicine technology after an introduction and the sustainment of telemedicine technology beyond implementation are overlooked factors (Kirbas & Bayilmis, 2012; Vowden, 2015). Achieving a broader understanding of consumer cognition and behavioral intentions is crucial to the implementation of wireless body area network technology (Baig et al., 2013; Misra & Chatterjee, 2014). It is important and necessary to collect and analyze research data to help understand the phenomenon (Cleary, Horsfall, & Hayter, 2014; Jacob & Furgerson, 2012). The knowledge, skills, and experience of a researcher are critical in establishing trust and respect of research participants (Belmont Report, 1979; Delost & Nadder, 2014). Ethical matters and assurances are imperative to a successful outcome of qualitative research, and will need 102 to be critical focal points of the researcher (Kennedy-Lewis, 2012; Nelson, London, & Strobe, 2015). 103 Chapter 4: Findings The purpose of this qualitative study was to explore research participants who experienced cognitive dissonance between their interest and the use of telemedicine. Chapter Four provides a synthesis of the data that emerged from focus group discussions, one-on-one interviews, and researcher field notes (Pietkiewicz & Smith, 2014; Snelgrove, 2014). An exploration into consumer experience and interaction with telemedicine were explored using one-on-one interviews and focus groups discussion techniques, and four research questions. This chapter is organized and presented in eight topical themes. The opening themes consist of comprised deliberations about the research inquiries that postulate cognitive physiognomies. The remaining topics present information characteristic to research discoveries. After that, closing arguments exemplify perspectives and appraisal prevalent to the outlook of the study. Lastly, a summary of business acumen aligns cognitive dissonance theory, research ideas, and contexts to telemedicine technology research (Cincera, 2013; Wang, Oh, Wang, & Yuan, 2013). Trustworthiness of Data Several methods were used to uphold trustworthiness of research data. The techniques and tools used helped enhance systematization, reliability, reflexivity and effectiveness of data analysis (Sinkovics & Alfoldi, 2012). Miles, Huberman, and Saldana (2014) wrote scrutiny of data requires and is driven by, displays focused on viewing of a full data set (Cope, 2014). Techniques such as open cycling coding helped achieve complete disclosure of data (Levitt et al., 2017; Saldana, 2013). This technique involved allocating summative, salient, and essence-capturing of extrapolated data (Saldana, 2013). Further strengthening credibility and validity of data entailed using 104 methodology triangulation (Sweeney et al., 2013; Yeasmin & Rahman, 2012). This approach comprised combined field notes, one-on-one interviews, focus group discussions, research questions, and observations to gather data. This technique encompassed using Skype, MP3 Skype Recorder, and researcher observations to capture and record data. ATLAS.ti was used to organize, categorize, relate, and analyze research data (Friese, 2016). Member-checking did not occur because all participants declined to participate. Individual textural descriptions and merged textural classification methods were used to synthesize meanings and essences of participant experiences (Humble & Green, 2016; Moustakas, 1994). This approach involved integrating textual descriptions, codes, and grouping universal textural descriptions to themes (Amankwaa, 2016; Connelly, 2016; Friese, 2016). Holistic, axial, and open coding were used to expose distinct concepts and categories, and apply unique codes to large units of data in the corpus (Saldana, 2013). This approach involved splintering data to illuminate concepts and linkages to themes (Levitt et al., 2017). The approach helped produce occurrences, cooccurrences about the research phenomenon, and form basic units of analysis (Graue, 2015; Hadi & Jose Closs, 2016). The methodologies used in this study complement potential audit, rigor, and trustworthiness of research findings and conclusions (Amankwaa, 2016; Hadi & Jose Closs, 2016). Results Three themes, predominant among those created, were well supported by the research data and persistently characterized crucial considerations in consumers’ decisions towards the use of telemedicine. These concerns were synonymous with the 105 research questions used in the data analysis process to align and focus themes to the account of the experiences of the participants. Considerations aided the researcher in setting aside owned subjective experiences and biases. This approach helped the researcher accommodate bracketing while reducing data collected into construct themes (Overgaard, 2015; Yuksel & Yildirim, 2015). The topics were: (a) the complexity between ambiguous discomfort and consonant cognition; (b) the protection of reason using dissonance reduction technique; and (c) upsurge of strategy for less resistant cognition. These themes, as illustrated in Appendix R, dominant among those created, were well supported by the research data (see Appendix R). These topics persistently characterized crucial considerations in consumers’ decisions towards the use of telemedicine. Deliberations, which are synonymous with the research questions, were utilized in targeting data analysis to align and focus themes to account for the experiences of the participants. Complex Bridge between Ambiguous Discomfort and Consonant Cognition Inquiry into telemedicine usage considerations aimed to partition cognitive elements about consonant cognition. Factors that stimulate boundaries of reasoning and cognitive dissonance play an excellent role balancing consistency in cognitions. Research participants routinely reflected on a wide-ranging spectrum of opposing sentimentality that could impact cognitions. Such sentiments were abstemiously evident in scenarios that involved perceptions about the characteristics of a locale. The considerations also intended to indulge the prevalence of emotions associated with external cognitive elements and situational environments. These inquiries found the small presence of mawkish divergences spawned by settings gave rise to both favorable and unfavorable 106 cognition. Findings also reveal murky convergences frequently overlap stable temperaments. Such overlaps provide the catalyst necessary to engage in contemplative mannerisms. For example, one participant said: I feel that the use of Telemedicine can be beneficial to folks who live in an isolated community. It's beneficial. And for me I have what they call White-coat syndrome... sometimes when I see a Doctor, my blood pressure goes up. So, that would be my view on telemedicine (DIS9903AONODS2728). The findings reflect that experiences of contemplated interactions often had tendencies to stimulate and discern cognitions. Contributing to those discernments were fundamentally undervalued factors, which subsequently intensify unforeseen imbalances between ambiguous discomfort and marginalized cognitions. An interviewed participant elaborated saying: Well, I'm am IT person, so I enjoy the aspects of new ways of diagnoses and new ways in which you interact with your doctor, but I still believe there's nothing that could replace the relationship we have with your, face to face with your doctor (DIS9903AONODB8794). Prospective influential drivers were found to contradictive cognitions, where individual perspectives and unpredictable internal obstacles aligned. Drivers discovered, such as opinions, integrity, and perceptions were abundant in participant experiences. Protection of Reason by Means of Dissonance Reduction Technique Investigation of telemedicine usage considerations sought to illuminate participant reactions that appealed to favorable outcomes and correlated hindrances that stimulated emotions. It was discovered some member behaviors contradict some attitudes, which 107 generate a state of discomfort. The findings illustrate such a state of uneasiness tended the motivational property to change cognitions instantly. The persistent disposition of this state frequently led to defensive postures of personal causes. Research considerations also targeted the prevalence of emotions associated with external cognitive elements and situational environments. The findings reflect the deep resolve to be comfortable with the least harmful consequence of several unfavorable alternatives. Research results reflect participant’s determination to seek cognitive consistency preempt or lessen contemptuous aftermath. One participant particularized the phenomena cognition, saying: That's when sometimes with most cases with regards to medicine or treatment or sometime in your views or your opinions really shouldn't get in the way because if there is something that has been medically tested medically reviewed documented tested and it's going to be a benefit. I really don't feel I have; I should use my opinion or my feelings for something if it's going to make me or my loved ones feel better or get better (DIS9903AONOAL3046). Individual acknowledgment or recognition of social norms helped motivate reestablishment of cognitive consistency. Emotions, such as dread, or regret may result in multi-directional impacts, or sway on cognition. The findings demonstrated the advent of aversive conditioning often evolved into a dominant factor, intensifying tension on cognitive consistency. Unforeseen or conjured alternatives lent to petition escape avenues, in a bid to reduce such tensions (Voisin & Fointiat, 2013). Standing ground on unstable convictions often prompted agonized protectionisms. One participant stood firm, saying: 108 Telemedicine I think that we need always to be concerned with costs. We also need to be concerned with making sure that there's no any information is protected that's my big concern. But in terms of people trying to have me have a negative thoughts or opinions about Telemedicine, I don't today (DIS9903AONODS2728). The findings illustrate participants’ willing to decrease dissonance ratio, often evoked techniques to contradict or misrepresent owned cognition. Reactions to contradictive views or characteristics of a location stimulate protective methods to countermeasure strain on cognition. Conceding to a predicament, such as unpopular opinions or unimposing environments, may serve as temporary reprieves (Kokkoris & Kuhnen, 2015). Upsurge of Strategy for Less Resistant Cognition Inquiry of telemedicine usage considerations wanted to petition passions that provoked rhythm to skepticism and disposition to internal or external dissonance resolution. The results of this review revealed the more confrontational cognition remains unchanged, behavior gravitates to lesser resistant cognition. In that transition change reduction focused on a perception that accommodated, versus cognition that commits. The findings illustrate when several committing cognitions repel, rather fail to mesh, the least resistant of the two morphs into an accommodating cognition. An example would be agreeing to a short-term solution to a problem, over an unwavering commitment to a permanent fix. The findings exemplify the absence of such strategy gave cause to a state of discomfort or cognitive dissonance. One participant characterizes the phenomena, saying: 109 Well I feel as if I'm using the system, if I'm using the system that means that, you know, I'm already satisfied what I have going on, so it wouldn't be no blockage there at all. I think the challenge is always looking at the alternative of something that you're receiving. So, if I'm receiving Telemedicine in a specific manner I will always try to get the right input to information for my health (DIS9903AFGD20161217). The findings demonstrated that free choice is widely used to strengthen counterattitudinal behavior. (Shareef, Kumar, & Kumar, 2014). Conflict motivate thus result in seeking out more information and opinions to support individual cognitions. Acquiring knowledge that lessens the support of the opposing course helps to minimize the dissonance (Allahyani, 2012; Vaidis & Oberle, 2014). Particularly acute to self-concept, uncertain discomfort inflates when opposing cognitions arise. One participant epitomizes this spectacle stating: I feel like I've done my due diligence and it's good to see with your continued use of Telemedicine or you go back to traditional ways I'm pretty at peace about it. So as long as I do due diligence I feel good about whichever direction I go in (DIS9903AFGD20161217). Synopsis of Research Inquiries This component outlines and exemplifies data salient to research questions identifying common themes or patterns that emerged during data analysis (Saldana, 2013). Data are illustrated in tables to accommodate meaningful models of relative themes and weight of occurrences (Nicol & Pexman, 2010). 110 Question 1. How do consumers describe experiences with individual beliefs and attitudes towards the use of telemedicine? This research inquiry sought to partition cognitive elements relative to consonant cognition, particularly those that stimulate boundaries of reasoning and cognitive dissonance. Drivers could be internal subjective perspectives, and unpredictable internal obstacles. The question was posed to participants using two inquiry: (a) When your views and feelings make you think a lot about the use of telemedicine, what do you feel? And (b) When your beliefs make you feel challenged about the use of telemedicine, what do you feel? The outcome of the inquiries is illustrated in Table 2 below. Table 2 Question 1 Weight of Themes Theme Consonant Cognition Dissonance Reduction Technique Strategy for Less Resistant Cognition Mitigating Approach Note. Total Weight: 164 Occurrence 32 26 89 17 Percent 20% 16% 54% 10% Question 2. In what settings do consumers experience individual beliefs and attitudes towards the use of telemedicine? This research enquiry aimed to indulge the prevalence of emotions associated with external cognitive elements and situational environments. Drivers could be reactions to contradictive views, or characteristics of a location. The question was posed to participants using two inquiry: (a) When the opinion of people affects your decision about the use of telemedicine, what do you feel? and (b) When people or places impact what you think about the use of telemedicine, what do you feel? The outcome of the inquiries is illustrated in Table 3 below. 111 Table 3 Question 2 Weight of Themes Theme Consonant Cognition Dissonance Reduction Technique Strategy for Less Resistant Cognition Mitigating Approach Note. Total Weight: 197 Occurrence 30 31 102 34 Percent 15% 16% 52% 17% Question 3. How do consumers reduce uncertainty to change individual beliefs and attitudes towards the use of telemedicine? This research question sought to illuminate reactions appealing to favorable outcomes, and correlating hindrances that stimulate emotions. Drivers could be prospects of improved conditions that collide into internal or external outlooks. The question was posed to participants using two inquiry: (a) What do you feel when you understand the benefits of using telemedicine but your views and feelings are a road block? and (b) What do you feel when you know that telemedicine is good for you but the feelings of other people are a road block? The outcome of the inquiries is illustrated in Table 4 below. Table 4 Question 3 Weight of Themes Theme Consonant Cognition Dissonance Reduction Technique Strategy for Less Resistant Cognition Mitigating Approach Note. Total Weight: 172 Occurrence 30 25 90 27 Percent 17% 15% 52% 16% Question 4. What challenges do consumers experience when personal beliefs and attitudes conflict with the use of telemedicine? This research request petitions passions that are rhythm to skepticism, and disposition to internal or external resolution. Drivers could be opposing propositions, and 112 yield to relevant perspectives, may they be internal or external. The question was posed to participants using two inquiry: (a) When you doubt a decision about the use of telemedicine, what do you feel? and (b) When your views and attitudes make you think twice about a decision about the use of telemedicine, what do you feel? The outcome of the inquiries is illustrated in Table 5 below. Table 5 Question 4 Weight of Themes Theme Consonant Cognition Dissonance Reduction Technique Strategy for Less Resistant Cognition Mitigating Approach Note. Total Weight: 245 Occurrence 35 36 134 40 Percent 14% 15% 55% 16% Portrayal of Data Magnitude of Transcripts. Minor editing was done to recover areas that were somewhat unintelligible. This approach applied to all but two of the transcripts, which accounted for 78% of the total transcripts. This rate illustrates difficulties associated with capturing the voice of a participant who either fails to speak slowly, clearly, or loud enough during recording. The magnitude of transcripts is shown in Table 6 below. 113 Table 6 Degree of Transcripts Transcript DIS9903AONORG0231 DIS9903AONOMC3448 DIS9903AONOKH1119 DIS9903AONOINSKYP DIS9903AONOET7393 DIS9903AONODS2728 DIS9903AONODD3778 DIS9903AONODB8794 DIS9903AONOAL3046 DIS9903AFGD20161217 Pages 2 2 2 2 2 4 2 2 3 2 Note. Total Records: 23 Participant Demographics. The participant pool included three women and seven men. Of the total sampling, three participants randomly claimed information technology professionalism, one declared community leadership, and the remaining five did not refer such information. Evaluation of Findings Cognitive dissonance could be very overwhelming when faced with haphazard choices. The findings illustrate occurrences where advancing accommodating cognition attributes to greater discomfort (Fransen, Smit, & Verlegh, 2015; Lui & Keng, 2014). The results exhibit instances of seeking out democratic compromise amid several participants. The findings demonstrate that strategy is useful for relinquishing dissonance and promoting egalitarian attitudes and behavior (Gregory-Smith, Smith, & Winklhofer, 2013; Timming, 2015). The findings also reflect members typically expressed cognitions, or cognitive elements, as an opinion, belief, or perception. Beasley (2016) noted dissonance reduction would most often result in some level of distortion of information. 114 Contrary to Beasley (2016), these findings indicate such cognitions coincide with the knowledge about something or someone. Beasley (2016) added particular information avoidance and various other techniques helped realign inconsistencies among beliefs, preferences, and behaviors (Beasley, 2016; Chang, Solomon, & Westerfield, 2016; Fransen, Smit, & Verlegh, 2015). The findings in this study were similar, demonstrating that attitudes, behavior, beliefs, and knowledge may help consumers achieve a state of compatibility. It was discovered participants ultimately sought a state of harmony, regardless the prevalence of dissonance. Overall, findings were consistent with similar works by Chapman and Clucas (2014); Guazzini, Yoneki, and Gronchi (2015); and Rodger, Neill, and Nugent (2015). As was this case in this study those researchers sought to affirm the notion that inconsistent elevations could lead to unfavorable behavioral responses (Kumar, Seay, & Karabenick, 2015; Sandvoll, 2014). Summary Telemedicine, a wearable health monitoring technology, continues to evolve as a premier technological breakthrough (Kirbas & Bayilmis, 2012; Vowden, 2015). Quests to improve, sustain, and preserve human anatomy are dramatically infused within the existence of telemedicine (Winstein & Requejo, 2015). The audaciousness to continually revisit healthcare business acumen consciously solidify such quests (Hughes, Xinheng, & Tao, 2012; Vowden, 2015). Consumers of telemedicine, such as patients, healthcare professionals, and commercialist encounter numerous challenges that manipulate telemedicine acceptance and use factors (Chang, Solomon, & Westerfield, 2016; Kokkoris, & Kuhnen, 2015). Lui and Keng (2014) noted that understanding both the nourished and undernourished appetite that emanates with such challenges is imperative. 115 Inaccessibility, injured cognitions, and benefit demotion to telemedicine technology cannot, and should not be allowed to continue status-quo (Jovanov & Milenkovic, 2011; Levine et al., 2014). Cognitive dissonance that jeopardizes and besieges behavioral intentions must be confronted on a large scale (Chang, Solomon, & Westerfield, 2016; Kokkoris, & Kuhnen, 2015). Pursuit of auspicious business and recipient consumerisms are crucial to abdicating impediments to telemedicine lifecycle (Nelson, London, & Strobe, 2015; Vowden, 2015). 116 Chapter 5: Implications, Recommendations, and Conclusions Consumers understand and appreciate the legitimacy and promise of telemedicine, but yield to dissension when its use traverses individual principals (Baig et al., 2013; Winstein & Requejo, 2015). The problem investigated was consumer experiences with cognitive dissonance towards the use of telemedicine (Baig et al., 2013; Solling, Caroe, & Mathiesen, 2014). The emergence of cognitive dissonance was assured when consumer beliefs and attitudes conflict (Attuquayefio & Addo, 2014; Martins, Oliveira, & Popovic, 2014). The purpose of this study was to investigate customer experiences towards using or not using telemedicine. Research activities focused on illuminating consumer cognitive about decisions to use or not use telemedicine (Festinger, 1957; Harmon-Jones, 2012). The interpretative phenomenological method was used to inform on user experiences and perspectives towards the use telemedicine (Moustakas, 1994; Pietkiewicz & Smith, 2014). Limitations to the study were sample size, locations for posting recruitment notices, and exclusion of healthcare and hospital facilities. Adherence to ethical principles prescribed by Northcentral University, and Guidelines for Protection of Human Subjects of Research of the Belmont Report were employed in this study (Belmont Report, 1979; Northcentral University, 2016b). Mutual participant and researcher written informed consent were acquired (Northcentral University, 2016b). The approach helped assure the protection and confidentiality of the data collected, and member association to the data (Pohling et al., 2016). Number pseudonyms helped to affirm assurances of participant anonymity. Member checking and quality control discussions were offered concluding one-on-one interviews and focus group discussions (Wallace & Sheldon, 2015). There were no signs of distress or distrust, 117 while some participants expressed inspiration and support. Chapter 5 consists of four topics, with the first discussing the researchers’ interpretations of research findings. The next section highlights practical application of the research results. The remaining segments summate final analysis of the research and relevant scholarly references to it. Implications The research findings exonerate the study purpose, illuminating instances where inconsistent beliefs and attitudes gave rise to consumer cognitive dissonance accompanying decisions toward the use of telemedicine (Festinger, 1957; Harmon-Jones, 2012). de Vries, Byrne, and Kehoe (2015) noted the occurrence of discomfort or dissonance motivates individuals to expend cognitive and behavioral efforts. These exertions promoted dissension decrease and restored cognitive consistency (Kumar, Seay, & Karabenick, 2015; Sandvoll, 2014). The research analysis elevated the significance of using the qualitative interpretative phenomenological approach to reveal probable sensitive discord. Through this technique, study participant experiences provide concrete evidence cognitive dissonance likely occur when faced with important choices towards the use of telemedicine (Beasley, 2016). This conclusion aligns with the study theoretical framework, which posits presence of cognitive dissonance when elevated inconsistencies in consumer cognitions surface (Hernandez, Haidet, Gill, & Teal, 2013; Yu-Lun & Ching-Jui, 2014). Research results clearly illustrate robust evidence of the legitimacy of the study’s theoretical framework and conclusions here within. Portrayed in Appendix R, are fortifying findings of consonant cognition and cognitive dissonance occurrences, alongside degrees of magnitudes comparative to research inquiries. The evidence presented suggests research participants routinely 118 reflected on a wide-ranging spectrum of dissimilar sentimentalities that influenced discrete cognitions. Implications derived from the research inquiries and following themes suggest dissonant sentiments were abstemiously evident in scenarios depicted in participant experiences. Research question one (Q1) partitioned cognitive elements about consonant cognition, summoning essential items such as original ideas, ambivalence, and self-perception. For example, the occurrences of consonant cognitions illustrated in Appendix R reveal participants exhibited favorable compatibility amongst internal principles and sentiments towards the use of telemedicine. The research findings postulate probability when attitudes, behavior, and beliefs achieve compatibility, internal consistency ascends, and harmony prevails. Research data are shown in Appendix R reflecting findings of dissonance occurrences resonating participant experiences, offsetting principles and sentiments. Antoniou, Doukas, and Subrahmanyam (2013) noted people with positive attitudes make optimistic judgments and choices, whereas people with negative attitude make pessimistic ones. Question two (Q2) intended to indulge the prevalence of emotions associated with external consonant elements and location dispositions. Data illustrated in Appendix R depict reliable indications resistance to outside opinion, and contemptuous settings accompanied decisions toward the use of telemedicine. Occurrences of dissonance prevalent in Appendix R illustrate probable evidence of energy to alleviate characteristics of a location and dismiss exterior contrary views. Research inquiries found the presence of mawkish divergences spawn by settings gave rise to both favorable and unfavorable cognition (Davis, 2016). Fransen, Smit, and Verlegh (2015) suggested people contest the validity of an opinion, decipher inclusive arguments, refuting an 119 unharmonious view with counterarguments. Research data outlined in Appendix R suggests probable evidence participant experiences reflect such an approach. Question three (Q3) sought to illuminate reactions to vague cognitions, and the advent of relative internal and external obstacles. Fransen, Smit, and Verlegh (2015) found people frequently try to convince others to change their attitudes, opinions, or behavior. The authors indicated people oppose, counter, and resist persuasive attempts by adopting lessening impervious strategies. Research information illustrated in Appendix R resonate probable evidence similar strategies intertwine participant experiences. Researchers suggest people condense dissonance after resolving challenging decisions, turning attention on accepting the chosen option, or discarding interest in the unchosen option altogether (Kokkoris & Kuhnen, 2015). The appeal and draw of potential benefitrisk cognitive dissonance impositions the instant internal or external obstacles levied. The findings in this study suggest erosive dissonance instigate self-affirmation tactics to alleviate correlating hindrances. Henriksen, Guessers, and Bordered (2015) found people typically lean towards psychological consistency to avoid ambivalent inconsistency. Research data shown in Appendix R suggests probable inharmonious obstacles interfere with self- integrity intensifying eagerness to restore comprehensible sense and selfconcept harmony (Fointiat & Pelt, 2015). Cognitive reappraisals often petition passions that appeal to skepticism, triggering temperament to internal or external resolution (Adams, Shakespeare-Finch, & Armstrong, 2015). Question four (Q4) sought to reveal challenges consumers experienced when personal beliefs and attitudes conflict. Research findings depicted in Appendix R indicate probable evidence such predicaments reverberate foundations of participant experiences. 120 The data findings reveal occurrences of consonant and dissonance plague decision processes, provoking divergences detrimental to potentially favorable outcomes. A possible example of a favorable outcome are benefits associated with using telemedicine. For example, this could include alleviating a commute for follow-up medical assessment by a physician located at a hospital or reducing patient stress related to visiting medical facilities (Castellano et al., 2015). Findings, in this study, appear to advocate undesired communication exchange and cherished internal concepts invoke cognitive counterbalances between inner and external intuitions (Henriksen, Guassora, & Brodersen, 2015). Such compensation promotes inevitable perceptions of dictatorial and uncaring bilateral communiqué. For example, evidence of occurrences levying evasive measures to resist outside influence towards the use of telemedicine exists in the findings. Chang, Solomon, & Westerfield (2016) noted when individuals encountered subsequent cognitions dissonant consistent decisions and various psychological means to reduce dissonance-related discomfort without relinquishing the original cognition. The magnitude of dissonance and subsequent attempts to resolve dissonance comingle variables, such as importance, attractiveness, and interests (Allahyani, 2012). Recommendations User acceptance and intention to use healthcare technology are crucial to the evolution of patient healthcare information technology (Martins et al., 2014). The importance of understanding and acknowledging what customers feel towards the use of telemedicine appears underrated (Butcher, 2015). This segment discusses practical and research recommendations, relevant to these phenomena, for future studies. Practical recommendations suggest these research findings could directly benefit researchers 121 seeking to enhance healthcare information technology acceptance and use (May, 2015). Research recommendations suggest the results of this study could directly benefit researchers seeking to further understand healthcare information technology acceptance and use (Vowden, 2015). Advocates of telemedicine may find these research results invaluable to enhancing business acumen and telemedicine consumer interests. Practical recommendations. The results of this study have far-reaching practical implications feasible to promoting user acceptance and use concerns in many areas. For example, these findings could be used to help understand the determinants of Internet banking adoption (Martins, Oliveira, & Popovic, 2014). Advocates planning to implement telemedicine in rural areas could use these findings to help diminish or subdue indigenous consumer anxiety towards the use of telemedicine (Kohnke, Cole, & Bush, 2014). This study affirms support for the core concepts of cognitive dissonance theory relevant to establishing intent towards the use of telemedicine. Correlation between consonant and dissonant cognitions indicate the importance for considering consumer cognitions when implementing telemedicine. Incapacitating consumer resistance towards the use of telemedicine may help improve implementing healthcare information technology where acceptance and end use is either small or non-existent. Implementation practitioners contemplating the future employment of telemedicine may explore corroborating these results with existing technology acceptance models that do not consider consumer cognitive dissonance towards the use of telemedicine (KnoblockHahn & LeRouge, 2014). Research recommendations. Undoubtedly these findings provide robust support for the cognitive dissonance theory. This study precipitates the practicality and need of 122 further investigation into the phenomena (Festinger, 1957; Harmon-Jones, 2012). Further research may well reveal vital data that may contribute to strengthening an understanding consumer acceptance towards the use of telemedicine. The interpretative phenomenological analysis used in this study was limited to adults haphazardly recruited using social media channels. Recommended future research could expand and imitate this qualitative study exploring perspectives and lived experiences of consumers located in hospitals and other medical facilities. Researchers may want to consider isolating future research to facilities specializing in administering telemedicine to consumers (Fiordelli, Schulz, & Zufferey, 2014). Future research may also consider aligning and employing use behavioral models, such as the social cognitive theory, or the social capital theory, to help increase knowledge and understanding of consumer cognitive dissonance towards the use of telemedicine (Sun & Rau, 2015). Researchers contemplating future acceptance of telemedicine challenges should explore corroborating these results with existing technology acceptance models that do not consider consumer cognitive dissonance towards the use of telemedicine (Kohnke, Cole, & Bush, 2014). Conclusions This researcher concludes information technologies are essential components to improving the healthcare treatment of patients while enhancing the knowledge of medical professionals and practitioners who manage healthcare. Inconsistent elevations of consumer emotions could lead to unfavorable behavioral intentions towards the use of telemedicine technology (Kumar, Seay, & Karabenick, 2015; Sandvoll, 2014). Mitigating elements about cognitive dissonance and consonant cognition portray credible evidence which corroborates the validity and probability of the research problem (Phichitchaisopa 123 & Naenna, 2013; Teoa & Noyesb, 2014). Modern business philosophy acumen motivated this study, embodied by the importance of theory in research (Kasemset & Kachitvichyanukul, 2010). Research findings resulting from interpretative phenomenological analysis of cognitive and consonant and dissonance concepts contribute to knowledge in this area. The findings add to the body of knowledge by exposing the relevance of understanding cognitive dissonance and its underrated affiliations. Such alliances play a meaningful role when embracing or rejecting the use of telemedicine thus indicating the need and importance for more research in this field of study. 124 References Abrahams, A. S., & Singh, T. (2013). Expeditionary learning in information systems: Definition, implementation, and assessment. 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Information Sciences, 314 (1), 255-276. 154 Appendices 155 Appendix A: Interview Protocol Interview #_______________ Date_______/_____/_______ Interview Protocol Script Welcome and thank you for your participation today. Thank you so much for your willingness to share your knowledge and experience. My name is Haywood Cutts and I am a candidate at Northcentral University conducting a Special Study in partial fulfillment of the requirements for the Doctor of Philosophy in Business Administration. Thank you for your interests in this study, and this follow-up interview. The allotted time for this interview/focus group discussion will be no more than 120 minute. Subsequent or follow-up interviews can be arranged when necessary. I will ask you a series of eight questions regarding your experiences towards the use of telemedicine. You are reminded this interview (or group discussion) will be recorded so that I may accurately document your responses. If at any time during the interview you wish to discontinue the use of the recorder or the interview itself, please let me know. All of your responses will be confidential. Your responses will remain confidential and will be used to develop a better understanding of your experiences towards the use of telemedicine and what might influence your decision to use or not use it. You are invited to do member-checking of transcripts, and are encouraged to share ideas to improve the interview questions. (Explain the purpose and intent of member-checking). The purpose of this study is to increase our understanding of consumer experiences towards the use of telemedicine. This study will involve minimal risk and discomfort. The probability of harm and discomfort will not be greater than your daily life encounters. Risks may include emotional discomfort from answering interview questions. You will not directly benefit from participating in this study. Indirect benefits will include the promotion of our understanding of what factors influence your decisions towards the use of telemedicine. At this time, I would like to remind you of your written consent to participate in this study. I am the responsible investigator, specifying your participation in the research project: An Investigation of Circumstances Affecting Consumer Behavioral Intentions to Use Telemedicine Technology: An Interpretative Phenomenological Study. You and I have both signed and dated each copy, certifying that we agree to continue this interview. Please keep your copy in a safe place and I will keep the other under lock and key, same as I will do with your interview/discussion responses. 156 Your participation in this interview/discussion is completely voluntary. If at any time, you need to stop, take a break, or reconsider your response to a question, please let me know. You may also withdraw your participation at any time without consequence. Do you have any questions or concerns before we begin? Then with your permission we will begin the interview/discussion. Thank you very much for your participation today. To conclude this interview, do you have any questions or concerns before we close? Then with your permission we will end this interview. 157 Appendix B: Informed Consent Form Introduction: My name is Haywood Cutts. I am a doctoral student at Northcentral University. I am conducting a research study to understand the reasons that helped you decide to use or not use telemedicine, and possible conflicts with that decision. I am completing this research as part of my doctoral degree. I invite you to participate. Activities: In this research, you will: • • • Be in a one-on-one interview for 2 hours, or less. We will use Facebook audio chat. Be in a focus group discussion for 2 hours, or less. We will use Skype audio chat. Check interview and discussion group transcripts for about 15 minutes, or less. Eligibility: You are 18 to 65 years, have experience with deciding to use or not use telemedicine, or have a relationship with someone who has such experience, and speaks English without a translator. You are not eligible to participate in this research if you: 1. Will not consent to the research. 2. Not interested. 3. Not eligible. 4. Scheduling conflict. I hope to include 16 people in this research. Risks: There are minimal risks in this study. Some possible risks include: • • Concern that answering a question could be stressful, and that information will not remain confidential. Concern answer may not be good enough or exactly what needs to be said. To decrease the impact of these risks, you can: • • Skip the question, and come back to it later. Have the researcher to break the question down. 158 • • Not answer the question at all. Explain in own words, with no pressure for a best answer. Benefits: There are no direct benefits. Indirect benefits may include feeling joy and comfort by sharing one’s past experiences. The information from this study may help other people consider the impact attitudes and beliefs have towards the use of telemedicine. Indirect benefits could include helping promoters of telemedicine increase the understanding of perceptions and knowledge about intentions to use of telemedicine. A copy of the results of the study can be provided for your review before it is published. Confidentiality: The information you provide will be kept confidential to the extent allowable by law. Some steps I will take to keep your identity confidential are use a fake name or number to identify you, and keep your name separate from your answers. The people who will have access to your information are myself and my dissertation committee. The Institutional Review Board may also review my research and view your information. I cannot promise that information in the focus group will remain confidential because there will be other participants there. These steps will be taken to keep your information safe: lock consent forms and data in a filing cabinet. Lock the computer file with a password. Use encryption on my computer. Transport data in a locked case. I will keep your data for 7 years. Then, I will delete electronic data and destroy paper data. Contact Information: If you have any questions, please contact me at: H.Cutts2747@email.ncu.edu. My dissertation chair’s name is Dr. Brian Allen. He works at Northcentral University and is supervising me on the research. You can contact him at: brianallen@ncu.edu If you have questions about your rights in the research, or if a problem has occurred, or if you are injured during your participation, please contact the Institutional Review Board at: irb@ncu.edu or 1-888-327-2877 ext. 8014. Voluntary Participation: Your participation is voluntary. If you decide not to participate, or if you stop participation after you start, there will be no penalty to you. You will not lose any benefit to which you are otherwise entitled. Compensation: 159 You will be given an Amazon gift card valued at $15.00 at the end of the research. Audio taping: I would like to audio record the interview and group discussion. If you do not wish to be recorded, you can still participate. Participants who decline to be recorded cannot participate in the focus group. Please sign here if I can record you: Signature: A signature indicates your understanding of this consent form. You will be given a copy of the form for your information. Participant Signature Printed Name Date Researcher Signature Printed Name Date 160 Appendix B: Informed Consent Form Readability Report 161 Appendix C: Recruiting Notice Participants Needed for Telemedicine Research Project The purpose of this study is to understand motives and decision to use or not use telemedicine, and possible conflicts with that decision. Telemedicine is a healthcare practice that people, such as doctors, nurses, and patients use to treat and check health from a remote place. This poster is not to tell you to join the research. Participation is voluntary. The decision is totally up to you. Your choice to participate or not participate will have no effect on your relationship with the Host of the Facebook site, or the Northcentral University. You can stop at any time. You can choose not to answer any question you feel uncomfortable with. In this study, you will do a one-on-one interview, a focus group, and review transcripts. You can do all of the research activities, or only the ones you prefer. The one-on-one interview will take about 2 hours; the focus group will also take about 2 hours. The review of the transcripts will take about 15 minutes. If you are an adult between the ages of 18 to 65, have experience with deciding to use or not use telemedicine, have a relationship with someone who has such experience, and speaks English without a translator, you are invited to join this study. You will receive a $15 Amazon gift card at the end of the research. If you are interested, please contact me. Haywood Cutts Ph.D. Candidate – Northcentral University H.Cutts2747@email.ncu.edu 162 Appendix C: Recruiting Notice Readability Report 163 Appendix D: Interview Questions Primary Research Question Subsequent (Topical) Interview Questions Q1. How do consumers describe experiences with individual beliefs and attitudes towards the use of telemedicine? Topical question-1.1. When your views and feelings make you think a lot about the use of telemedicine, what do you feel? Topical question-1.2. When your beliefs make you feel challenged about the use of telemedicine, what do you feel? Q2. In what settings do consumers experience individual beliefs and attitudes towards the use of telemedicine? Topical question-2.1. When the opinion of people affects your decision about the use of telemedicine, what do you feel? Topical question-2.2. When people or places impact what you think about the use of telemedicine, what do you feel? Q3. How do consumers reduce uncertainty to change individual beliefs and attitudes towards the use of telemedicine? Topical question-3.1. What do you feel when you understand the benefits of using telemedicine but your views and feelings are a road block? Topical question-3.2. What do you feel when you know that telemedicine is good for you but the feelings of other people are a road block? Q4. What challenges do consumers experience when personal beliefs and attitudes conflict with the use of telemedicine? Topical question-4.1. When you doubt a decision about the use of telemedicine, what do you feel? Topical question-4.2. When your views and attitudes make you think twice about a decision about the use of telemedicine, what do you feel? 164 Appendix D: Interview Questions Readability Report When your views and feelings make you think a lot about the use of telemedicine, what do you feel? When your beliefs make you feel challenged about the use of telemedicine, what do you feel? When the opinion of people affects your decision about the use of telemedicine, what do you feel? When people or places impact what you think about the use of telemedicine, what do you feel? What do you feel when you understand the benefits of using telemedicine but your views and feelings are a road block? What do you feel when you know that telemedicine is good for you but the feelings of other people are a road block? When you doubt a decision about the use of telemedicine, what do you feel? When your views and attitudes make you think twice about a decision about the use of telemedicine, what do you feel? 165 Appendix E: Member Check Thank you for sharing your experience. I have considered the answers of about the reasons that helped participants decide to use or not use telemedicine, and possible conflicts with that decision. Here is a draft of the interview findings, which I hope you will review. I would appreciate you taking a few more moments to review it and let me know of any errors or misinterpretations that needs addressing. Thank you again so much for your time and sharing your experience. 166 Appendix F: Informed Consent Signature Procedure • Potential participant contacts the researcher via NCU email. • The same day, or following day, researcher sends signed (by researcher) informed consent form to potential participant via HelloSign application. The following will be added: After your consent form is received, a follow-up email will be sent to arrange date and time you can be available to do the interview. • Prospective participant will either return a signed (participant) consent form through HelloSign, or via NCU email. • Consent forms returned via HelloSign are saved to an encrypted SD card, and stored in a safe. • Consent forms returned via NCU email are saved to an encrypted SD card, and stored in a safe. 167 Appendix G: Research Activities Procedures • Initial recruiting cutoff is after five (5) days, thereafter until target sample is reached, or interest is exhausted. • Interviews start end of initial recruiting, until pool/interest exhausted. • Focus group discussions are three separate occasions; two (2) over a four (4) day period, starting ten (10) days after end of initial recruiting, one (1) afterwards to exhaust pool. • To curtail responses to a Facebook site, a subsequent caption is inserted underneath the Recruiting Notice, which will read “Please express your interest in this study by directly emailing the researcher. Please do not post or LIKE your response here.” The Facebook owner or the researcher will add this note. Individual Participant Interview • After consent form is received, post email to establish the interview period, and arrange date and time prospective participant can attend. (Dialog until date/time is confirmed). • Scheduled interview is added to NCU outlook, and an invite sent to prospective participant. Prospective participant are reminded to connect to Researcher Facebook ID to initiate the interview. • Scheduled interview is given a unique ID and affixed to an Interview Protocol, along with the date and time the interview is scheduled. This Interview Protocol will be used only for and associated to that interview. • The Interview Protocol is delivered (read) to start the interview. • The Interview Protocol is delivered (read) to end the interview. Participant Group Discussion (FGD) • After consent form is received, post email to propose two (2) FGD dates and times, and arrange preferred session prospective participant can attend. (Dialog until date/time is confirmed). • Two (2) separate FGD are established in Skype, with a link to these sessions added to NCU outlook, and an invite sent to prospective participants. Prospective participant were reminded to connect to Skype on the agreed date. 168 • Scheduled FGD are given a unique ID and affixed to an Interview Protocol, along with the date and time the FGD is scheduled. This Interview Protocol will be used only for and associated to that FGD. • The Interview Protocol is delivered (read) to start the interview. • The Interview Protocol is delivered (read) to end the interview. Interview Member Check (IMC) • Immediately following interview, recording is immediately transcribed using Trint transcription software and emailed cognizant participant within two (2) hours. • At participant convenience, but not more than twenty-four (24) hours, returns unchanged or updated transcripts; sanitized (spelling only) and used as research data. FGD Member Check (FMC) • Immediately following FGD, recording is immediately transcribed using Trint transcription software and emailed cognizant participants within two (2) hours. • At participant convenience, but not more than twenty-four (24) hours, after reviewing off-line returns unchanged or updated transcripts; sanitized (duplication/spelling only) and used as research data. Confidentiality Affirmation Procedure • To curtail responses to a Facebook site, a subsequent caption is inserted underneath the Recruiting Notice, which will read “Please express your interest in this study by directly emailing the researcher. Please do not post or LIKE your response here”. The Facebook owner or the researcher will add this note. • An encrypted mini SD card is purchased and used exclusively for research activities. Signed consent forms are saved directly to the encrypted mini SD card. The email exchanges of the signed consent forms are permanently erased to accommodate confidentiality. The interviews are one-on-one, and are held in a private Facebook audio chat session between the researcher and the individual participant, which accommodates confidentiality of the names. The group discussions are held in a private Skype session, which allows the researcher to hide the names of participants and accommodate confidentiality. 169 • The interview and group discussions are conducted in a private closed room, and hosted on a desktop PC unmuted, with the voice recording application of an Apple iPad Air 2 used as a recording device to capture the audio output from the desktop PC speakers. There will be no transfer or saving of transcripts, recordings, and data analysis files to the desktop PC hard-drives. The recordings are saved to an encrypted mini SD card that is attached to the recording device. The SD card is insert a desktop PC card port for research activity and transcribing. • The final transcripts are saved to the encrypted mini SD card. The data analysis process is conducted, with the results saved to the encrypted mini SD card. Once the research findings are finalized, the results of the data analyses, the recordings, and the transcripts saved to encrypted mini SD card are stored and locked in a metal combination safe located in the researcher’s residence to accommodate confidentiality. The recordings on the recording device are permanently erased. All equipment and software applications used to conduct research activities will be sanitized to ensure there are no residue transcripts, recordings, or results of the data analysis remaining. 170 Appendix H: UVA IRB Inquiry RE: NCU Doctoral Candidate Research Inquiry HR Hoffman, Susan R. (srh) Reply all| Today, 05:21 PM Cutts, Haywood; Rowe, Megan B. (mbr4p) ; Mimms, Karen Coleman (kcm6t) ; Gaucher, Tara Lynn (tlg2t) Inbox Action Items Hi As the UVA IRB is not approving your advertisement, nor is any UVA personnel posting the advertisement there is no approval form. You may use this email to provide confirmation to the NCU IRB. Susie Hoffman IRB-HSR Director University of Virginia From: Cutts, Haywood [mailto:H.Cutts2747@email.ncu.edu] Sent: Wednesday, August 24, 2016 4:53 PM To: Hoffman, Susan R. (srh); Rowe, Megan B. (mbr4p) Cc: Mimms, Karen Coleman (kcm6t); Gaucher, Tara Lynn (tlg2t) Subject: Re: NCU Doctoral Canditate Research Inquiry Hi Susan and Megan, Thank you for the speedy response. Is it possible to provide some sort of confirmation or consent response that can be provided to NCU IRB (something similar to the NCU IRB approval letter)? Thank you so kindly for your patience and consideration, and my utmost apologies for any inconveniences. s/Haywood From: Hoffman, Susan R. (srh) Sent: Wednesday, August 24, 2016 08:14 AM To: Rowe, Megan B. (mbr4p); Cutts, Haywood 171 Cc: Mimms, Karen Coleman (kcm6t); Gaucher, Tara Lynn (tlg2t) Subject: RE: NCU Doctoral Canditate Research Inquiry Megan If no one from UVa will be posting the ad then no submission to the IRB is required. Susie -----Original Message----From: Rowe, Megan B *HS [mailto:MBR4P@hscmail.mcc.virginia.edu] Sent: Wednesday, August 24, 2016 7:27 AM To: Hoffman, Susan R. (srh); Cutts, Haywood Cc: Mimms, Karen Coleman (kcm6t) Subject: Re: NCU Doctoral Canditate Research Inquiry Hi Susan, I work in the UVA Health System marketing department and have been talking with Haywood about this post. My understanding from emailing with Tara Gaucher a few weeks ago is that the UVA IRB office only needed to be involved if the study was being conducted at UVA. To be clear, Haywood is going to be posting this on our Facebook page himself; I will not be involved with the writing or the actual posting. It will go on https://www.facebook.com/uvahealth/ in the right hand corner under "visitor posts." In any case, if you do need me to fill out the non-engaged application, can you please tell me where I would find it? Thanks, Megan Megan Rowe Online Marketing Specialist 434.996.1669 mbr4p@virginia.edu Follow us: Twitter.com/uvahealthnews Like us: Facebook.com/uvahealth Subscribe: uvahealth.com/blogsignup 172 RE: NCU Doctoral Candidate Research Inquiry HR Hoffman, Susan R. (srh) Reply all| Today 10:04 AM Cutts, Haywood; Rowe, Megan B. (mbr4p) ; Mimms, Karen Coleman (kcm6t) Site Approvals Action Items Haywood, Just to clarify, it sounds like all you plan to do is advertise to recruit subjects for your research on the UVa Facebook page and that no UVA personnel will be involved in conducting the research. Is this correct? If so, whomever you are working with at UVa would submit a Non-engaged application to the UVA IRB-HSR along with a copy of your IRB approval checking the nonengaged category # 4 (4) Institutions whose employees or agents: (a) inform prospective subjects about the availability of the research; (b) provide prospective subjects with information about the research (which may include a copy of the relevant informed consent document and other IRB approved materials) but do not obtain subjects’ consent for the research or act as representatives of the investigators; (c) provide prospective subjects with information about contacting investigators for information or enrollment; and/or (d) seek or obtain the prospective subjects’ permission for investigators to contact them. Submit the IRB approval from the institution that is engaged in Human Subject Research. Susie Hoffman IRB-HSR Director From: Cutts, Haywood [mailto:H.Cutts2747@email.ncu.edu] Sent: Thursday, August 11, 2016 4:44 PM To: irbhsr@virginia.edu Cc: Rowe, Megan B. (mbr4p) Subject: NCU Doctoral Canditate Research Inquiry 173 Dear IRB Representative, My name is Haywood Cutts and I am a candidate at Northcentral University conducting a Special Study in partial fulfillment of the requirements for the Doctor of Philosophy in Business Administration. The purpose of this study is to understand motives and decision to use or not use telemedicine, and possible conflicts with that decision. My plan is to target and recruit participants through Facebook sites that promote telemedicine interests. Several site representatives have expressed willingness to support this approach, one of which is UVA Health System Facebook representative. The study population could include UVA patients and healthcare providers that are engaged or affiliated at that site. In the event this happens, please let me know if UVA Institutional Review Board (IRB) approval is needed. It is important to let you know that the Institutional Review Board (IRB) approval, which is the Northcentral University authorization I need for the data collection phase of my research, has not yet been granted. I will be glad to answer any questions or address any concerns you may have in the interests of your members and your organization. Please contact me directly or my doctoral mentor Dr. Brian M. Allen at brianallen@ncu.edu if you have any questions. Thank you very much; I anxiously await your prompt response in assisting with this timely and important research. Haywood Cutts PhD Candidate – Northcentral University H.Cutts2747@email.ncu.edu 174 Appendix I: UVA FB Representative Inquiry It is: Megan Rowe, online marketing specialist, 434-996-1669. Megan Sent from my iPhone On Jul 30, 2016, at 7:01 AM, Cutts, Haywood > wrote: Hi Megan, Welcome back! I hope you plans went well. Pressing onward with the IRB! I am hoping the following could be provided: your full name, job title, and phone number. Your quickest turn-a-around will be very much appreciated. Thanks! s/Haywood PhD Candidate - Northcentral University Phone: 703-349-0536 H.Cutts2747@email.ncu.edu Rowe, Megan B *HS Reply all| Sun 7/17/2016 01:07 PM To: Cutts, Haywood Inbox Blue category I am out of the office until July 28 and will respond when I return. Please contact CLWebTeam@hscmail.mcc.virginia.edu if you have an urgent need. Cutts, Haywood Sun 7/17/2016 01:07 PM To: Rowe, Megan B *HS Sent Items Blue category Hi Megan, 175 Pressing onward with the IRB! Need a few things if you will; would you please share the following with me - your full name, job title, and phone number. Your quickest turn-a-around will be very much appreciated. Thanks! s/Haywood PhD Candidate - Northcentral University Phone: 703-349-0536 H.Cutts2747@email.ncu.edu 176 Appendix J: UVA FB Rep IRB Inquiry Rowe, Megan B *HS Reply all| Today 12:52 PM Cutts, Haywood Inbox You replied on 8/3/2016 04:38 PM. Hi Haywood, I emailed our IRB office, as I wondered if I should have involved them in the first place. They said this is not an issue and they only need to review studies being conducted at UVA. However, if you need to provide their contact info, it is: 434-924-2620 irbhsr@virginia.edu http://www.virginia.edu/vpr/irb/hsr/index.html ---------------------------------------------------------------------------------------------------------From: "Cutts, Haywood" > Date: Tuesday, August 2, 2016 at 10:13 AM To: Megan Rowe > Subject: UVA Institutional Review Board (IRB) Inquiry Sent Aug 2, 2016 Hi Megan, Because the target population may include patients and providers at UVA, it may be necessary that I contact the UVA IRB to determine whether their approval is required. The NCU IRB is considering whether this approach is necessary. In the interim, I am hoping you could point me in the right direction, preferably with an email or phone number if possible. If the NCU IRB deem UVA IRB s necessary or otherwise, I will let you know. Thanks, and hope to hear from you soon. s/Haywood PhD Candidate - Northcentral University H.Cutts2747@email.ncu.edu 177 Appendix K: FB Rep Notification Dear XXXXXX, Subject: Research Recruitment Process The Northcentral University Institutional Review Board (IRB) has officially granted approval of this research project, allowing recruitment of potential research participants to proceed. The purpose of this study is to understand motives and the decision to use or not use telemedicine, and possible conflicts with that decision. NCU IRB protocol requires that none other than the researcher post the approved recruitment notice to an approved Facebook site. I understand and appreciate privacy concerns and am willing to work with you personally to ensure that your page security is maintained. The recruitment noticed is attached as Appendix C for your review. If there are no issues, please grant the necessary permissions (if any) and instruction to accommodate posting of the recruiting notice by this researcher to your Facebook site. I anticipate the initial recruitment process will consist roughly of a 10 – 15-day period. Thereafter, I hope to keep the recruitment notice posted an additional ten 10 – 15 days to accommodate any potential interests beyond the initial period. If additional time is needed beyond that, I will bring it to your attention. To curtail potential participants responding directly to the Facebook site, I will insert a subsequent caption underneath the recruiting notice. It will read “Please express your interest in this study by directly emailing the researcher. Please do not post or LIKE your response here.” Please let me know of any questions or concerns you may have. Please contact me directly or my doctoral mentor Dr. Brian M. Allen at brianallen@ncu.edu if you feel it is necessary. Thank you very much; I anxiously await your prompt response in assisting with this timely and important research. Haywood Cutts PhD Candidate – Northcentral University H.Cutts2747@email.ncu.edu Attachment (1): Appendix C 178 Appendix L: Approval to Post on HIMSS Facebook Account Burkey, Amanda Fri 6/10/2016 10:25 AM To: Cutts, Haywood ; Categories: Blue category Good morning Haywood, The HIMSS team approves of your posting a recruitment notice to our Facebook site (https://www.facebook.com/HIMSSpage/) via the visitor posting option laid out below: To post on a Page that you visit: Type your post into the box at the top of the Page's Timeline. You can tag friends or add a location. Depending on the Page's settings, you may be able to add a photo or video. Click Post. Amanda Amanda Burkey New Media Producer, Social Media HIMSS Media Office: 312.915.9297 | @A_Burkey 33 West Monroe Street | Suite 1700 | Chicago, Illinois 60603 179 Appendix M: Approval to Post on UVA Health System Facebook Account From: Rowe, Megan B *HS Sent: Thursday, June 9, 2016 08:05 PM To: Cutts, Haywood Subject: Re: Research Inquiry Haywood, My understanding is you will post this information on our Facebook wall yourself? That's fine. You are welcome to do so. Thank you for asking. Megan Sent from my iPhone 180 Appendix N: IRB Approval with Conditions Letter Haywood Cutts Date: 8/22/16 PI Name: Haywood Cutts Chair Name (if applicable): Dr. Brian Allen Application Type (Initial, Continuing, Pilot): Initial Review Level (Exempt, Expedited, Full Board): Expedited, Category 7 Study Title: An Investigation of Circumstances Affecting Consumer Behavioral Intentions to Use Telemedicine Technology: An Interpretative Phenomenological Study Approved with Conditions Date: 8/22/16 Full Approval Date: Pending NCU IRB verification of items outlined below Dear Haywood: The purpose of this letter is to inform you that your IRB application is Approved with Conditions. The remaining items are: receipt and verification of the site IRB approval and application materials (from UVA). You have met all federal requirements and all other NCU requirements. Once you receive the missing item(s), please make a notation on your IRBA (application), add the material to your IRBS (supplemental form), and submit both IRBA and IRBS to your chair. Your chair will submit to the NCU IRB for review. Once all conditions are met, you will receive a final approval letter from the NCU IRB. Please do not distribute any recruitment or consent materials, do not contact any potential participants, and do not collect any data until after you receive your final approval letter from the NCU IRB. Please let us know at irb@ncu.edu if you have any questions or concerns. Respectfully, Northcentral University Institutional Review Board Email: irb@ncu.edu 181 Appendix O: Example Site Telemedicine Research Dissertation Research Project in Telemedicine To read about Telemedicine, a few links are provided. Just click on any of them: The Wall Street Journal: http://www.wsj.com/articles/how-telemedicine-is-transforminghealth-care-1466993402 Medicaid.gov: https://www.medicaid.gov/medicaid/benefits/telemed/index.html eVisit: https://evisit.com/what-is-telemedicine/ 182 Appendix P: Example Site Readability Report 183 Appendix Q: IRB Modification Approval Letter Haywood Cutts Date: 11/28/16 PI Name: Haywood Cutts Chair Name (if applicable): Dr. Brian Allen Application Type: Modification Review Level (Exempt, Expedited, Full Board): Expedited, Category 7 Study Title: An Investigation of Circumstances Affecting Consumer Behavioral Intentions to Use Telemedicine Technology: An Interpretative Phenomenological Study Initial Approval Date: 8/29/16 Modification Approval Date: 11/28/16 Continuing Review Due Date: 8/29/17 Expiration Date: 8/29/17 Dear Haywood Cutts and Dr. Brian Allen: Congratulations! The purpose of this letter is to inform you that the IRB has approved your request to modify your study. Your responsibilities include the following: 1. Follow the protocol as approved. If you need to make changes, please submit a modification form requesting approval of any proposed changes before you make them. 2. If there is a consent process in your research, you must use the consent form approved with your final application. Please make sure all participants receive a copy of the consent form. 3. Continuing review is required as long as you are in data collection or if data have not been de-identified. Failure to receive approval of the continuing review before the expiration date means the research must stop immediately. 4. If there are any injuries, problems, or complaints from participants, you must notify the IRB at IRB@ncu.edu within 24 hours. 5. IRB audit of procedures may occur. The IRB will notify you if your study will be audited. 6. When data are collected and de-identified, please submit a study closure form to the IRB. 7. You must maintain current CITI certification until you have submitted a study closure form. 8. If you are a student, please be aware that you must be enrolled in an active dissertation course with NCU in order to collect data. 184 Congratulations from the NCU IRB. Best wishes as you conduct your research! Respectfully, Northcentral University Institutional Review Board Email: irb@ncu.edu 185 Appendix R: Code to Theme Cooccurrence Table
The Perceptions of Ethical Decision-Making Processes by Leaders and the Influences they have on Entry Level MBA Graduates Dissertation Manuscript Submitted to Northcentral University Graduate Faculty of the School of Business in Partial Fulfillment of the Requirements for the Degree of DOCTOR OF PHILOSOPHY by BRANDON M. GLOVER Prescott Valley, Arizona September 2017 ii Abstract Some major corporations that have had huge impacts on economical and social structures within the United States have been accused or caught in scandals that have spawned numerous studies by scholars and researchers to better understand the ethical behavior and decision-making of individuals within businesses. Ethical behavior and the perception and affect it has on others has become a study ground for researchers to gain better insight on what may be causing unethical behavior in businesses. The purpose of this study was to examine the leader-follower relationship within the workplace from the perspective of the followers to better understand how their perception of their leaders affects their own ethical and moral development, and their own decision-making skills within the workplace. A qualitative, multiple-case study was chosen as the methodology of this research to achieve the purpose of the study. The researcher interviewed 16 MBA entry-level graduates to gather their perceptions of their leaders and how it affects their own ethical and moral development. A thematic analysis was utilized to analyze the data collected from the interviews and questionnaires, resulting in themes emerging, addressing the research questions of the study. It was then found that entry-level MBA graduates ethical behavior and decision-making processes are not easily influenced by their leader’s ethical or unethical behavior. It was also found that any ethics courses or ethical training the participants received was not negated by any unethical behavior by their leaders and the participants were able to maintain their own moral and ethical standards when faced with ethical dilemmas. The researcher recommends further research to study entry-level graduates who have taken ethics courses, but in another area of study in order to compare and contrast with the findings in this study. iii Acknowledgements I never dreamed that I would have made it this far in my pursuit for higher education. It has been a long journey and I know that I could not have made it on my own. I would first like to thank God for His everlasting grace and mercy that He has placed on my life. I would like to thank my wife, Mrs. Kristine A. Glover for her love, support and patience as I went through this process. I would also like to thank my mother Henrietta Glover, my grandparents, the late Rev. Dr. H.T. Williams, Sr. & Willie Mae Williams, Eric Cameron, George E. Williams, the Valentine family, the Kirksey family, Thaddeus Jones Jr., Selaman Bell, Lee Sisk, Christen M. Glover, Adelbert A. Glover, Bryana A. Jamison, Brandezea M. Glover, Braelynn G. Glover, Bible Way Church of Atlas Road, and everyone else who has come along and prayed for me and encouraged me on this journey. I would also like to thank Dr. Brian M. Allen for his leadership and guidance through the dissertation process and how he encouraged me when things got rough. Thanks guys & Blessings to you all! Brandon M. Glover iv Table of Contents Chapter 1: Introduction ....................................................................................................... 1 Background ................................................................................................................... 2 Statement of the Problem .............................................................................................. 4 Purpose of the Study ..................................................................................................... 5 Theoretical Framework ................................................................................................. 6 Research Questions ....................................................................................................... 8 Nature of the Study ..................................................................................................... 10 Significance of the Study ............................................................................................ 11 Definition of Key Terms ............................................................................................. 12 Summary ..................................................................................................................... 12 Chapter 2: Literature Review ............................................................................................ 14 Effective Leadership and Business Ethics .................................................................. 19 Summary ..................................................................................................................... 40 Chapter 3: Research Method ............................................................................................. 42 Research Methods and Design .................................................................................... 44 Population ................................................................................................................... 46 Sample......................................................................................................................... 47 Instrument ................................................................................................................... 47 Assumptions................................................................................................................ 51 Limitations .................................................................................................................. 52 Delimitations ............................................................................................................... 52 Ethical Assurances ...................................................................................................... 53 Summary ..................................................................................................................... 55 Chapter 4: Findings ........................................................................................................... 57 Results ......................................................................................................................... 60 Evaluation of Findings ................................................................................................ 84 Summary ..................................................................................................................... 87 Chapter 5: Implications, Recommendations, and Conclusions ........................................ 89 Implications................................................................................................................. 92 Recommendations ..................................................................................................... 105 Conclusions ............................................................................................................... 108 References ....................................................................................................................... 109 Appendix A: Interview Guide ......................................................................................... 117 Appendix D: Recruiting Email to recent MBA graduates .............................................. 126 v List of Tables Table 1 .............................................................................................................................. 59 Table 2 .............................................................................................................................. 61 Table 3 .............................................................................................................................. 67 Table 4 .............................................................................................................................. 74 Table 5 .............................................................................................................................. 79 1 Chapter 1: Introduction Between November 8, 2001 and June 3, 2002, major corporations and their leaders at Enron, Adelphia Communications, and Tyco, either admitted to bad business practices or faced criminal indictments and judgments (Davidson & Stevens, 2013). The unethical practices and behavior that took place within these businesses and organizations have since spawned ongoing studies and research by scholars as well as becoming a topic of concern for consumers (Demirtas, 2015). Thiel, Bagdasarov, Harkrider, Johnson, and Mumford (2012) noted, because of the financial misconduct of some corporations such as Ameriquest, Goldman Sachs, and IndyMac Bank, a focus on ethics in leadership is important. However, Rawwas, Arjoon, and Sidani (2013) found in their analysis most of the research conducted focused on relativism and idealism. However, they noted, assessing ethical behavior and its influence is much more complicated. There exists a need to explore and conduct research on how “differences between leaders and followers might impact employees’ perceptions of leaders” (Brown & Mitchell, 2010, p. 604). The researcher’s goal in this study is to analyze Master of Business Administration (MBA) graduates, who are entry-level employees and how they perceive the ethical standards of their managers or leaders once they are hired. In a study exploring “how positive and negative role models of business affect students’ attitudes, expectations, and behavioral intentions relating to their future business behavior,” Baden, (2014) found both types of role models could indeed have a positive impact on the attitudes of their followers (p. 154). However, Baden’s findings also indicated only positive role models (PRMS) had a positive affect on the perception of students in regards to self-efficacy, where the negative role models (NRMS) seemed to cause a 2 decrease in self-efficacy in entry-level MBA graduates. Baden’s research indicated both PRMS and NRMS both play important roles in how followers perceived the ethical standards of their leaders within their organizations. Background Business ethics instruction and courses in United States based universities go as far back as 1902 when four universities (University of California, Yale University, University of Chicago, and Northwestern University) were accredited with implementing and establishing such courses in an effort to promote ethical behavior in businesses (Abend, 2013). A review of historical literature suggests that the original objective of integrating business degree programs schools within U.S. universities was to promote business as a profession holding it in the same regard as doctors and lawyers implicating a codes of ethics where the sole purpose was to serve and not just profit (Abend, 2013). This is important, as it suggests that university leaders were interested in creating business professionals who would serve society. It further indicates that “ethics was conceived as constitutive of business schools’ point, mission, and self-understanding; it was not one additional objective that business schools should have, among others” (Abend, 2013, p. 191). However, in modern U.S. university academics, business ethics courses are reduced to single courses instead of being the underlying theme in all business courses (Abend, 2013). The United States over the past four decades became saturated and economically affected by business scandals and unethical behavior by executives in major corporations (Steinbauer, Renn, Taylor & Njoroge, 2014; Stucke, 2014). Within the past 20 years, the U.S. Government under the U.S. Federal Sentencing Guidelines (United States 3 Sentencing Commission, 2016) urged organizations to establish compliance and ethics strategies even offering financial incentives to create such programs (Steinbauer et al., 2014). The New York Stock Exchange and National Association of Securities Dealers Automated Quotations (NASDAQ) now require stock listed companies to have a written ethics code (Stucke, 2014). Though these requirements by the U.S. Federal Sentencing Commission and the stock markets diffused some unethical and illegal behavior by businesses, both practices are still widespread and “illegal corporate conduct is still pervasive” (Stucke, 2014, p. 771). McCann and Sweet (2014), claimed it is the “lack of ethical and sustainable decision making in the leadership…” (p. 373) that is responsible for the continuing ethical issues and moral dilemmas within corporations. McCann and Sweet (2014) also pointed out that employees or followers maintain interest in how their leaders behave and if their leadership is worthy of their personal trust. This indicates that followerleadership is important in regards to ethics and how followers perceive the behavior of their leaders may dictate their own behavior in some manner, whether it is negative, positive or a combination of both. Reiley and Jacobs (2016) stated, “followers’ perceptions of their leaders’ ethics have the potential to impact the way they react to the influence of these leaders” (p. 69). How followers perceived the behavior of their leaders is an important element of the leadership dynamic as followers responded to how their leaders lead and unethical or immoral behavior may change how followers respond or react to leader influence (Reiley & Jacobs, 2016). Based on the seeming importance of follower perception, the researcher will study how perception of leader actions and behaviors affect follower’s own ethical and moral behavior and how past ethics courses 4 and training influence ethical behavior outside of the classroom in a real work environment. Statement of the Problem Because of the authority that most business leaders possess and their ability to set the ethical climate within an organization, Ho and Lin (2016), noted unethical behavior by leaders may negatively influence the perceptions and behaviors of workers, negating to the ethics courses and training provided in collegiate and corporate training (Boddy, 2014). Business scholars are now tenaciously determined in gaining more insight and understanding in the business ethics field by focusing on specific academic disciplines such as, entrepreneurship, information systems and accounting to name a few (Holland & Albrecht, 2013). There exists a tremendous amount of research in regards to business ethics where scholars and scientists attempted to understand how ethical and unethical practices impact the workforce, economy and organizations in general (Demirtas, 2015; Hunter, 2012). However, there exists a gap in the literature, where there is little understanding of the follower-leader relationship in business (Gaudencio, Coelho & Ribeiro, 2014), and how the ethical climate of an organization and the various styles of leadership affect the perceptions and moral development of the followers (Ho & Lin, 2016), in contrast with the ethics training received in college and other higher learning institutions. To understand the dynamics of how followers perceive and respond to the ethical standards of their leaders, the researcher in this study concentrated on entry-level MBA graduates that were exposed to new leadership. The researcher’s focus was to concentrate on how the follower-leader relationship based on the ethical climate and 5 leadership style within an organization affects the perception and moral development of entry-level followers. The perspective represented in this study starts at an individual problem level and, transcends into organizational, industrial, and social problems. Purpose of the Study The purpose of this qualitative multiple-case study is to explore how ethical climates and leadership styles contribute to the ethical and moral development of entrylevel MBA graduates. The study also seeks to gain a better understanding of how entrylevel MBA graduates perceive the ethical behavior of their bosses or leaders when they are put under ethical or moral dilemmas, in contrast to their training and knowledge of ethics learned in business ethics courses. The goal is to further understand how entrylevel employees with prior training in ethics courses perceive the ethical standards of their leaders within their organization. To date most studies involving ethics primarily focused on how the ethical standards of the actual leaders and managers affected their organizations and businesses and not on how their employees or subordinates might affect ethical and unethical leadership (Hunter, 2012). Testing only entry-level MBA graduates will help to control for confounding variables such as the level of education, work experience, job position, time exposed to their leadership, ethics training and ethical climate. Each of these factors identifies the characteristics of novice employees who are more likely to be influenced by the ethical or unethical behavior of their leaders. Data was collected through in-depth interviews and a questionnaire where the study participants were available and accessible. The geographic location of the study was Columbia, South Carolina and online via Facebook and LinkedIn social media groups. 6 Theoretical Framework Mehrdad, Mojtaba, and Mohammadreza (2012) noted the culture of businesses and organizations may be a key factor regarding ethical and unethical behaviors by individuals and that both types of behavior are the results of individual and contextual factors. Many organizations within the United States incorporated ethical guidelines or codes of ethics, and some (businesses) even offer incentives that are directly related to ethical behavior (Mehrdad et al., 2012). Initial theory and conducted research in regards to ethical leadership has primarily been rooted in philosophy and defined by both normative and descriptive approaches, which attempted to prescribe how individuals within an organization ‘ought’ or ‘should’ behave ethically (Kim, Monge, & Strudler, 2015). The theoretical framework of this study builds upon ethical climate and moral behavior within the workplace and examines how entry-level MBA graduates perceive and are affected by these behaviors from their leaders. A prodigious amount of scholarly research and journals exist on ethics, therefore the researcher addresses the imperative that both ethics and morality are articulated for its purpose within this study. Ethics and morality are often interchangeably used in academic studies as both imply subjective codes of conduct that in the most basic sense, mean doing what is right versus what is wrong in any given situation (Nguyen, Basuray, Smith, Kopka & McCulloh, 2008). Throughout this study, the researcher uses the terms interchangeably, but it is important to identify the differences between the two. Ethics are usually defined as “the code of moral principles and values that governs the behaviors of a person or group with respect to what is right or wrong” (Acevedo, 2013, p. 64). However, morality may be defined in two different aspects: 7 descriptive and normative (Luco, 2014). The descriptive definition of morality refers to; (a) “a code of conduct endorsed by an individual or group but a normative definition refers to”; (b) “a code of conduct that, given specified conditions, would be put forward by all rational persons” (Luco, 2014, p. 361). Though both morality and ethics are used interchangeably, the latter definition is the appropriate definition for use throughout this study. By this definition the researcher deemed the theory of ethics and morality implied are intentionally universal, or in other words, not subject to individual interpretation of what ought to be right and wrong. They are, thus, defined by what is more commonly understood as being right and wrong. For example, apart from extreme situations and irrational behavior, it is a universal principle that murder, stealing, lying, and cheating are not moral or ethical actions. This is what is meant by “put forth by all rational persons” (Luco, 2014, p. 361). The relevant theory to the phenomenon presented in this study is the normative social contract theory. The normative social contract theory proclaims that “all businesses are ethically obligated to enhance the welfare of society by satisfying consumer and employee interests without violating any of the general canons of justice” (Hasnas, 1998, p. 29). Two types of generalizations form from the normative social contract theory: social welfare and social justice (Hasnas, 1998). Social welfare allows for consumers and employees (in this case entry-level MBA graduates) to benefit from their organization through income and economic stabilization. However, the social justice term is what connects entry-level MBA graduates and how they perceive the ethical behaviors of their leaders and managers. In general, the social justice term of the normative social contract theory requires businesses to “avoid fraud and 8 deception…show respect for their workers as human beings, and… avoid any practice that systematically worsens the situation of a given group in society” (Hasnas, 1998, p. 31). This general definition implies that managers and leaders are ethically obligated to adhere to the terms of this social contract, which also imposes significant social and ethical responsibilities. Therefore, (in accordance with the theory) the leader or manager ‘ought’ to behave in a manner that is deemed ethical so that their followers (including consumers) perceive their actions as being in line with normative social contract theory. The researcher in this study focused on whether entry-level MBA graduates perceived their leaders to be upholding this theory and how that perception in turn affected their own moral and ethical behavior within the workplace. Also, the researcher sought to answer; if the perception of an entry-level MBA graduate was negative because they believed that their leader or manager was not upholding ethical standards in accordance with normative social contract theory; how did their behavior influence their ethical behavior and decision-making processes within the workplace? Research Questions The primary goal of this qualitative investigation was to gain a better understanding of how the ethical climate and standards of leaders and managers are perceived by entry-level MBA graduates and how it affected their own ethical decisionmaking processes. Groves, Vance, and Paik (2008) stated that prior research on ethics in business focused on large numbers of factors that may caused or influenced unethical behavior by leaders and managers. Some of the factors included, “pressures of the business environment, organizational culture, common cognitive errors, performance appraisal and reward practices, and the cognitive moral development of managers” 9 (Groves, et. al, 2008 p. 306). Though these different factors may, in fact, link together to formulate an overall possible theory of why ethical or unethical behavior exists in organizations, each of these factors must be separated, studied, and researched individually to better understand (specific to each case) the causality and underlying problems or factors leading to certain immoral or unethical practices and vice versa (Groves et. al, 2008). The researcher focused directly on how the actions of managers and business leaders impacted entry-level and novice employees, attempting to close a gap in the existing body of literature in regards to ethical climates and leadership styles, and practices within organizations by managers and leaders, which in turn may give scholars a different perspective to consider when attempting to find some of the underlying factors involving ethics in business. To organize this research the researcher framed these study questions: Q1. How do followers perceive their leaders ethical behavior and how will that perception affect their own ethical decision-making processes? Q2. How does the ethical climate and style of leadership within an organization influence the behavior of entry-level MBA graduates when they are faced with ethical or moral dilemmas? Q3. How does unethical leadership negate the ethical training received by their followers affect the perception and behavior of the followers? Q4. What do entry-level MBA graduates who have had ethical training courses believe about negative or immoral behavior by their leaders influencing their own ethical and moral beliefs and behaviors? 10 Nature of the Study The researcher conducted this study using a qualitative, multiple-case study methodology. This methodology was effective for investigating leader-follower perception of ethics as it allowed the researcher to formulate an in-depth analysis of each individual case in regards to the followers’ perceptions of their leaders and how the ethical climate of their organization affected their own ethical decision-making processes. A qualitative research method aligned well with the nature of the study, as compared to a quantitative approach, because the qualitative method allows for distinct data to be collected in a specific context (Yin, 2009). The target population for this study included entry-level MBA graduates who have received their degree within the past five years. The goal was to have the entrylevel MBA graduates participate in interviews, and answer a questionnaire about their past experiences in business ethics courses, ethical training, and how knowledgeable they were about their leaders ethical behavior, and organizations standards in regards to business ethics. The interviews were structured to gather data on the participants’ experiences relative to business ethics and any ethics courses and training they may have had in the past. The researcher used thematic analysis to examine the data gained from each study participant as it allowed for certain patterns to emerge from within the data. Data collection started with basic information of each participant, including age, gender, expertise, what institution they were awarded their MBA from, and so on. This basic information allowed the researcher to construct a coding system for analysis in the data analysis software Nvivo 11 for Mac, (developed by QSR) to organize and analyze the 11 data as it was entered into the system. The information from the transcripts helped to move the study closer to answer the initial research questions. Significance of the Study As briefly noted in the introduction, the literature indicated that bad business practices and unethical standards held by major organizations causes serious concerns for economists, government, and consumers. McCann and Sweet (2014) claimed it is the “lack of ethical and sustainable decision making in the leadership” (p. 373) that is responsible for the continuing ethical issues and moral dilemmas within corporations. Because of the financial misconduct of some corporations such as Ameriquest, Goldman Sachs, and IndyMac Bank a focus on ethics in leadership is important (Thiel et al., 2012). Thiel et al., (2012) stated, “government and public officials and including the Securities and Exchange Commission and The United States Senate have questioned organizational leaders over their dubious and, seemingly, misguided decision-making” (p. 49). The fact that the US Senate and the Securities Exchange Commission are questioning leaders and their decision-making processes indicates that there is a huge need for a study on how these types of unethical behaviors affects those who look up to leaders and follow their leadership. This study is significant because the findings may help future business leaders understand how leadership within their organization affects their followers, and ultimately, the success of the business, especially in the financial industry (McCann & Sweet, 2014). Also, the researcher sought to provide future researchers additional information on how ethical perception is formulated through the leader-follower relationship. 12 Definition of Key Terms Business Ethics are a part of an ethical system that primarily focuses on ethical principles and issues that arise within organizational and business environments, (Vrdoljak Raguž & Matić, 2016). MBA Graduates refer to Master of Business Administration graduates that have earned their degree from a regionally-accredited institution of higher learning since the year of 2014 and have recently become employed by an organization or business within their field of study. Morality is defined as “a code of conduct that, given specified conditions would be put forward by all rational persons” (Luco, 2014, p. 361). Nvivo for Mac is software developed by QSR to organize and analyze qualitative data, allowing for themes and other patterns to emerge where the responses of the participants can be compared and contrasted. Subjective Well-being is defined “as the state of happiness or a positive emotional state in which negative feelings such as fear, anxiety, or anger is not present (Yang, 2014 p. 515). Summary There are many scholarly theories and studies involving business ethics and leadership decision-making processes, however, there are still gaps in understanding the follower-leader relationship in business (Gaudencio, Coelho & Ribeiro, 2014). With this the researcher sought to close a gap in the body of scholarly literature that focused on understanding how followers with limited or novice work experience in their area of study, who have been exposed to business ethics training, perceived the ethical standards 13 of their leaders within their organization and how that perception affected their own decision-making skills. The study participants included entry-level MBA graduates who have graduated within the past five years and are currently employed in their field of study. In summation, the researcher proposed the problem that exists related to ethical leadership and the perception of followers, the purpose for the study, and some of the gaps in the literature that needs addressing and is significant to the study. The literature review section that follows provides a summation of scholarly studies, reviews, and research related to ethical leadership, leader-follower relationships, and philosophical issues surrounding business ethics. The research method will then be addressed in the following chapter followed by the researcher’s findings in the study. 14 Chapter 2: Literature Review The literature review that follows lays the foundation for this qualitative multiple case study. The review begins with an assessment of previous studies that examined ethical leadership then effective leadership and business ethics. The following area of review examines business ethics and how followers perceive them. The next area of review examines the philosophical problems of normative business ethics theories and then concludes with an area of review on closing the gap in literature. Finally, the researcher provides a brief review of the qualitative methodology used in similar studies examining similar topics. Documentation The literature review information cited and examined is from peer-reviewed articles and research journals found in the Northcentral University library specifically from utilizing the EBSCO, Ebrary, and SAGE journals databases. Some of the key words used to search the electronic databases mentioned above included: ethics, business ethics, morality, MBA graduates, entry-level graduates, ethics courses, business scandals, perception, leader-follower, leadership and codes of ethics. Most of the references used for this literature review were studies and research published within the previous 5 years, however, some earlier studies are cited in an effort to emphasize applicable ethics theories and concepts that remains relevant to current research in regards to business ethics and the follower-leader relationship. The peer-reviewed information and studies that are provided in this literature review are critical to this qualitative research study as it provides the necessary case studies and foundation needed to understand the similarities and differences in past and present ethics theories related to business ethics and leader- 15 follower perception and its affects. Though there exists a multitude of studies in regards to ethics in business, this study provides new scholarly insights in the area of business ethics in regards to the leader-follower relationship and employee perception. Ethical Leadership The study and identification of ethics and moral principles in leadership is not new and much of the literature highlights the normative and philosophical perspectives where the researchers are focusing on what leaders ought or should do, identifying ethical leadership (Crews, 2015). Ethical leadership requires ethical leaders where they may be identified as individuals whose contributions help move an organization and their followers in a positive direction by taking advantage of opportunities that consumers and stakeholders consider ethically appropriate and morally correct (Lam, Loi, Chan, & Liu, 2016). Another way of describing ethical leaders held by scholars simply state that ethical leaders are “honest, fair, and caring individuals who hold high moral standards” (Lam et al., 2016, p. 279). These describe the characteristics of an ethical leader, but leadership is identified more clearly by “the nature of their influence, how they engage followers in accomplishing mutual goals and the affect leaders have on the organization’s values” (Crews, 2015, p. 30). Based on the characteristics of ethical leaders and their influences, ethical leadership can be characterized by two facets: “the moral person someone who is honest, caring, principled, who makes fair and balanced decisions and the moral manager, who sets clear ethical standards, acts as a role model for ethical behavior… uses rewards and sanctions to reinforce ethical standards and holds followers accountable for ethical conduct” (Midgen, 2015, p. 85). 16 Scholars argue that it is the moral manager aspect of ethical leadership that separates it from other forms of leadership, such as spiritual, authentic and transformational leadership, though all of these leadership styles similarly emphasize many of the same characteristics as ethical leadership (Midgen, 2015). Mumford and Fried (2014) stated, “all ideological systems, including authentic leadership, spiritual leadership and ethical leadership, propose multiple behavioral dimensions that might contribute to follower perceptions of leader effectiveness” (p. 625). Also, though not exclusive to the ethical leadership style, ethical leaders look for their followers to have high moral standards (Lam et al., 2016). They look to achieve their moral expectations of their followers utilizing transactional methods, such as offering rewards for achievements and punishment for insubordinate behavior (Lam et al., 2016). In return, followers who perceive their leaders to be ethical, find them to be legitimate role models and are more likely to emulate their actions, thus developing positive work attitudes and appropriate behavior (Lam et al., 2016). A trickle-down model shows that based on behavioral norms, followers will emulate their immediate leaders (Kihyun, 2016). Ethical leadership also attributes to followers’ outcomes, including “job satisfaction, organizational citizenship behavior (OCB), and organizational commitment” (Crews, 2015, p. 30). The term ethical leadership often refers to behavior, which consist of proper norms and can also be defined as “the demonstration of normatively appropriate conduct through personal actions and interpersonal relationships, and the promotion of such conduct to followers through two-way communication, reinforcement, and decisionmaking” (Demirtas, 2015, pp. 273-274). As most leaders possess some power and influence over their followers, ethical leaders distinguish themselves by having the 17 capability of utilizing their power and influence in a manner that brings out the best in their followers while avoiding mistreating them and respecting their rights at all times (Reiley & Jacobs, 2016). In other words, the conceptualization of ethical leadership is determined by how leaders set the right course of action for their followers and making decisions with their employees best interests in mind (Demirtas, 2015). Also, ethical leadership behavior helps individuals who are anxious or uncertain about their jobs and work responsibilities by expressing honesty, trustworthiness, consideration, openness and emphasizing the significance of adherence to the organization’s codes of conduct or ethical principles (Demirtas, 2015). The overall goal of an ethical leader is to be able to achieve moral good that inspires their followers to behave in ethical ways (McCann & Sweet, 2014). In contrast to what we have discussed up to this point in regards to ethical leadership and the definition thereof, some scholars argue that their remains unclear what the definition of ethical leadership actually entails, for example: what are the specific behaviors that an ethical leader portrays on a day-to-day basis (Frisch & Huppenbauer, 2014)? According to McCann & Sweet (2014), unethical behavior in leadership still exists in businesses today because there are still fundamental underlying issues that have not been addressed because scholars and researchers do not know enough about leadership to do anything to improve it. In much of the literature on ethical leadership, scholars have focused primarily on leadership behavior toward their followers, however, organizations involve more than just leaders and employees, but also stakeholders, consumers, suppliers, the environment and many other organizations and resources (Frisch & Huppenbauer, 2014). Leaders who are obligated to interact with those 18 mentioned (as well as their followers) are in positions known as boundary role positions which brings about a separate set of concerns in regards to ethics (Mumford & Fried, 2014). Because some leaders, such as executives are in a position where they must also care about their stakeholders in addition to their employees and followers (Frisch & Huppenbauer, 2014), it must be recognized that “different stakeholder groups have different interests, and these interests imply differences in their ethical concerns” (Mumford & Fried, 2014, p. 626). This perspective of ethical leadership belongs in the realm of corporate social responsibility as Demirtas (2015) stated, “when the value system of a corporation explicitly acknowledges the importance of human values by granting them parity with the values of profit and technology, then economic responsibilities will be balanced with moral responsibilities, the corporation will seek to balance the interests of the stakeholders without sacrificing its economic responsibilities, and the responsibilities of its managers will be not only to the corporation and its shareholders but also to other stakeholders” (p. 275). Thus, executive ethical leadership is important as it plays a leading role in magnifying ethical behavior as they usually have the authority and influence to do so within their organization (Frisch & Huppenbauer, 2014). It is has been noted that the center of motivation of ethical leaders is based on unselfish intentions, and if this is so, followers may perceive the executive’s ethical leaders use of power as “well intentioned and ultimately beneficial for the followers, the organization, and other stakeholders” (Reiley & Jacobs, 2016, p. 73). This allows the leaders to set the standards for ethical behavior for their followers and stakeholders while also being an example by following these standards themselves. 19 Effective Leadership and Business Ethics Business ethics and ethical issues involving leadership is not a new concept it has been an important topic for a very long time (McCann & Sweet, 2014). Two major perspectives on business ethics, and ethical issues in regards to leadership have been either “philosophically grounded (justice, truthfulness, etc.), or looked at from the solely managerial perspective (authentic/inauthentic, transformational/transactional leadership styles)” (Vevere, 2014, p. 160). In contrast with both of the above noted perspectives, there exists individuals who dissociate ethics from business practices altogether, where they believe that moral deliberations can be a hindrance to successful business (Vevere, 2014). Dependent on the perspectives of business ethics within an organization; it may determine leadership norms are formed, whether the leadership style is ethical or unethical, how followers may perceive their behaviors, and how it may affect follower ethical behavior and moral decision-making skills. The perception of followers toward their leaders is an important element of the leadership dynamic (Reiley & Jacobs, 2016). Pless and Mark (2011) noted most current researchers assume that leadership belongs to a basic structure based on hierarchical relationships within an organizational structure and how effective leaders are formulated can be uncovered through research. Researchers also focused their attentions on how the ethics of leaders may impact the way followers react to their leadership based on their own perceptions (Reiley & Jacobs, 2016). However, leadership and considering what makes it effective proves to be more complex (Pless & Maak, 2011). One of the key problems seems to translate directly from the objectivist point of view based on traditional concepts, and the incomprehension of normative or modern issues, which 20 hinders some researchers in an effort to provide guidance for those seeking it in matters of responsible leadership (Pless & Maak, 2011). Also, to gather more pertinent research concerning leadership, the investigation of stakeholders and how they possibly shape ethical behavior needs consideration throughout the research process (Hunter, 2012). Labor outsourcing appears to suggest that organizations are building tight relationships with suppliers, which in many cases may allow a higher degree of toleration for unethical behavior in the leadership realm (Hunter, 2012). As Hunter (2012) noted, it is important to understand if these types of relationships actually result in a more positive or negative affect on ethical leadership. Further, as Steers, Sanchez-Runde and Nardon (2012) posited in a review of existing studies, “differences in cognitive processes… influence how attitudes are developed and behaviors are manifested in local environments as they relate to leadership” (p. 425). Analyzing the behavior of leaders and managers in businesses and trying to understand how they perceive ethical behavior and morality in the workplace has in some researchers’ studies crossed over from the normative approach to business ethics to a scientific approach (Francés-Gómez, Sacconi & Faillo, 2015). The normative approach is a philosophical way of analyzing behavior within the workplace based on what we think leaders should or should not do, and the scientific approach allows researchers to analyze ethical behavior of leaders in the workplace by using psychology and sociology as methodological grounds (FrancésGómez, Sacconi & Faillo, 2015; Brown & Mitchell, 2010). The main objective of the latter method was to gain a better understanding of how leaders perceived ethical behavior versus what might be thought of as right or wrong behavior within the workplace. Before this idea of using the scientific approach for studying business ethics 21 was brought to the scholarly table, research on business ethics was drawn from two basic sources: social science methods and speculative philosophical methods (Francés-Gómez, Sacconi & Faillo, 2015). The social sciences, is to appropriate empirical or descriptive business ethics, while philosophical methods are used to for normative business ethics (Francés-Gómez, Sacconi & Faillo, 2015). Moral competencies (moral virtues) in the work environment are key elements that also need to be analyzed to further our understanding of why moral characteristics contribute to decision-making abilities and ethical behavior in leaders (Morales-Sánchez & Cabello-Medina, 2013). Studies in this specific area of ethics include a “universal nature of four moral competencies” which are: prudence, justice, fortitude and temperance” (Morales-Sánchez & Cabello-Medina, 2013, p. 717). Each of these four moral competencies influences the ethical decision-making process at different stages. The problem is the ability to design “suitable measurement tools of moral competencies in the workplace” (Morales-Sánchez & Cabello-Medina, 2013, p. 732). Incorporating the scientific method of analyzing behavior in the workplace may be a start to building the necessary tools to measure moral competency in the workplace. Using sociological and psychological methods of understanding and reasoning to understand certain moral behaviors in leaders apart from philosophical biases may be a necessary element of study that should be considered if researchers are to take further steps in understanding the cognitive processes of leaders that goes into their decision-making practices. There remains insufficient data and understanding of exactly how to include a scientific method of study into a normative study dealing with ethics and morality in the work environment and how they are truly perceived by leaders and managers. 22 As leaders are in a position of authority, they have the ability to set the organizational tone in regards to ethics within their workplace (Steinbauer, Renn, Taylor, and Njoroge, 2014). Steinbauer et al. (2014) stated “ethical leaders set the tone in an organization by displaying, communicating and reinforcing appropriate behavior” (p. 382). However, it is appropriate to point out that effective leadership does not always ensure that leaders are ethical or have high moral values as noted in the examples of Enron, Adelphia Communications, and Tyco (Davidson & Stevens, 2013). It is impossible, therefore, to state that only ethical or moral leaders are effective. Also, scholars’ studying effective leadership and how the effect they might have on their followers has not been easy to confirm empirically (Steinbauer et al., 2014). Steinbauer et al. (2014) noted that only a limited amount of studies exist where scholars empirically confirmed that leaders do have some effect on the decision-making skills and the conduct of their followers. However, it is safe to reason that leaders are in a position to set the ethical standards within a workplace just by exemplifying or practicing moral conduct themselves. This does not definitively mean that ethical behavior by leaders will cause positive ethical shift in behavior by everyone who is a part of that particular work culture, but once the standards and the codes of ethics are in place, it may bring an awareness of ethical value within the organization. Ethical leadership can also be defined as, transformational leadership where the leaders looks to accomplish moral good where integrity is a core value that they look to instill into their followers (McCann & Sweet, 2014). Reiley and Jacobs (2016) stated, “leaders who engage in ethical behavior strengthen interpersonal relationships… which may reinforce the mechanisms that encourage followers to recognize and accept leaders’ 23 personal influence” (p. 72). The ability of leaders to personally influence their followers is characterized by their own moral identities or MI. Moral identity (MI) is conceptualized as “a self-conception organized around a set of moral traits” (Aquino & Reed, 2002, p. 1424). These traits include: honesty, compassion and caring (Giessner, van Quaquebeke, van Gils, van Knippenberg & Kollée, 2015). Because of the traits and characteristics of MI, a moral character perspective is represented in an individual through MI internalization and MI symbolization (Giessner et al., 2015). Giessner et al. (2015) stated, “MI internalization refers directly to how important moral characteristics are to the self, while MI symbolization relates to the moral self as a social object which individuals can use to convey to others that they have these characteristics” (p. 2). These two characteristics of MI allow ethical behavior to be subjective and objective simultaneously, where the subjective idea of ethics is personal to the individual and others objectively perceive the ethical behavior of that individual. Skubinn and Herzog (2016) also noted MI can be socially constructed based off certain situations, even those where the moral dimensions are hardly noticeable or less visible. In a recent study, Zhu, Treviño, and Zheng, (2016), suggested that not only does the moral identity of leaders effect their followers, but also moral attentiveness. The theory is that leaders that are more attentive to ethical and moral issues are associated with how their followers perceive them as ethical or moral leaders (Zhu, Treviño & Zheng, 2016). Zhu et al. (2016) indicated there is a relationship between strong ethical leaders and ethical-related characteristics of their followers where the moral attentiveness and identity of the follower, which in the past were considered more trait-like, could in some way become altered by an “external stimuli such as strong ethical leadership” (p. 24 97). Based on this particular reasoning, Zhu et al. (2016) found it to be particularly important at the theoretical and empirical level as it demonstrates that strong ethical leadership may influence the ethical characteristics of followers’ in a positive manner. In other studies, researchers indicate that it’s not so much as the moral attentiveness or the moral identity of the leader that portrays strong leadership and have the ability to influence ethical behavior by their followers, but more of moral judgment that builds strong ethical foundations within an organization (Ho & Lin, 2016). Ho and Lin (2016), revealed in their studies that ethical concerns of leaders possess the ability to influence the decision-making skills of their followers and that the relationship between a follower and a leader is built upon moral judgment. The central theme that seems to be evident throughout many of the studies based on business ethics is that most of the scholars agree business ethics is an essential leadership characteristic in that it impacts how organizational values are established, which allows for leaders and followers to accomplish organizational goals (Ho & Lin, 2016; McCann & Sweet, 2014). Moral judgment is an integral part of ethical leadership because it is the element of business ethics where leaders make the decision to behave ethically or not; in direct relation to their daily work related decision-making processes (Ho & Lin, 2016). The perception of leaders by followers’ and how their moral reasoning is established in the workplace may be a direct result of the moral or immoral decisions made by their leaders. Therefore, the “moral judgment development and ethical philosophy” of a leader plays a critical role in how the moral culture is shaped and developed within a workplace (Ho & Lin, 2016, p. 308). 25 Some scholars believe there is more involved in moral and ethical leadership than just the elements of the decision-making processes and the leader-follower relationship, but key elements also include the importance of shared needs, goals and values (McCann & Sweet, 2014). Shared values and needs allows followers to help in the decision-making process where in return, the leaders take responsibility and commit themselves to moral and responsible leadership (McCann & Sweet, 2014). Shared values amongst leaders and followers is integral in modern business practices as modern society is becoming increasingly characterized by the rising of global integration, including the ease of staying globally connected within complex business strategies (McCann & Sweet, 2014). With these new ways to conduct business in modern society, ethical issues have become an even more essential element of socially responsible business, which may be almost impossible without good or ethical leadership (Vevere, 2014). The sign of good ethical leadership within an organization may be based on the characterization of their followers. Some followers view their leaders as role models and will mirror their characteristics such as attitudes, values and behaviors (Fa-Wang, JianQiao & Jin-Ming, 2016). Ethical leadership also provided other positive outcomes according to scholars that include “voice behavior, task significance, job autonomy, effort, job security, interactional justice, supervisor effectiveness, satisfaction with supervisors, and citizenship behavior” (Wu, Kwan, Yim, Chiu & He, 2015 p. 819). Through positive relationships, two-way communication between followers and leaders, reinforcement (positive or negative), and decision-making (Wu et al., 2015) positive leader-follower relationships can exist, and the moral or ethical culture that is created within an organization may possibly shape the moral characteristics of their employees. 26 Some examples of effective leaders who have been acknowledged for their positions of moral authority include Martin Luther King, Jr., Mahatma Gandhi, Winston Churchill, and Mother Theresa. Though these individuals would not be considered traditional business leaders, they all had something in common that is pertinent to ethical leadership – “an ability to motivate their followers to do good deeds” (Fehr, Kai Chi & Dang, 2015, p. 182). Though these examples provide people who many consider to be ethical leaders, based on what they have accomplished historically, the organizational sciences have not been able to paint a clear view of what it actually means to be an ethical leader (Fehr et al., 2015). While there is limited research that can clearly explain or define exactly what an ethical leader is and the consequences of their leadership, research that defines toxic leadership and unethical behavior in leaders and their consequences is just as scarce (Boddy, 2014). Fehr et al., (2015), state, that “a focus on only a narrow slice of moral domain provides an unstable foundation on which to build a comprehensive theory of ethical leadership” (p. 182). This means that both sides of the “coin” must be considered in research if scholars are going to identify what ethical leadership really means and its basic elements whereas, unethical leadership must be clearly identified in the same manner. Without a more in-depth study of what it means to be an ethical leader, scholars are at risk of creating an oversimplified view of ethical leadership by acknowledging only a subset of its consequential behaviors (Fehr, et al., 2015; Haidt, 2012). Understanding human behavior is critical to understanding ethical behavior because, according to the social learning theory, behavior is learned from observing the behavior of others (Boddy, 2014). Therefore, leaders are important role models to their followers as they lead, regardless of what type of behavior their leader 27 displays. In the same manner that followers can learn functional and ethical behavior from their leaders, they can also learn dysfunctional and unethical behavior as well (Boddy, 2014). Zhu, Sun and Leung (2014) conducted an extensive study of the literature on ethical leadership and reported their findings that ethical leadership involved a moral component that included certain traits or characteristics such as honesty, integrity, and trustworthiness. Brown & Treviño, (2014) noted in addition to leaders portraying these characteristics, there are other elements involved in ethical leadership that must be executed in order to have a positive effect on their followers. One is that leaders must also be able to be moral managers in addition to being moral people (Brown & Treviño, 2014). As moral managers, “ethical leaders use leadership tools such as rewards, discipline, communication, and decision making to communicate the importance of ethics, to set standard, and to hold employees accountable to those standards” (Brown & Treviño, 2014, p. 587). Ethical leaders must also be able to communicate the importance of ethics to their followers, to build and maintain a moral and ethical culture within their organization (Zhu, Sun & Leung, 2014). It is important to note that although prior researchers found that followers and employees are less likely to behave unethically when their leaders are ethical, it is unknown if all followers and employees respond in the same manner or to the same extent (Taylor & Pattie, 2014). Researchers who attempted to link ethical leadership to perverse employee behavior produced inconsistent results where other researchers found negative relationships between ethical leadership and deviant behavior by their followers and yet other researchers found null relationships between the two (Taylor & Pattie, 2014). 28 Brown and Treviño, (2014), stated, “most adults are not ethically self-sufficient,” but rather rely on external guidance from their “peers and significant others for ethical guidance” (p. 588). According to Brown and Treviño (2014), the reasoning behind this claim is because of the ambiguity involved in ethical dilemmas and people tend to look to others, attempting to reduce such ambiguity. Through social learning theory, ethical leaders are able to influence their followers to uphold ethical standards through “rewards and punishments and through vicarious learning” (Taylor & Pattie, 2014, p. 597). Through rewards and punishments, followers learn there are benefits and consequences to ethical and unethical behavior within the workplace. Through vicarious learning, followers look to the emotions, feeling and actions of others to gain the ethical guidance they need as mentioned earlier in this literature review Taylor & Pattie, 2014). Taylor and Pattie (2014) suggested vicarious learning is particularly important when it is necessary to learn about immoral the acts and unethical behavior of others. Ethical leadership over time can also lead to unethical leadership, which is called ethical erosion (Cannon, Hughey, Frederiksen & Smith, 2015). Ethical erosion is explained as a phenomenon that occurs without a person necessarily realizing it is happening (Cannon et al., 2015). Very limited literature exists in regards to ethical erosion, but the logic behind this theory may explain how leaders who were once strong in their ethical and moral values strayed away from their belief system. Cannon et al., (2015) noted that ethical erosion can be implicit or explicit, where “implicit refers to the organizational culture that supports ethical behavior… while explicit refers to the ethical infrastructure such as policies and procedures that support ethical behavior (p. 12),” and both components are essential for an ethical organizational culture. Ethical erosion may 29 start with the simplest unethical act such as taking a pen or making personal copies at work until it gradually escalates to a point of greater deviation from ethical leadership leading to calamitous results (Cannon et al., 2015). Causes that may lead to ethical erosion may stem from leaders dealing with ethical dilemmas or complex situations involving moral conflicts where there seems to be no obvious right or wrong options or scenarios (Cannon et al., 2015). Business Ethics and How Followers Perceive Them Presently, there is a lack of scholarly research focused specifically on how followers perceived ethics within their workplace (Beeri, Dayan, Vigoda-Gadot, & Werner, 2013). However, ethical-leadership theory does exist and allows researchers the ability to account for how the behavior of leaders within a business influences their followers and their ethical decisions and actions in regards to ethics (Steinbauer, Renn, Taylor, & Njoroge, 2014). As Steinbauer et al. (2014) noted, ethical-leadership theory stated, “leaders influence followers’ ethical decisions and actions through [the] sociallearning process, communicating the importance of ethical standards, social exchange process, and using performance management systems to make employees accountable for their conduct” (p. 381). There exists a need for research for addressing how followers perceive ethical behavior of their leaders and to what extent it affects and formulates their own ethical decisions and actions (Brown & Mitchell, 2010). Researchers on ethics and the leader-follower relationship, indicated that leader moral identity or MI was the predictor of how followers perceived the moral behavior of their leaders, and to what extent they considered their behavior as being ethical (Giessner, Van Quaquebeke, van Gils, van Knippenberg & Kollée, 2015). However, because leadership involves 30 relationship between both the leader and the follower, both the MI of the follower and the leader interacts in predicting whether followers perceive their leaders as being ethical, ultimately resulting in the quality of the leader-follower relationship (Giessner et al., 2015). The researchers claim that leaders who have a high MI are often seen as more ethical than leaders with lower MI by their followers (Giessner et al., 2015). The awareness of an ethics code system implemented within an organization, ethical leadership, and ethical decision-making are three ethics resources that allow for a positive relationship between follower perceptions and an ethical organizational structure (Beeri et al., 2013). Though these three ethics resources may allow for positive perceptions of leaders by their followers, the processes that followers are sometimes forced to engage in are not directly constructed by ethical leaders and their leadership capabilities (Steinbauer et al., 2014). Gaudencio et al. (2014) noted that positive follower behavior and performance is not solely based on ethical leadership. It is also based on leadership and management satisfaction, which may also influence follower perception and actions in regards to ethics. Gaudencio et al. (2014) also pointed out that followers’ and employees’ values on the ethical component of their organization increased when they were satisfied with the actions and behaviors of their leaders and managers. Increased satisfaction with leaders may also lead to a state of subjective well-being, also defined as the state of happiness (Yang, 2014). The subjective well-being of followers is not only important for the follower and the leader, but also for the organization holistically speaking. Yang (2014) stated, “the importance of subjective well-being is crucial since empirically it has been shown that a happy worker is more likely to be successful in many aspects” (p. 515). The purpose for 31 pointing out the importance of subjective well-being for followers, is that as Yang (2014) noted, scholars believe that ethical leadership is a key factor in leading to the perception of happiness or subjective well-being in their followers (Yang, 2014). Brown & Mitchell (2010) noted that ethical leadership sometimes leads to subjective well-being because some employees who are lead by ethical leaders, feel obligated to perform better on their own behavior. Yang (2014) further stated, “prior studies have shown that the manager’s ethical leadership can influence the employee’s organizational loyalty and also ethical behavior in the workplace” (p. 515). In general, ethical leadership builds organizational loyalty because followers generally expect or want their leaders to be honest, ethical and to always consider the overall good (Grover, 2014). Though these expectations are reasonable, leaders are not always able to achieve them, even those who consider themselves to be highly ethical, simply because people make mistakes (Byrne, Barling & Dupré, 2014). Consequentially, mistakes by leaders may affected the perception of their followers with regards to the ethical quality of leadership, usually based on whether an apology was given or not, and if so, how sincere the stated apology for the offense (Basford, Offermann & Behrend, 2014). Researchers in their studies have indicated that if a leader was viewed as being someone who could be trusted and seemed to care about others before any offense or wrongdoing, then his or her followers are more likely to perceive their apology as being genuine (Basford et al., 2014). Followers who had perceived their leaders to be untrustworthy and had doubts about their ethical standards did not believe their apologies were genuine as noted by Basford et al., (2014) in the same study. 32 Scholars have taken the time to study and address the significance of leaders apologizing after making mistakes and the impact that it has on the leader-follower relationship (Byrne et al., 2014). Byrne et al., (2014) stated, the “recent emergence of an ‘apology culture’ may promote specific benefits with organizational contexts, and in particular, the relationship between leaders and their followers” (p. 91). After a leader has made a mistake, especially a significant one, what happened next presented a critical moment for that leader (Basford et al., 2014). Infrequent mistakes by leaders who have gained the trustworthiness of their followers, created events that stands out, as their followers were more likely to be especially attuned to their leader’s apologies and responses (Basford et al., 2014). How followers react to the actions of their leaders is important because honest leadership is a system that involves both the leaders and the followers (Grover, 2014). Grover (2014) noted that scholars are starting to give more attention to followers in studying business ethics because “through a process of intermixed behaviors among leaders and followers” (p. 61) a system of honest leadership can be built. Follower perceptions of ethical leaders cannot only build a system of honest leadership, but can also help build the followers into future ethical leaders (Kihyun, 2016). Ethical leaders have the ability to encourage their followers to involve themselves in “extra-role behaviors through social learning processes” (Kihyun, 2016, p. 1794). Organization citizenship behavior (OCB) is one of those extra-role behaviors that include ethical connotations, usually leading to good social outcomes (Tu & Lu, 2016). Ethical leaders can augment the chances of their followers becoming ethical leaders by motivating them to proactively participant in certain job functions, that also gives the 33 leader an opportunity to increase the self-efficacy of their followers (Kihyun, 2016). As a relationship mediator between followers and ethical leaders, leaders may increase selfefficacy in followers when they provide constructive criticism and chances to actively participant in the decision-making process (Kihyun, 2016; Tu & Lu, 2016). This style of leadership is also known as servant leadership, where the leader has the ability to help their followers unleash their full potential (Van Winkle, Allen, De Vore & Winston, 2014). When leaders evince unambiguous communication and their actions directly align with that communication then, “this alignment between words and deeds engenders a perception of leader integrity among followers, and establishes the foundation of an effective leader-follower relationship” (Smothers, Doleh, Celuch, Peluchette & Valadares, 2016 p. 482). When these types of leaders communicate the importance of certain agendas and goals within the workplace, and their actions align with trying to successfully meet those goals, followers perceive their leaders “as having behavioral integrity” (p. 482) and look to mimic their leaders in prioritizing their work roles to help reach those goals (Smothers et al., 2016). The leadership’s character impacts the perception of their followers by creating a willingness to follow versus having to follow because of job duties or position (Liborius, 2014). Liborius (2014) stated, “when discussing leadership, one must necessarily be referring to people who have followers; that is, not only subordinates, but indeed followers…thus the outcome of the willingness to follow the leader is fundamental” (p. 349). Strong relationships originated through ethical leadership and follower results in benefits including better job performance, organizational commitment and increased moral behavior (Smothers et al., 2016). In a 34 study conducted by Zhu et al., (2016), the researchers noted it is a leader’s MI and MA that directly correlates with ethical leadership and ethical leadership leads to a positive MI and MA in followers. However, the researchers also suggested “only when leaders ‘walk the talk’ through ethical leadership behaviors can followers become aware of their thoughts and decision processes, witness their behaviors in a variety of organizational settings and learn from their leader’s daily moral talk and actions” (Zhu et al., 2016, p. 101). The researchers are saying that without ethical behaviors to identify true MI and MA, followers may not perceive their leaders to be ethical, though they may portray themselves to be such (Smothers et al., 2016; Zhu et al., 2016). Fehr et al. (2015) considered ethical leadership with a more expansive view of morality where a “follower-centric definition of ethical leadership focused on the moralization of a leader’s actions–that is, a follower’s perception of a leader’s actions as morally right” (p. 183). The researchers argue that there are stages to the followers’ perceptions of how they first moralize their leaders’ actions as being right. The first stage is usually when the leader’s moral actions align with the follower’s moral foundations or the moral foundations of the organizational culture aligns with the followers’ moral values (Fehr et al., 2015). This can also be explained as modeling where observational learning, imitation, and identification result in leadership influence on their followers (Vevere, 2014). After moralization occurs, the followers believe the organizational values and the actions of their leaders are aligned with their own moral values, which allows leaders to influence the motivations and behaviors of their followers (Fehr et al., 2015). When leaders engaged in ongoing behaviors that are viewed as normatively appropriate, their followers perceived their leaders to be “attractive, credible, and 35 legitimate ethical role models” (Vevere, 2014, p. 161). Moralization occurs when follower moralizes their leader’s behavior thus causing the behavior to become a matter of right and wrong (Fehr et al., 2015). When a leader’s behavior is perceived as morally right, this is considered positive moralization versus when a leader’s behavior is perceived as being morally wrong, which is considered negative moralization (Fehr et al., 2015). As noted in the literature reviewed thus far, researchers have repeatedly indicated that ethical or unethical behavior of leaders moralizes and conditions the behaviors of followers based on their perceptions of their leaders (Kihyun, 2016; Smothers et al., 2016; Fehr et al., 2015; Vevere, 2014). However, some researchers suggested that not all followers will emulate the ethical or moral behaviors of their leaders (Taylor & Pattie, 2014). Leadership researchers seeking to link leader behavior to follower behavior to understand effective leadership seem to focus primarily on the behavior and traits of leaders and have producing inconsistent results (Giessner et al., 2015; Taylor & Pattie, 2014). Giessner et al. (2015) studying on leader-member exchange (LMX) found “leadership can be understood as a process involving specific leader-follower dyads” (p. 3), which indicated the effect of leadership and the moral and behavioral outcomes may vary from follower to follower. Though these behavioral outcomes may vary, the leaderfollower relationship “plays a significant role in shaping important follower attitudes and behaviors” (Harris, Ning & Kirkman, 2014, p. 314). Harris et al. (2014) found negative relationships between ethical leadership and follower deviance. Taylor and Pattie (2014) noted, “intuitively, it seems reasonable to presume that only some–but not all–subordinates would emulate behaviors displayed by a 36 leader, or that employees would respond to ethical leadership with varying degrees of acceptable and unacceptable behavior” (p. 596). What researchers seem to be suggest is not all followers emulate or model leadership behaviors and actions from personal perceptions of their leaders: including when the leadership is considered ethical (Giessner et al., 2015; Taylor & Pattie, 2014). Taylor and Pattie (2014) noted in their research that different personality traits might be reasons that followers do not all react in like manner to ethical leadership. Also, followers may fail to perceive their leaders are acting ethically resulting from the moral disengagement from their leaders which in turn affects their followers moral conduct (Bonner, Greenbaum, & Mayer, 2016). This is related to moral disengagement theory (Bonner et al., 2016), which will be discussed in more detail in the next section of the literature review. The Philosophical Problems of Normative Business Ethics Theories Contemporary psychologists suggest, there exists a philosophical problem in regards to normative business ethics theory identified as a phenomenon called “bounded ethicality” (Kim, Monge, & Strudler, 2015). Bounded ethicality means that people who have good intentions are sometimes constrained by psychological limitations where when they are faced with ethical decision-making dilemmas, their choices are sometimes in contrary to their ethical or moral belief system (Kim et al., 2015). This means it is possible for the study subjects (entry-level MBA graduates) to possibly make an unethical decision based on their perception of their leaders that might not align with their own ethical values. Bazerman and Tenbrunsel as cited by Kim et al. (2015) described bounded ethicality as “an umbrella term used to describe a diverse variety of psychological mechanisms that putatively lead people astray” (p. 341). 37 Follower perceptions of ethical leadership may also be predicted by what is known as the moral disengagement theory (Bonner et al., 2016). In a recent study, Bonner, Greenbaum and Mayer (2016) argued followers “who are lower (versus higher) in moral disengagement are less likely to perceive their morally disengaged supervisors as being ethical leaders” (p. 732). To better understand what these researchers mean, it is imperative to first know and understand what moral disengagement theory actually intails. Bonner et al, (2016) defined the theory stating, “people have set moral standards, which, if violated, will lead to personal discomfort and/or self-condemnation,” (p. 732) however, moral discomfort can be avoided by disconnecting from the adverse consequences of their behaviors. Moral disengagement theory allow for leaders and followers to comfortably justify any behaviors that would normally be viewed as unethical. Gini, Pozzoli, and Bussey (2015), described moral disengagement as moral reasoning being selectively disengaged from behavior through cognitive processes. Such disengagement from normal moral beliefs may be the result of certain offensive behaviors perceived as reasonable or justifiable under certain conditions or circumstances (Gini et al., 2015). Baron, Zhao & Miao (2015) suggested there exists basic moral selfregulation mechanisms that normally prevent individuals from participating in behaviors in which they do not personally approve. These self-regulation mechanisms operate through at least 3 processes: “self-monitoring, in which individuals examine their own decisions and actions; self-judgmental processes, in which specific actions are interpreted as good or bad; and self-reactive mechanisms, which censure or approve specific behaviors” (Baron et al., 2015, p. 108). When these self-regulatory mechanisms operate collectively, individuals are usually able to restrain or remove themselves from certain 38 behaviors or actions from which they would normally disapprove (Baron et al., 2015). However, Baron et al., (2015) noted, these mechanisms do not always function automatically as individuals “…can be cognitively disengaged (or deactivated), so that individuals can then perform actions of which they would otherwise disapprove without experiencing self-censure or negative self-evaluation” (p. 108). Much of the researchers’ findings on unethical behavior indicated that selfinterest or self-gain drove unethical behavior. Chen, Chen & Sheldon (2016) found a trend indicating some leaders and employees engage in unethical behavior with the intentions of better serving the interests of their organizations. Leaders or employees may engage in certain unethical behaviors such as destroying certain documents that may incriminate the organization attempting to protect the organization reputation or relaying exaggerated or false information to the public and stakeholders. These types of behaviors are unethical, yet the intentions behind them may not be (Chen et al., 2016). The ability to morally disengage varies by individual dependent on the way decisions are cognitively processed allowing “those inclined to morally disengage to behave unethically without feeling distress” (Moore, Detert, Trevino, Baker & Mayer, 2012, p. 2). Baron et al. (2015) in their research discussed three categories that identify the mechanisms that link certain behaviors with moral disengagement. First, individuals may knowingly pervert repugnant acts so they appear more favorable, where one example stated: “true–we did dump our waste into the river, but the pollution we generate is trivial, and other companies are much worse in this respect than we are” (Baron et al., 2015, p. 108). The second category includes an individual displacing or diffusing of responsibilities in order to minimize their personal role in immoral behaviors or unethical decisions such as 39 suggesting: “The government’s unreasonable tax policies forced us to conceal some cash flow in order to stay in business–they virtually forced us to do this” (Baron et al., 2015, p. 108). The third and final category that identify the mechanisms that link certain behaviors with moral disengagement is where individuals diminish empathy with the victims of pernicious acts, and in some instances, even attempt to hold the victims responsible for the wrong or damage they have experienced (Baron et al., 2015). An example of this would be “My primary competitor is such a terrible, exploitative employer that I am fully justified in attempting to hire her best employees” (Baron et al., 2015, p. 108). Albert Bandura (2016) offers a strong model of moral agency through social cognitive theory where moral reasoning, reactions to self-evaluation, ethical conducts and environmental influences all function as “interacting determinants of each other” (Zsolnai, 2016, p. 426). According to the theory, “moral agency is exercised through selfregulatory mechanisms [where] transgressive conduct is regulated by two sets of sanctions, social and personal” (Zsolnai, 2016, p. 426). Bandura in his research discovered multiple psycho-social mechanisms that would allow moral control to be selectively disengaged harmful behavior (Zsolnai, 2016). These particular mechanisms enables people who are normally considerate of their conduct and would not involve themselves in detrimental acts, to morally disengage and commit harmful or unethical acts without experiencing any personal despair or guilt (Zsolnai, 2016). Psychologist Robert Trivers (2011) noted that [moral disengagement] involves people doing everything to fool themselves to be able to fool others (Zsolnai, 2016). 40 Closing the Literature Gap Scholars produced studies that focused on, student perceptions of exercising ethical influence in an organization (Vevere, 2014), the perceptions of ethical and sustainable leadership (McCann & Sweet, 2014), ethical leaders and their followers (Zhu, Treviño & Zheng, 2016) and the moral judgment relationship between leaders and followers (Ho & Lin, 2016). However, the researchers have generally noted in each of these studies that a gap exists in the literature on how the moral development between leaders and followers are developed and that there is a need for future researchers to “analyze the mediating roles of leadership style and organizational ethical climate in linking leaders’ and followers’ moral judgment development” (Ho & Lin, 2016, p. 309). The gap in the literature lies between the assumptions that the moral judgments of a leader will affect both the ethical climate and the leadership style within an organization (Ho & Lin, 2016) leading to how the moral judgment develops for followers and how the influencing mechanisms of ethical leadership develops their followers’ moral identity (Zhu et al., 2016). Through thematic analysis, the researcher was able to identify themes utilizing Nvivo 11 for Mac, a qualitative analysis program that allowed the researcher to assess the ethical impressions leaders had on each one of the study participants. Summary Attempting to understand the dynamics of ethical leadership and how it may or may not influence followers has proven more complex than scholars initially thought, especially when dealing in terms of responsibility (Pless & Maak, 2011). Objective ideas and the complexity in applying modern issues hinders the ability for researchers to measure all the pertinent factors in regards to ethical behavior by leaders and how their 41 followers perceived and responded to them when using traditional concepts of ethics (what’s right and what’s wrong). The ethical-leadership theory allows for researchers to expand on how the ethical behavior of followers are shaped by those who are direct leaders over them in the workplace and, how their social interaction affect ethical decision-making processes (Steinbauer et al., 2014). This is important because this theory allows researchers to not only analyzes the affects of leader decision-making influence, but also how social interaction may be considered and it’s influences on ethical behavior. Social interaction may also play an important role in employee or follower perception of their leaders as it deals more directly with relationship versus leadership (Steinbauer, 2014). Is it possible that a leader may be ethical in actions, but bad in social interaction? How does this affect followers perceptions of that leader, and does it have any influence on ethics or not? From the review of literature it is clear that it is important for researchers to understand the social aspect of leadership as well as the traditional concepts of business ethics and how they play a role in the leader-follower relationship. 42 Chapter 3: Research Method There exists a tremendous amount of research in regards to business ethics where scholars and scientists attempted to understand how ethical and unethical practices impact the workforce, economy and organizations in general (Demirtas, 2015; Hunter, 2012). However, there exists a gap in the literature, where there is little understanding of the follower-leader relationship in business (Gaudencio, Coelho & Ribeiro, 2014), and how the ethical climate of an organization and the various styles of leadership affect the perceptions and moral development of the followers (Ho & Lin, 2016), in contrast with the ethics training received in college and other higher learning institutions. To understand the dynamics of how followers perceive and respond to the ethical standards of their leaders, the researcher in this study concentrated on entry-level MBA graduates who were exposed to new leadership and experienced leaders. The researcher’s focus was to concentrate on how the follower-leader relationship based on the ethical climate and leadership style within an organization affected the perception and moral development of entry-level followers. The perspective represented in this study starts at an individual problem level and transcends into organizational, industrial, and social problems. The purpose of this qualitative multiple-case study was to explore how ethical climates and leadership styles contributed to the ethical and moral development of entrylevel MBA graduates. The study also sought to gain a better understanding of how entrylevel MBA graduates perceived the ethical behavior of their bosses or leaders when they were put under ethical or moral dilemmas, in contrast to their training and knowledge of ethics learned in business ethics courses. The goal is to further understand how MBA 43 entry-level graduates who had prior training in ethics courses perceived the ethical standards of their leaders within their organization. To date, most researcher studies involving ethics primarily focused on how the ethical standards of the actual leaders and managers affected their organizations and businesses and not on how their employees or subordinates might affect ethical and unethical leadership (Hunter, 2012). Testing only entry-level MBA graduates helped to control for confounding variables such as the level of education, work experience, job position, time exposed to their leadership, ethics training, and ethical climate. Each of these influences identified the characteristics of novice employees who are more likely to be influenced by the ethical or unethical behavior of their leaders. Data was collected through a questionnaire and in-depth interviews with the study participants. The geographic location is Columbia, South Carolina and online via Facebook and LinkedIn social media groups. The main question guiding the study is: Q1. How do followers perceive their leaders ethical behavior and how will that perception affect their own ethical decision-making processes? Below are the following sub-questions: Q2. How does the ethical climate and style of leadership within an organization influence the behavior of entry-level MBA graduates when they are faced with ethical or moral dilemmas? Q3. How does unethical leadership negate the ethical training received by their followers affect the perception and behavior of the followers? 44 Q4. What do entry-level MBA graduates who have had ethical training courses believe about negative or immoral behavior by their leaders influencing their own ethical and moral beliefs and behaviors? Research Methods and Design This qualitative study was conducted by using a multiple-case study design. The case study design, one of the oldest qualitative research methods, allowed an in-depth study of the individuals that participated in the study (Yates & Leggett, 2016). The researcher’s focus in this study was to learn more about how the ethical climate of an organization and how the leader-follower relationship affects and influences the ethical and moral behavior of MBA graduates in entry-level positions. Also, through this multiple-case study, the researcher attempted an appropriate investigation of how MBA graduates perceived their individual leaders over time, resulting from certain conditions, ethical training through courses and interventions that may take place or have already taken place in the past. A qualitative method was chosen for this particular research over a quantitative method because the research questions align more with behavioral and social phenomenon versus brand awareness, penetration, percentages or elicits numbers seeking facts from sampling a certain population (Barnham, 2015). The first two research questions presented in this study seek to address the how which is more commonly answered by qualitative research and also serves as a critical component of the case study research design (Barnham, 2015; Yin, 2009). The third research question is a what question, which is more commonly answered by quantitative research (Barnham, 2015), however, the what question can either be exploratory or about prevalence (Yin, 2009). In 45 this study, the what question presented is an exploratory question which per Yin (2009), any research strategy can be utilized to address this type of what question. Therefore, a qualitative research design was the most appropriate for this study versus a quantitative research design in that a multiple-case study design will allow for all three questions to be addressed whereas, the how questions are inappropriate for any type of quantitative research design. The cases analyzed included individual studies of recent MBA graduates and how their perception of their leaders behaviors in regards to ethics affects their own ethical behavior. Each case studied also sought how unethical leadership may negate any ethical training the follower potentially received, and also how the followers might react when faced with their own ethical or moral dilemmas within the workplace. The multiple-case study design is the choice design for this particular study because it allowed the researcher to formulate an in-depth analysis of each individual case in regard to the followers’ perceptions of their leaders and how the ethical climate of their organization has affected their own ethical decision-making processes. The advantage of this research method over any alternative qualitative research design is that the researcher was able to observe and gather data directly from the study participants, as well as observe the work environment of the organization in some instances. The cross-sectional qualitative method was an alternative method for this study, as it would have allowed the researcher to find prevalence and infer causation in the phenomena being studied (Mann, 2003). Also, the grounded theory design is another research method that would have allowed the researcher to develop a theory that could possibly explain how perception may affect the individuals from their own perspective. However, this design method was not chosen for this study because it involves 46 constructing a theory through the analysis of data, and this study is designed to do the exact opposite. Population The population studied was recent MBA graduates who are already working, but are novice employees or working in entry-level positions in their field of study. The researcher built the population that was studied through social media by creating a Facebook and LinkedIn profile that specifically advertised to MBA graduate groups and word of mouth resulting in snowball sampling. Once the MBA graduate groups were identified via social media, the researcher received written permission from the group leaders to contact the members of their group via email, instant messenger, and mailed correspondence. The multiple cases to be studied included sixteen MBA graduates for replication purposes. All participants had the choice of anonymity and only needed to be recent MBA graduates working in an entry-level position in their field of study or reported directly to a supervisor or manager with their employment being related to their MBA to have met the criteria to participate in the study. Exclusion from the study could only have happened via the participant’s request or if the researcher found that the participant was not providing the necessary data that was required for the study. This study involved gathering data from each participant in the research, which included interviews, a questionnaire, observations, and finally, the coding of the data. This included gathering information about the participant’s physical environments, and historical, economic, and social factors in order for the researcher to gain a better understanding of the leader-follower relationship of the participants. 47 Sample All participants were selected and identified through Facebook groups, LinkedIn groups and word of mouth or snowball sampling. A list of eligible participants and groups were identified through these channels. Once the prospective list was populated, a recruiting email was sent to each of the group leaders or individual (if they were not in a social media group, but was identified as a eligible candidate) asking permission to contact the members of their group or the individual to participate in the study. A similar email was sent to those who chose to participate, asking for a meeting place and a time to conduct the interviews. The snowball sampling technique was also utilized where participants who had agreed to be a part of the study was asked to tell any of their acquaintances that were qualified about the study to see if they were interested in participating (Emerson, 2015). Yin (2009) stated because there is no sampling logic used in case studies, the common measures used to create sample sizes are irrelevant. In a multiple case study, sampling should be thought of in terms of the number of case replications (Yin, 2009). Based on the study questions, the researcher is looking to gain a higher degree of certainty, which calls for five, six, or more replications (Yin, 2009). For the purpose of this study, a sample size of 16 MBA graduates was interviewed. Instrument Open-Ended Question Based Interviews. The researcher developed 10 openended interview questions to understand their experiences as MBA graduates under their current leadership, how any ethics training they received in the past affected their current perception of their leaders, and how it impacted their own decision-making skills within 48 the workplace. Open-ended interview questions allowed for follow-up questions to be added when necessary during the interviews. The follow-up questions allowed the researcher to clarify certain answers or statements given by the participants as they answered the initial research questions. The researcher created consent forms for each individual that was interviewed with the details and nature of the study. To ensure credibility, trustworthiness, and credibility of the data collected each individual was asked the same base set of open-ended questions. However, the researcher, as mentioned, did ask some follow-up questions for clarity and further discovery during the interviews. When the researcher has little control over events, and the focus is on a contemporary phenomenon within a real-life context (as is the case in this proposed study), the case study method as qualitative approach is the preferred method (Yates, 2016). The setting for this type of research is critical to provide the needed context for the study and to triangulate the findings of the study as multiple methods of data collection may be necessary (Yates, 2016). Ellis (2016) stated, “the key advantage of interviews is that they have the potential to create deep, rich data because they explore topics in considerable detail as opposed to surveys and questionnaires which are generally superficial” (p. 106). Interviews along with open-ended questions allowed the researcher to tailor the interview as it continued in accordance to what was said or heard when participants responded to a specific question (Ellis, 2016). Questionnaire. A questionnaire was also emailed or given directly to the individuals in order to add an additional data collection source for data triangulation. The questionnaire was developed to ask questions about the individual’s knowledge of their 49 leaders ethical behavior, their organization’s ethical standards and their own background in ethics courses and training. The questionnaire also asked participants how affective they felt ethics and training courses are for the work environment. The participant’s identities are continually being kept confidential and they had the option to not complete the questionnaire if they chose not to. The questions were formatted in a matter where the respondents would not feel uncomfortable answering them, minimizing them feeling as if their career or job stability would be in jeopardy. The participants was told in advance that in no way would their responses be published in a matter that could identify them personally or given to anyone that is not directly associated with the study. Data collection and processing. The multiple case study method is a qualitative research design therefore the collection of data is done primarily in the natural setting or location where the participants may experience the phenomenon that is being studied (Creswell, 2014). The first step in collecting data for this study included gathering the contact information from everyone that was involved in the study. Before any data collection, approval from Northcentral University Internal Review Board (IRB) was obtained. After the IRB approval, the researcher started to recruit the participants for the study. The recruiting was done by formal invitation (face-to-face) and by email. Once all of the participants were identified, the researcher requested a meeting with all of the study participants to gather sign the consent forms, explain the nature of the study and conduct the interviews. The discussion included: the study, what is required of the participants’ if they chose to participate, the purpose of the research, and that the study was purely voluntary, therefore including their right to withdraw from the study at any time. 50 Also, the meeting provided the opportunity to give participants a hard copy of the consent form for their own record. The consent form included all of the specific details surrounding the study, including the assurance of not bringing the participants unnecessary risks, protection of their anonymity, and contact information for any questions or concerns they may have at any given point during the study. The participants were not required to sign the form on site if they choose not to do so. They had the opportunity to take the form with them to make sure they completely understood the purpose of the study and what their role would be before they signed the document. No participant chose this option, and each individual was willing to sign the document on site and be interviewed at the same meeting. The participant’s signature not only confirmed that they were willing to be included in the study, but also, that they completely understood what the study entailed. No data was collected from any participant until they signed the consent form. Once all consent forms were signed, and all of the pre-study requirements were met and the interview times and places were set, the researcher commenced with the interviews. Each interview was scheduled to last at least 30 minutes but did not exceed 60 minutes in respect of the participant’s time. The researcher (interviewer) did not give any opinions or thoughts during the interviews and only responded to the participants respective to their responses. With permission, each interview was recorded for audio only with an audio recorder. A semi-structured interview format was used where the participants was asked to respond to open-ended questions (Ellis, 2016). Also, the participants was given a questionnaire in order to answer questions about the individual’s knowledge of their leader’s ethical behavior, their own experience and beliefs about 51 ethics and morals within the workplace, and their knowledge of the ethical standards within their workplace. Data analysis. Along with the responses from the interviews and the answers to the questionnaires, the researcher was able to triangulate all of the data in order to check for trustworthiness, transferability and credibility (Denzin, 2012). The data was organized, coded, and analyzed in the data analysis software Nvivo for Mac. Utilizing a thematic analysis, which emphasizes discovering and examining themes in the data, the researcher was able to analyze and build a narrative based on the responses and data collected from the participants. The Nvivo for Mac software that was utilized has the ability to find patterns through keywords of the transcripts to pull out possible themes from the interviews. The researcher then sought to extract minor and major themes from the data, in an attempt to answer the given research questions for the study. Assumptions This multiple case study had a few assumptions. One assumption was that all of the participants would answer all of the questions (interview & questionnaire) to the best of their ability and honestly. Another assumption was that each participant would participate voluntarily, and would not feel forced in any manner. Also, because the participants were answering questions involving perception of their leaders, it was assumed that they would be comprehensive in describing their feelings to the interviewer. There was an assumption that collecting data with the defined instruments would best provide clear and concise data that would provide a measurable analysis of the study topic. Finally, it was assumed that the data collected would present sufficient themes for triangulation analysis to occur. 52 Limitations In the past, there has been trouble generalizing case study research as researchers viewed this method as a less desirable form of study compared to other empirical inquiries (Yin, 2009). Yin (2009) stated, “perhaps the biggest concern has been over the lack of rigor of case study research… too many times, the case study investigator has been sloppy, has not followed systematic procedures, or has allowed equivocal evidence or biased views to influence the direction of the findings and conclusions” (p. 14). In this study, only 16 entry-level MBA graduates were studied, so the findings were not easily generalizable to all entry-level MBA graduates and their perceptions of their leaders. Also, because the study was based on the perceptions of followers and their leaders, their responses to the interview questions may have contained some personal biases (Ellis, 2016). Delimitations A delimitation of the proposed study is that only 16 participants entry-level MBA graduates were interviewed. The findings of the study were not easily generalizable to all entry-level MBA graduates and their perceptions of their leaders. The size and scope of this sample was in keeping with the researchers set objectives of time to complete the study, capacity to solicit participant participation, and the scope of data analysis to follow. While this may, as noted in the limitations section above, limited the generality of the study results, it is not believed that it diminished the usability and validity of the findings within the framework of this defined study. 53 Ethical Assurances As a student of Northcentral University, it is a requirement to read, understand, and adhere to all their policies on academic integrity. Plagiarism is considered one the most serious violations of this policy. Throughout the research and documentation process, the researcher understood that this policy remained in place and that all work must have been appropriately cited in to prevent any violations of university policy and adhered in keeping with that policy. Risk assessment is one of the key issues in responsible research as it allowed the researcher to minimize and balance risks, which is also a requirement of ethical research (Gefenas, 2006). Informed consent is another area of concern and the researcher infored all participants that participated in the study and the subsequent triangulation and analysis of data collected will be stripped of all identifying personal information to ensure anonymity for participants. Each set of data from each participant was assigned a number in place of the participant’s name. These stages allowed the participants to choose whether or not they would like to participate in the study and continue to participate in the study. Because the research involved interviewing, surveying, and document of observations, there were some ethical concerns involving potential perceptions of participant invasions of privacy and confidentiality. Some of this was covered above however, in order to gain meaningful information that will lead to new knowledge, information gathered directly from interviewing or indirectly from documented observation could have posed an ethical problem if the subjects were not truly aware of exactly how or why information was being gathered. When interviewees or subjects for research find questioning to be intrusive, then the likelihood of the perception of the 54 invasion of their privacy may occur (Hicks, 2011). Questions that involved certain personal issues could be considered intrusive to the subject and the subjects were informed about the nature of these types of questions in advance before the interview or survey data collection process by way of a consent and acknowledgement letter to be signed by each participant physically or electronically (Hicks, 2011). Also, the questionnaire and the interview questions were designed in a manner that allowed the interviewees or subjects to choose not to answer any question that they did not feel comfortable answering for any reason. Additionally, the researcher provided an opportunity for each participant to accept or reject inclusion of any information from the collected data through an individual review of the data collected or observed from them. This ensured that documentation of observations produced no intrusions on the privacy or any breach of confidentiality with any participants. Participants had the right to wave the option for post data collection review when signing the consent to participate letter. It is not only a requirement, but also critical that the procedure utilized to produce data in the study were described in full detail in order for readers and researchers to be able to validate the data and also conclude that the methods that was used to derive the data was reliable (United States National Academy of Sciences et al., 2009). Data collection is as important as the data itself, which means that throughout the study, there continued to be a strong emphasis on the creation and maintaining “an accurate, accessible and permanent record” of what has been done in fine detail in order to allow other researchers and scholars to check and replicate the work put forth (United States National Academy of Sciences et al., 2009, p. 9). 55 The “Ethical Principles of Psychologists and Code of Conduct” (2015), put forth by the American Psychological Association (APA) noted that there must be reasonable steps taken by the researcher to correct or minimize any misuse or misrepresentation of any work put forth once identified. Mistakes made unknowingly will not be held as excusable at any point throughout any research project. Therefore, to ensure a true representation of all work put forth, there was a very careful analysis of all sources used, and proper citations and credit given to the ideas and work put forth by others. Northcentral University’s Institutional Review Board (IRB) first required that the Dissertation Proposal (DP), had been approved before the IRB application could be submitted. The department of Business Administration chairperson at Northcentral University is the only person that could submit the IRB application to the university’s IRB. There was not any sort of recruitment; direct or indirect contact with any potential participant, and data collection until after the IRB had approved the application, staying in accordance to the IRB information section of Northcentral University’s dissertation center webpage. Once the IRB approved the application, the dissertation center was utilized for the information, forms and confidentiality agreements, which were accessible and available for download. Summary The purpose of this multiple case study was to examine entry-level MBA graduates and how they perceive the ethical behavior of their leaders, and how it affected their own ethical choices and decision-making skills in the workplace. This qualitative research explored followers and how the influences of each of their leader’s ethical behavior affected a normal business day in regards to ethical decisions and moral 56 behavior. The study involved researcher a questionnaire and face-to-face interviews for the triangulation of data. The Nvivo 11 for Mac qualitative data analysis software was utilized to analyze the patterns and themes from the data collected. The reason that a qualitative design, more specifically the multiple case study method, was chosen as the research method was discussed in the research method and design section of this chapter. Following, the population, sampling method, data collection and analysis procedures, and the measurements were presented were described in detail. In conclusion, a brief summary of what was presented throughout the chapter has been presented. 57 Chapter 4: Findings The purpose of this qualitative multiple-case study was to explore how ethical climates and leadership styles contributed to the ethical and moral development of entrylevel MBA graduates. The study also sought to gain a better understanding of how entrylevel MBA graduates perceived the ethical behavior of their bosses or leaders when they are put into ethical or moral dilemmas, in contrast to their training and knowledge of ethics learned in business ethics courses. Over the past forty years, organizations and corporate businesses became saturated and economically affected by business scandals and unethical behavior by unethical leaders and executives (Steinbauer, Renn, Taylor & Njoroge, 2014; Stucke, 2014). Within the past 20 years, the U.S. Government under the U.S. Federal Sentencing Guidelines (United States Sentencing Commission, 2016) urged organizations to establish compliance and ethics strategies. This study examined entrylevel MBA graduates and how they perceived their leader’s ethical behavior and how it affects their own moral and ethical behavior with regards to decision-making in contrast to what they learned through business ethics courses. Chapter four of this research presents the findings from the qualitative thematic analysis of the entry-level MBA graduates and also the questionnaires they completed to triangulate the data collected. The interviews transcriptions took place within one week of each interview. The research was guided by one main research question, with three sub-questions: Q1. How do followers perceive their leaders and how will that perception affect their own ethical decision-making processes? Below are the following sub-questions: 58 Q2. How does the ethical climate and style of leadership within an organization influence the behavior of entry-level MBA graduates when they are faced with ethical or moral dilemmas? Q3. How does unethical leadership negate the ethical training received by their followers affect the perception and behavior of the followers? Q4. What do entry-level MBA graduates who have had ethical training courses believe about negative or immoral behavior by their leaders influencing their own ethical and moral beliefs and behaviors? Participants of the study consisted of 16 entry-level MBA graduates including government employees, corporation employees, non-profit employees, and healthcare industry employees. Each participant was also given a questionnaire to allow for data triangulation, and to ensure that each individual qualified for the study. Triangulation is used to validate data collected and to ensure the credibility of the sources by confirming their responses through an additional source (Denzin, 2012). Participants were both male and female and all received their MBA’s within the last five years from a total of seven regionally accredited universities in the United States. Each participant physically signed the informed consent acknowledgment for before participating in the research. Two of the informed consent forms had to be signed and then emailed to the researcher as the interviews were conducted through video chat via Facebook Messenger and Facetime due to their physical locations at the time of the interviews. The informed consent forms outlined the purpose of the study and how it would be conducted and also explained the participants right to remain anonymous and the choice to withdraw from the study at any time without any consequences or repercussions. Though each participant was willing to 59 speak openly about their job positions and their line of work, all of the participants chose to remain anonymous and preferred their place of employment not be disclosed in the study. Fourteen of the sixteen interviews were conducted in-person at the convenience of participants’ schedules and two of the interviews were conducted digitally through video chat at the participants’ convenience. To ensure trustworthiness, transferability, and credibility of the data collected, all participants were asked and answered the same set of opened-ended questions. Participants were given alias names in the coding process to ensure anonymity and to preserve their confidentiality. Interviews and data collection were conducted over a 3-month period, beginning May 1, 2017 and ending July 23, 2017. Table 1 Demographics for Study Participants Participants Gender Age Group University P #1 P #2 P# 3 P #4 P #5 P #6 P #7 P #8 P #9 P #10 P #11 P #12 P #13 P #14 P #15 P #16 Male Male Female Female Male Female Female Male Female Female Female Female Female Male Female Female 21-29 21-29 30-39 30-39 30-39 30-39 30-39 30-39 30-39 30-39 30-39 40-49 40-49 40-49 40-49 50-59 Strayer University Capella University Strayer University Strayer University Strayer University Strayer University Webster University South University University of Phoenix Cambridge College Liberty University University of Phoenix Capella University Strayer University South University University of Phoenix 60 For the data analysis of the study, a qualitative thematic analysis was used both on the interviews and the questionnaires from the participants of the study. This method of analysis was utilized to identify and bring together the perceptions of the participants based off of their ethics trainings and life experiences. The perceptions were then categorized and grouped accordingly through thematic analysis to address the research questions of the study. In the next section, the themes that were identified from the interviews and questionnaires will be presented. There exist two types of themes that will be presented: major and minor themes. The most number of occurrences from the data identified the major themes. The less number of occurrences identified the minor themes (though still considered significant for the purpose of the study). The themes identified from the study will include verbatim comments and texts directly from the participants in order to support the researcher findings of the study. Results Research Question 1. Through the qualitative thematic analysis of the study, the participants perceived their leaders to be both ethical and unethical depending on the experiences of each participant, and according to each individual response, affected their decision-making processes in the workplace in various ways. Table 2 contains the themes addressing how each participant perceived their leader’s ethical behavior and how it affects their decision-making processes, which is the main research question for the study. Because this is a two-fold question, two major themes were formulated from the data collected. 61 Table 2 How followers (recent MBA graduates) perceive their leaders and how that perception affects their own ethical decision-making processes. Themes Positive perception of leader’s ethical behavior Negative perceptions of leader’s ethical behavior No positive or negative perception of leader’s ethical behavior Both positive and negative perception of leader’s ethical behavior Positive affects on ethical decision-making processes Negative affects on ethical decision-making processes No affect on ethical decision-making processes Number of Occurrences (n=16) 8 Percentage of Occurrences (n=16) 50.00% 5 31.25% 2 12.50% 1 6.25% 6 37.50% 2 12.50% 8 50.00% Major Theme 1: Positive perception of leader’s ethical behavior. The first major theme that emerged from the data collected through the interviews is that exactly one-half of the participants perceived their leader’s behavior to be ethical. Because there were at least four different ways for each participant (their answers collectively resulted into four different themes), this finding is significant. Participant #14 with regards to his leadership stated, “ethics is very important…especially in education and we do have quarterly goals, weekly goals or whatever, but the VP and my director will tell you at all times, do what’s right.” Participant #11 who works in Human Resources said, “I perceive that we have a very high ethical climate in my area and that is in part due to my manager… she is also a very ethical person and believe in just doing the 62 right thing.” Participant #1 who is a government employee based his positive perception of his leader according to the guidelines and code of ethics they are sworn to abide by. He stated, “I would say that she follows the handbook 100%. She doesn’t sway away from it.” Participant #5 who is a corporate worker expressed his positive perception of his leader’s ethical behavior stating, “I guess when I look at ethics, you are looking at being authentic, having morals and values and kind of sticking to what you believe in and she’s that way.” Participant #3 simply stated, “they uphold high ethical standards” while participant #12, said, “the ethical behavior within my workplace for my leadership [is] conducive to be appropriate for the work environment.” Participant #8 said, “I feel like their moral and principles are very professionally performed and implemented.” Finally, participant #16, who works for a non-profit agency stated, “They have high moral and ethical attitudes.” Minor Theme 1: Negative perception of leader’s ethical behavior. Though this theme is considered minor, 31.24% of the participants perceived their leader’s behavior to be unethical and is also significant to the study. Participant #6, another corporate worker said,” I feel like we have ethics right, we have those moral principles, and, we know they are there, but we don’t always act accordingly [pause] at all, depending on the situation.” Participant #8, who works in finance believes his leader to be a “great person” but does not like his decision-making processes as a leader, which in turn, affected his perception of his ethical behavior. He stated, “It’s okay. It could be better. He is a great person but I feel like some of his decisions… I don’t agree with some of his decisions.” Another corporate worker, participant #4, said her leader cares more about success, than being ethical. She replied, “I think the leadership that I am 63 currently under, how can I put this, their drive for success is clouding their judgment.” Participant #7 who works in a legal department said, “I think on a personal level, ethics might be a little shaky.” The final participant of this theme, participant #10 simply said, “It’s horrible.” Minor Theme 2: No positive or negative perception on leader’s ethical behavior. This theme accounted for 12.5% of the participants, and though seemingly insignificant, on a broader scale could possibly become increasingly significant. Participant #13, who works in education, claimed that her place of employment is why she did not perceive any ethical or unethical behavior in her leadership. She stated, “It’s almost no right or wrong answer to that when you work in a high school.” Participant #9 who works in healthcare, seemed also be caught in the middle according to her statement, “So they are fair to me to a degree, but at the same time I don’t feel like I’m being treated fairly.” Minor Theme 3: Both positive and negative perception on leader’s ethical behavior. This theme accounted for only 6.25% of the participants, but could also be significant on a broader scale, as this particular participant had somewhat of a unique situation. This participant decided to answer on multiple (2) leaders that she had encountered in her current positions. Participant #15 who also works in healthcare, in multiple statements said, “The first one wanted to be friends with the staff”, referring to her first leader. In reference to her second leader, she said, “The second one had that line between the staff and friendship and just kept it business, which I felt that all managers should.” She justifies why her perception of her second leader is positive and why she 64 doesn’t agree with the first leader’s, leadership style by stating, “There’s a line you should not cross when you are having to manage different people because other employees might get the perception that you show favoritism.” After each participant expressed their perception of their leader’s ethical behavior, they were also asked to explain how their perception of their leader’s ethical behavior affected their own ethical decision-making processes. The second major theme from the second part of this two-fold question emerged through their responses. Major Theme 2: No affect on ethical decision-making processes. The second major theme that emerged through the interviews is even though the majority of the participants perceive their leader’s ethical behavior to be ethical; it had no affect, positive or negative, on their own ethical decision-making processes. I believe it is also important to point out that not all of the participants who viewed their leader’s behavior to be ethical, stated that it had a positive affect on their ethical-decision making processes. Only 37.5% of the participants who perceive their leader’s behavior to be ethical said their perception of their leader had a positive affect on their own decisionmaking processes. However, 50% of all participants expressed that regardless of how they perceive their leader’s ethical behavior, it does not affect their decision-making processes. Here are the statements made by the participants in regards to this question, including the three participants from the first major theme that does have a positive view of the their leader’s ethical behavior. Their statements will be presented first. Participant #11 said, “I go back to how I answered before, because I am a very ethical [person], and try to be a moral person, then even if she didn’t, that wouldn’t change the way that I perceive because I have to give an account for me, regardless to what anyone else does.” 65 Participant #3 stated, “It doesn’t have an impact because I’m my own individual, so I’m going to make my own decisions and the right decision.” Participant #5 goes on to say “I always kind of fall back on my morals and beliefs first and then…I’ll kind of get her opinion based off of mine, but I always fall on my morals and ethics first.” The following participants did not necessarily view perceive their leader’s behavior to be ethical. However, according to their statements, it had no impact on their own ethical behavior or decision-making processes. Participant #2 said, “It doesn’t change it because I feel that I, being that we went to school and we’ve had jobs…we are considered seasoned as I call it. So it’ll be hard for somebody to come in now and try to change your thoughts on ethics or anything that happens in business. His behavior won’t change mine.” Participant #13, an educator, simply said, “it really doesn’t affect me directly.” Participant #9 had a similar answer where she stated, “It doesn’t affect my own ethical behavior, no” and participant #7 replied, “It doesn’t. I take pride in what I believe in to be ethical and I know that I have to obey the rules that are set by the company.” Finally, participant #10 said, “It doesn’t affect me because I still do what I supposed to do.” Minor theme 1: Positive affect on ethical decision-making processes. This minor theme also carries some significance, because although a majority of the participants did not believe their leader’s ethical behavior influenced their own in a positive manner, this theme still accounted for 37.5% of all participants, and could likely increase on a broader scale. These participants, according to their statements, viewed their leader’s ethical behavior as influential to their own ethical behavior and decisionmaking processes. Participant #12 stated, “Because my leadership leads by example, it 66 helps me to understand the importance of doing so as well as a supervisor.” Participant #8 said, “It sets a model. It really sets a tone as far as how you can maneuver and be flexible in the workplace and build relationships with other people.” For participant #15, her perception of her leader’s, leadership style allows her to better interact with her own subordinates as she said, “I think I pretty much work more with drawing the line, keeping that open communication [and] making sure my staff know they can come talk to me about anything, but knowing that there’s not a friendship.” Participant #1, a government employee, expressed that his leader requires ethical behavior at all times, and that it helps maintain accountability for their actions as he responds, “She requires me to maintain ethical behavior too. I work on a team and we all keep each other responsible.” Participant #14 implies that his perceptions of his leader’s ethical behavior affects him emotionally, allowing him to be comfortable in his decisionmaking skills in the workplace as he stated, “I think it’s positive and it makes you feel good that you, that people are more important than a goal or a number, or a mission and that people come first.” Finally, participant #16 believes that ethical behavior by her leader, allows ethical behavior to filter down through the hierarchy of business as she stated that “Well, things start at the head, so if ethically and morally the right attitude and behavior is displayed, then it tends to filter down.” Minor theme 2: Negative affect on ethical decision-making processes. This theme accounted for 12.5% of all participants. These two participants felt that their leader’s ethical behavior could affect them in a negative way. Participant #6 expressed that she would handle certain scenarios differently than how her leadership has handled them. She stated, “What they do might be different [from] maybe what I do in a 67 certain scenario…if I get to this position, I’d probably handle it a little bit differently.” Participant #4 said her leadership’s ethical behavior affects her in a negative way because she believes that everyone can be successful together through ethical behavior. Her response was, “It affects it, because just based on life… I try to be fair to everyone. So when I see little things like that, it kinds of aggravates me because I don’t feel like it’s being fair.” Research Question 2. Two major themes emerged from research question number two. After each participant was asked to express how they felt their leader contributed to their ethical and moral development, they were then asked about their exposure to ethical dilemmas within the workplace and, if they handled the dilemmas on their own, or if they sought leadership for the best way to handle the dilemmas. These two questions went hand-in-hand to answer the second research question. This question resulted into six different themes, two being major and, four being minor. Qualitative thematic analysis of the study was also used to identify the themes for research question number two. Table 3 How ethical climates and leadership styles within the workplace influences the behavior of entry-level MBA graduates when they are faced with ethical or moral dilemmas. Themes Leadership style does contribute to ethical and moral development Leadership style does not contribute to ethical and moral development Have faced ethical dilemmas and handled them on their Number of Occurrences (n=16) 10 Percentage of Occurrences (n=16) 62.50% 6 37.50% 7 43.75% 68 own Have faced ethical dilemmas and did not handle them on their own (went to leadership) Have faced ethical dilemmas and have both handled them on their own and went to leadership in some cases Have not faced any ethical dilemmas within the workplace 4 25.00% 3 18.75% 2 12.50% Major Theme 3: Leadership style does contribute to ethical and moral development. The third major theme resulted in over 60% of the overall participants admitting that their leader’s leadership style did contribute to their overall ethical and moral development in the workplace, regardless of whether they identified their leader’s to be ethical or not. This theme is one of the significant findings of the study. Participant #15 expressed that her leader contributes to her moral and ethical development by learning how to respect her employees as a leader where she stated, “I have more respect for my employees…I make sure everything gets done, I make sure it’s done fairly.” Participant #6 feels that the contribution that her leader makes in her ethical development allows her to better understand how to make decisions based on the company’s code of ethics, in contrast to how she might normally react to a situation. She said, “Yes it does, because there might be things that, let’s say my leader does, that or how she may handle certain situations, that I wouldn't because I still want to keep a level of respect for the company’s ethics and moral, so there are things that I would do that would align with that, versus kind of going way outside.” Participant #2 implied that his leader’s leadership style 69 forces the development of his moral and ethical principles in the work place because as a part of finance, everything is numbers driven. He said, “Yes, because they are directly in contact with the owner that makes the decisions as far as promotions, your numbers for the month… that’s what’s being reported to the boss. So yeah, directly, it does.” Participant #11 indicated that both the environment of her workplace and her leader’s leadership style contributes to her moral and ethical development, saying, “Sure, again because of the environment and the climate, absolutely. It aids and makes it a lot easier, I guess because being ethical is not always easy, because it’s easy to cut corners and the wrong things, if you think no one is looking. But the fact that the climate is there and she supports…so yes.” Participant #13 indicated that her relationship with her leader started in junior high school, which is where she initially started to contribute to her ethical and moral development. She said, “I learned a lot from her in the seventh and eighth grade as far as what’s wrong [and] what can be perceived as wrong.” Participant #9 indicated that her leader actually put her in a situation where she had to develop ethically and morally, comparing her situation with what she learned in her ethics training courses. She said, “Yes and I say that because… she put me in a situation where they kind of give you those scenario questions where they ask you in school, ‘if you are in this situation, what should you do’, and she put me in a situation where I had to learn something.” Participant #12 explains why her leader’s leadership style contributes to her ethical and moral development by stating, “Yes I do. I feel that the leadership style definitely helps me because, I do see that it’s not about what is said, but what is done and, that speaks louder than anything you could ever try to teach someone.” Participant #1 70 simply replied, “Yes”, with no further explanation. Participant #5 implied that she believes that her and her leader may both contribute to each other’s ethical and moral development on a daily basis within the workplace. She said, “Yes in a way, because we are kind of on the same page, so we kind of have the same morals, ethics and beliefs, so yeah, it’s kind of hand and hand.” Finally, participant # links her ethical and moral development to both her leader and her ethical training. She stated, “It enhanced it, with the course of the studies, they were very detailed and in depth and the training that we received only enhanced what we were taught, what I was taught.” Minor Theme 1: Leadership style does not contribute to ethical and moral development. These participants, 37.5%, expressed that their leader’s leadership style does not contribute to their ethical and moral development. Participant #14 said, “Not necessarily. I think my leader’s leadership style is her leadership style [and] it works for her. I think my ethical behavior basically comes from my parents. I just know what’s right and wrong and try to live by that. I try to do unto others as I would have them do unto me.” Participant #8 stated, “I say no. I think honestly, I feel like my growth only comes from my exposure into the workplace.” Participant’s #3, #4, #7 and, #10 all simply stated, “It doesn’t”, “no” and, “nope.” Major Theme 4: Participants faced ethical dilemmas and handled them on their own. Each of these participant’s have faced some type of ethical dilemma within their respective workplaces, and instead of going to their leaders for guidance, advice or decisions, they decided to handle the dilemma on their own. Some of the reasoning 71 behind this is simply because they are following protocol such as Participant #15 who said, she handled the dilemma, “because I already knew the proper protocol in healthcare.” Participant #14 actually believes that even though they are in an entry-level position, because of his life experiences, he felt himself to be more qualified to make certain decisions without the guidance of his leader. He stated, “Nine times out of ten, I handle it on my own…why not, in most cases, in a lot of cases, I’m a little bit more seasoned than my leader. I have dealt with a little more ethical dilemmas I believe in my lifetime than my leader and I believe the connection that I have, the one on one connection that I personally have with the student makes me the best person to handle the situation.” Participant #2 said he made the decision to handle the dilemma on his own, but got in trouble for doing so. He stated, “I handled the decision, I handled it on my own and I got in trouble.” After the researcher as the participant why he decided to handle the situation on his own, he replied, “Yeah because, from my understanding, it wasn’t a bad situation.” Participant #11 after saying that she handled her situation on her own, said, “I believe that any dilemma that comes up, that you should handle it at the lowest level first. And then if you can’t, then you proceed to management. But because I was able to handle it at my level, there was no need to take it further.” Participant #9 felt that she had been around her leader enough to make a decision in her stead. She replies, “In that situation, I knew what she was going to say… I’ve been working for her for about four years now so there’s no point to say anything about it. You what it is at the end.” Participant #1 said, I like to do it myself, deal with it first myself and then once I feel like I covered what I needed to cover, I’ll present it to her and then I’ll tell her what I did, the 72 stuff that I did, just to show her that I am taking the initiative as a leader… to show her that I am capable of doing the job and I can do it without supervision.” Participant #16 who is a non-profit worker said, “it wasn’t a situation that required me to go to them because I’m the one that’s here full time, they have full time jobs, so a lot of the things that I have to handle head on and then bring them up to breast on what transpired.” Minor Theme 1: Participants faced ethical dilemmas and did not handle them on their own. These participants have also faced ethical dilemmas in their workplace, but instead of handling the dilemmas on their own, they decided to go to their leadership. This minor theme accounts for 25% of all participants. Participant #6 said that she had to go to her leader because “this was a scenario that I have never encountered before… it very well could lead to like a H.R. issue, impacting someone’s position. So I had never been faced with something like that, so I’m like let me get some advice before I actually take my own initiative.” Participant #13 indicated that she had no choice in her ethical dilemma, because it involved an accusation placed on a co-worker and, was called in by her leader. She stated, “In that situation with that teacher, I was called in.” Participant #4 could not go to her supervisor in her dilemma, because, she said, “they were part of the issue.” Participant #12 said she goes to her leader when faced with ethical dilemmas to “ensure consistency.” Minor Theme 2: Participants who faced ethical dilemmas and have both handled them on their own and went to leadership in some cases. This minor theme accounted for 18.75% of all participants. This theme emerged from participants who say they have handled some ethical dilemmas on their own and 73 others they have gone to leadership. It is important to point out that the researcher did not ask any participant if they have been faced with multiple ethical dilemmas, yet, this theme still emerged. Participant #3 stated, “it just depending on the situation. One scenario was grander, but if it’s something small where a conversation or a coaching, where I’m able to deliver on my level, can resolve it, then I’ll handle it that way. But if it’s something where it involves multiple individuals and the impact can be greater for the individuals and, or the company, then I have to get others involved.” Participant #7, who’s dilemma dealt with a legal issue said, “So a part of my job, of course I have to represent my company, and that sometimes involve going to court, being sworn in, and one of the questions that I was asked when I was on the witness stand. I didn’t agree with the response that I had to give, and it definitely dealt with my ethical, me being ethical, but I knew that because of my job, this is what I signed on the dotted line to do. So at that very moment, I had to do what the business told me to do, and I dealt with how unethical it was afterwards, because when I’m on the witness stand, I can’t call my leader and say, ‘oh I can’t do this’, [I] just had to kind of deal with it at the moment.” Participant #10 was in a situation where she said that she wanted and attempted to go to her leader for advice on an ongoing ethical dilemma, and was not able to get any results, so had to start handling the dilemmas on her own. She said, “I am an enrollment advisor and we service people in a community [of] need… So these people, they need our full attention and they need our help… and if she [co-worker] continues doing what she’s doing, she is tarnishing the whole department. So I felt it was necessary that I spoke up… In the interview, all the co-workers said the same thing [and] nothing happened. So at this point, nobody is saying anything…” 74 Minor Theme 3: Participants who have not faced any ethical dilemmas within the workplace. Only 12.5% of the total population said that they have never faced any ethical dilemmas within the workplace. The significance of this minor theme is, the lower the percentage, the higher the evidence of unethical practices, behaviors and, or instances are happening within the businesses and organizations. Participant #8 simply stated “no”, and participant #5 said, “I haven’t as I can recall, nothing that really stands out. No sir.” Research Question 3. This question sought to see how unethical leadership (if applicable) might affect the ethical training each participant received. The researcher was interested in identifying if unethical leadership would negate any ethical training received by the participants. Also, if unethical leadership did negate any ethical training, how does that affect the participant’s perception of their leader and, also how does it affect their own ethical and moral behavior. Two major themes also emerged from this research question. According to the responses, most participants have experienced unethical leadership, however, almost the same amount of participants who have experienced unethical leadership, also implied that their ethical training was not negated by their unethical circumstances, and that they were able to hold on to their moral and ethical development. Table 4 How unethical leadership (may or may not) negate the ethical training received by their followers affect the perception and behavior of the followers. Themes Participants who have experienced unethical Number of Occurrences (n=16) 12 Percentage of Occurrences (n=16) 75.00% 75 leadership in school or the workplace Participants who did not experience unethical leadership in school or the workplace Ethical training allowed participants to hold on to their moral and ethical beliefs under unethical leadership Ethical training somewhat allowed participants to hold on to their moral and ethical beliefs under unethical leadership Ethical training did not allow participants to hold on to their moral and ethical beliefs under unethical leadership Latter themes did not apply to participants 4 25.00% 11 68.75% 1 6.25% 0 0.0% 4 25.00% Major theme 5: Participants who experienced unethical leadership within the workplace. This is a major theme for a couple of reasons. The first is that 75% of all participants said that they have been exposed to unethical leadership. That means that only 25% of the participants have never experienced unethical leadership, which is significant. Another reason that this is a major theme is because, according to the first research question, only 31.25% of the participants perceived their current leader’s ethical behavior to be negative, but their overall experience of unethical leadership more than doubled at this point in the interviews. Only one of the participants went into any major detail at this part of the interview. Participants #15, #6, #14, #2, #11, #3, #4, #1, #7, &, 76 #10 all replied with a simple “yes,” “yes I have,” “I definitely have,” “absolutely,” and, “oh, yeah.” Participant #12 did point out that her experience of unethical leadership happened more in school than the actual workforce as she said, “Yes, I think I received it more so when I was in school and, it did allow me to [later] approach it in an appropriate manner.” Participant #5 was a little “on-the-fence” about his experience of unethical leadership as he explains, “I had an instance were we had a lunch, a group meeting at lunch and one of our co-workers had too many drinks and probably shouldn’t have came back to work. But my manager allowed her to come back to work but she didn’t sign in on the phone, and I didn’t think that was fair for the other representatives on the team. I kind of think that was a ethical issue, but other than that, I hadn’t had any major issues. Minor Theme 1: Participants who did not experience unethical leadership in school or the workplace. These participants said that they have never personally experienced any unethical leadership in school or the workplace. This theme accounts for 25% of all participants. Participant #13 stated that in the education field that have what is called “professional development” when they are faced with any ethical issues or leadership and her reply was, “I don’t think we… I don’t recall having any professional development as we call it on ethical training or ethics.” Participants #9 & #8, both simply said, “no.” Participant #16 said, “No, I don’t think I have ever experienced any, in school or here at the workplace.” Major Theme 6: Ethical training allowed participants to hold on to their moral and ethical beliefs under unethical leadership. 77 This theme, also significant at 68.75% of all participants, indicated that the ethical training that most participants, was not negated by exposure to unethical leadership. None, or 0% of the participants said that their ethical training did not allow them to hold on to their moral and ethical beliefs under unethical leadership. Also, since not all of the participants had been exposed to unethical leadership, this theme only accounted for twelve of the sixteen participants. During the interview with participant #6, she indicated that she went through an ethical dilemma that was out of the norm in her work place and that her moral and ethical training allowed her to not deter “from my own moral standards.” Participant #14 believes that his ethical training allows him to hold on to his moral and ethical standards when faced with unethical dilemmas because, the ethical training he is most comfortable with and holds on too comes from his parents and not a classroom. He said, “I think that the ethical training I received just helped to highlight it, it helped to show me that these things really happen and again, I go back to tell you the ethical [training] … just helps me to see that they happen but most of my ethical training that I feel comfortable with comes from my mother, how my parents raised me.” Participant #2 also indicated that through a combination of what he was taught in ethics courses and who he has become as a person, he was able to hold on to his ethical and moral standards when faced with an ethical dilemma. He said, “Actually the first job and the only job that I’ve ever been terminated from, my leader was unethical. I held on to my morals and teachings because that, that’s just who I am. Like I, I don’t think you should let people change you.” Participant #11 repeated the question the researcher had asked her and then replied by repeating the question and answering. She said, “Yes I have had unethical leaders, I think was the first question? And did the training I received 78 allow me to hold on? Yes, it did.” Participant #3 simply replies, “absolutely,” and participant #4 said, “yes”, in replying to being asked by the researcher if their ethical training allows them to hold on to their moral and ethical beliefs when faced with ethical dilemmas. Participant #12 indicated that her ethical training did more that just allow her to hold on to her moral and ethical standards by stating, “The training really did allow me to gain insight on not only the fact that identifying that it was unethical, but also on how to make the appropriate approach.” Participants #1, #7, #10 & #5 all said “yes” or “it did”, in regards to their ethical training and that it did allow them to hold on to their moral and ethical standards when they were faced with ethical dilemmas under unethical leadership. Minor Theme 1: Ethical training somewhat allowed me to hold on to my moral and ethical beliefs under unethical leadership. The minor them only accounts for 6.25% of all participants. The “somewhat” emerged from this theme because the participant indicated that her ethical training was only a part of why she was able to hold on to her ethical and moral standards when faced with ethical dilemmas by unethical leaderships. She said, “A little bit yeah, A little bit… I think more of the experience you get with ethics you have to have hands on in the business experience. That’s the only way you are going to be able to develop it, that’s the only way.” Research Question 4. The major theme that emerged from research question number four indicated that most participants, which has be a reoccurring theme throughout this study, perceived immoral and unethical behavior by their leaders in a negative light. Throughout the study, no participant believed that unethical behavior is 79 acceptable, though one participant did believe that in some circumstances, the lines between what is ethical and non-ethical are blurred, and sometimes making a decision may “on-the-books” be deemed unethical, but in a particular situation, is the right thing to do. The responses that correlate with research question number four showed that most participants, though they scrutinize unethical leadership, does not let it influence their own ethical and moral beliefs. Table 5 Entry-level MBA graduates who have had ethical training courses and what they believe about negative or immoral behavior by their leaders and its influence on their own ethical and moral beliefs and behaviors. Themes Negative perception of leader’s behavior with positive influence on participant’s own behavior Negative perception of leader’s behavior with no influence on participant’s own behavior Negative perception of leader’s behavior with negative influence on participant’s own behavior No negative or positive perception of leader’s behavior with no influence on participant’s own behavior Number of Occurrences (n=16) 2 Percentage of Occurrences (n=16) 12.50% 11 68.75% 1 6.25% 2 12.50% Major Theme 7: Negative perception of leader’s ethical and moral behavior, with no influence on participant’s own ethical and moral behavior. 80 This is the final major theme that emerged through qualitative thematic analysis. This theme accounted for 68.75% of all participants, making it significant. 100% of the participants had some type of ethical training courses before entering in their current positions. However, as noted earlier, not all participants had encountered unethical and immoral behavior from their leadership. This theme points out that with the ethical training that each participant has received, their exposure to unethical leadership had no influence, positive or negative, or their own ethical and moral behavior within the workplace. Participant #6 stated, “It doesn’t affect my moral and ethical beliefs in the workplace, it’s just, I think the thing that it really impacts is how I would react.” Participant #14 said, “I perceive it as uncalled for, as something that needs to be eliminated. It does not affect my ethical judgment or how I perform in a workplace, at all.” Participant #2 replied, “I don’t like it… and if it does happen, I still, like I been saying, I’ll still keep my own moral standards.” Participant #11 decided to use an example that she experienced to help the researcher better understand her position on unethical behavior by her leader. She said, “So I guess an example to kind of help, I had a leader who tried to, wanted me to lie and say that I submitted some paperwork that I had not submitted at a particular time. And I wasn’t going to do that and this was one of my top leaders that was asking me to do that and I told them that I cannot be a part of that because simply, that was lying. So I could have gotten push back…if I wasn’t standing strong on what I believe, could have been intimidated by that, but I wasn’t because I knew I wasn’t [about] to be a part of that. Because whatever would happen as a result of that, I didn’t what that on my conscious because I knew that wasn’t the right thing so, ultimately it goes back to again, you have 81 to have a firm foundation within yourself or else you will succumb, because you will have some leaders, sometimes that will push the bounds to see what you will do.” Participant #3, pointed out that unethical leadership may change her perception of her leader, but not her behavior as she said, “I’m going to make my own decision and uphold my ethical standards and morals, but…other than that, depending on the person and what they displayed to me, would change my perception of that individual.” Participant #9 indicated that it’s a matter of knowing right and wrong and this is why her behavior doesn't change. She said, “I don’t think it affects my own moral and ethical beliefs, because I think that within yourself, you know what you should and what you should not be doing…so I don’t think it necessarily affects me.” Participant #1 make a strong statement as he said, “I’m absolutely against it, but sometimes I think people in life situations, causes them to try to rationalize it, that being unethical can be right, when it’s not, when it’s never right, so I’m very black and white about it and I think you should just follow the book at all times.” Participant #7 indicated that she has certain level of understanding of why some leaders may seem to behave unethical, but that she still does not agree with it personally. She stated, “I understand it, I don’t agree with it. I think there is a better way to do it, so I take what I stand for and I try to hold to that to the best of my ability and if I feel like it’s leading me to do something unethical, I’m very honest with my leaders. I have built that rapport and that relationship with them to let them know, ‘I can’t do this…you are going to have to give it to somebody else, and they respect me for it.” Participant #10 stated, “Did it affect me where I didn’t stand by the bylaws or the codes of ethics? No. It didn’t affect me because I know me. No matter what [my] employer does, I know what’s morally and ethically right.” Participant #16 82 said, “I haven’t experienced any, but if I had, then it would make me question that leadership, because I would not want to work under someone who does display unethical behavior of any type. Participant #5 simply said, “It does, it doesn’t.” Minor theme 1: Negative perception of leader’s behavior with positive influence on participant’s own behavior. Only 12.5% of all participants said that even when their perception of their leader is negative, it influences their own ethical and moral behavior in a positive manner. Participant #15 said, “with my first manager, there was some unethical issues going on with her, so that made me want to be a manager, that [would] keep an open eye and open mind to everyone.” Participant #12 stated, “I do think it’s important to ensure that you are being ethical in what you are doing on a daily basis, and it, it spills over into your personal life as well.” Minor theme 2: Negative perception of leader’s behavior with negative influence on participant’s own behavior. An even smaller amount of the participant’s, 6.25%, indicated that their perception of their leader’s negative behavior, did affect their own ethical and moral development in a negative manner. According to her statement in her interview, it wasn’t that it affected her where she would behave in an unethical manner, but the perception of her leader’s unethical behavior did not help her to develop ethically or morally in her workplace. Participant #4 said, “It affect me because, like I said…I do try to be fair across the board and I can say that due to situations previously, I have, like this is it. I do not want to work for another corporate job.” 83 Minor theme 3: No negative or positive perception of leader’s behavior, with no influence on participant’s own behavior. The final minor theme of the study included 12.5% of all participants of the study. These participants said that the neither perceived their leader’s behavior as being ethical or unethical, and that it had no influence on their own ethical and moral behavior within the workplace. Participant #8 had no comments on this particular question. Participant #13 had much to say about the perception of what’s ethical and unethical in general. She explained, “Do I believe, do I believe people on some level are always unethical… I’ll use [a] University as an example. Their president has been there twenty-seven years. He hasn’t been there twenty-seven, twenty-eight years because he is unethical surely. Now probably has he done some unethical things? To maybe assist a student short on financial aid, or assist a student who didn’t have any books? You know some things can be deemed as unethical, but there is a fine line between ethical and unethical as I stated, where is it for the overall good? Student needs textbooks, me sliding them an extra two hundred dollars in scholarship money that they probably don’t deserve, or the school can’t afford? Yeah, probably, but that versus that student failing those two class because that student don’t have books…so generally I think the people that are more ethical, tend to be around longer. Their stay in power is longer.” In summary, most participants could at least identify with unethical behavior, even if they haven’t necessarily experienced it. The participants all leaned toward doing what they see as being ethical in the workplace, regardless of how they perceive their leader’s ethical behavior. Each participant articulated their beliefs in a simple matter, 84 though some were more detailed than others. In the next section, the evaluation of the findings will go further in detail on these matters. Evaluation of Findings This study was important as to Beeri et al. (2013) noted there is a limited amount of research conducted specifically on how followers perceived ethics within the workplace. This study attempted to close a gap in the literature through the multiple case-study methodology, by directly interviewing followers and gaining a better understanding of how they perceived their leader’s ethical behavior and how it affected their own ethical and moral decision capability through open-ended questions and a questionnaire. Through qualitative thematic analysis, the findings in this study are consistent with Reiley & Jacobs (2016), who noted, how followers react to their leaders is based off of their own perceptions of their leader’s moral and ethical behavior. Participants in this study, according to the data, reacted to their leaders in either a negative manner or a positive manner, depending on their perception of their leader’s ethical behavior. However, these reactions did not result in negative moral or ethical behaviors by the participants. Even in the case of negative reactions, the participants claimed that it did not alter or affect their own ethical or moral behavior within the workplace, only their perception of that leader. One participant claimed that her perception of her leader, though it was negative, allowed her to gain knowledge of what not to do in certain ethical dilemmas. Steinbauer et al., (2014) posited in their study, that leaders have the ability to set an organizational tone within the workplace in regards to ethics, but this is not always the case depending on that leader’s own moral and ethical behavior and the perception of their behaviors by their followers. Davidson & Stevens 85 (2013) noted effective leadership does not guarantee ethical or moral values within the workplace as displayed in some organizations like Enron, Adelphia Communications and Tyco. In this study, there were some participants who said that they have experienced unethical leadership, and still were able to remain ethical based off of how they were raised by their parents, and the ethical training they had received in ethics and business courses. Unethical behavior by leaders, as the findings in this study demonstrate, did not negate the ethical training that the participants had received before they entered into the workforce. The findings in this study are also consistent with Zhu et al. (2016), and their study on the moral identity of leaders, moral attentiveness, and the affect it has on their followers. The theory put forth in their study was that, leaders that give more attention to ethical and moral issues within the workplace directly associated with how their followers perceive them as ethical or moral leaders (Zhu et al., 2016). Fifty percent of all participants viewed their leader’s behavior to be ethical and over sixty-two percent said that their leader’s, leadership style does contribute to their own ethical and moral development within the workplace. Based on the data collected through the interviews, the participants that perceived their leaders to be ethical seemed to have a stronger workrelated relationship with their leaders, which in turn, did have some positive affect on their ethical and moral development within the workplace. However, it is important to note that seventy-five percent of all participants, at some point during their tenure at school and, or their workplace had experienced some unethical leadership. Over ninetyone percent of that particular group said that their ethical training allowed them to hold on to their moral and ethical beliefs under unethical leadership. 86 The data retrieved from the participants through the interviews and the questionnaires remained consistent throughout the study. The following themes were all present throughout the sixteen interviews and sixteen questionnaires: how the participant’s perceived their leader’s ethical behavior and how that perception of their leader affected their own moral and ethical behavior; how leadership styles contributed to their own moral and ethical development; the ethical training they received and how it affected their moral and ethical beliefs; and how unethical leadership and the affects on morality and ethics within the workplace. All participants interviewed took some type of business ethics courses or training prior to their new careers. Steinbauer et al. (2014) on ethical-leadership theory stated, “leaders influence followers’ ethical decisions and actions through [the] social exchange process, communicating the importance of ethical standards, social exchange process, and using performance management systems to make employees accountable for their conduct” (p. 381). However, this did not seem to be a theme that emerged from the interviews conducted with the participants of this study. The findings from the data retrieved demonstrated the participants were more influenced by their own experiences from the way they were raised, and the moral and ethical values they possessed prior to any ethical training or experience in the workplace. Participants did indicate that the ethical training courses had an effect on their moral and ethicaldecision making processes, highlighted the importance of ethics in the workforce, and reinforced why moral and ethical behavior is important within business. Questionnaires completed by the participants revealed that 100% of the participants agreed that all undergraduate and graduate business students should enroll in business ethics courses, even though not all of the participants thought the classes were “very effective,” as some 87 said they were only “somewhat effective.” No participant thought that ethics courses were altogether ineffective, and that there is some benefit from taking them, but they may not necessarily have any effect on any individual’s ethical and moral behavior dependent on how they were raised by their parents or guardians. The triangulation of the data revealed consistent themes where some supported the expected results based on the literature reviewed and some of the themes that emerged did not support some of the literature reviewed. For example, the theme where there was a negative perception of the participant’s leader’s behavior, and that this perception had no influence on the participant’s own behavior, was not expected, yet 68.75% of all participants accounted for this theme. As noted earlier, the researcher expected more of an influence on the participant’s ethical and moral behavior, whether, positive and negative, according to Steinbauer et al. (2014) claim that “leaders influence followers” (p. 381). Though it did affect some, it was not a major theme in the study. Summary Chapter 4 of the study presented the results from the interviews with entry-level MBA graduates who received their MBA within the past five years. A qualitative thematic analysis was utilized, which resulted in several major themes emerged, which addressed the research questions of the study. The first research question addressed, how followers (recent MBA graduates) perceive their leaders and how that perception affects their own ethical decision-making processes, it was discovered that half of the participants perceived their leader’s ethical behavior to be positive and the others sought it to be negative or had no positive or negative perception at all. Also, half of these participants said that their perception of their leader’s ethical behavior had no effect on 88 their own ethical decision-making processes, while the others indicated that it had either a positive or negative affect on theirs. The second research question addressed, how ethical climates and leadership styles within the workplace influences the behavior of entry-level MBA graduates when they are faced with ethical or moral dilemmas. It was discovered that even though not all of the participant’s perception of their leader’s moral and ethical behavior had an effect on their own ethical decision-making processes, that their perception of their leaders did contribute to their ethical and moral development in some manner whether in a positive or negative way, when they were faced with ethical dilemmas within school or the workplace. The third research question addressed, how unethical leadership (may or may not) negate the ethical training received by their followers affect the perception and behavior of the followers. In this instance, it was discovered the ethical training received by the participants, was not negated by those who experienced unethical leadership, and they were able to hold on to their moral and ethical values when faced with those dilemmas. The final research question addressed, entrylevel MBA graduates who have had ethical training courses and what they believe about negative or immoral behavior by their leaders and its influence on their own ethical and moral beliefs and behaviors. The majority of the participants had a negative perception of a leader’s behavior with no influence on their own behavior in regard to negative or immoral behavior, and its influence on their own moral and ethical beliefs. The evaluation of the findings in this study supported some of the evidence found in the literature, but not all of it. Chapter five will present the implications, limitations, recommendations and conclusions of the study. 89 Chapter 5: Implications, Recommendations, and Conclusions Unethical behavior by managers and leaders within the workplace may negatively influence the perceptions and behaviors of followers, negating ethics courses and training received in college and their respective organizations (Boddy, 2014, Ho & Lin, 2016). As Holland Albrecht (2013) noted, business scholars are now tenaciously determined in gaining more insight and understanding in business. As stated earlier in this study, “followers’ perceptions of their leaders’ ethics have the potential to impact the way they react to the influence of these leaders” (Reiley & Jacobs, 2016, p. 69). How followers perceived the behavior of their leaders is an important element of the leadership dynamic, as followers responded to how their leaders lead and unethical or immoral behavior may change how followers respond or react relative to leader influence (Reiley & Jacobs, 2016). Though there is no shortage of literature in regards to business ethics where scholars have attempted to understand the dynamics of ethical and unethical behaviors and practices and how they affect the workforce (Dermirtas, 2015; Hunter, 2012), Guadencio et al. (2014) noted there exists minimal progress in scholars gaining a better understanding of the follower-leader relationship in business. The purpose of this qualitative multiple-case study was to explore how ethical climates and leadership styles contribute to the ethical and moral development of entrylevel MBA graduates. The study also sought to gain a better understanding of how entrylevel MBA graduates perceive the ethical behavior of their supervisors or leaders when they were put under ethical or moral dilemmas, in contrast to their training and knowledge of ethics learned within business ethics courses. A qualitative method was chosen for this particular research over a quantitative method because the research 90 questions aligned more with behavioral and social phenomenon versus brand awareness, penetration, percentages, or elicits numbers seeking facts from sampling a certain population (Barnham, 2015). Also, as noted earlier, a qualitative research method aligned well with the nature of the study, as compared to a quantitative approach because the qualitative method allowed for distinct data to be collected in a specific context (Yin, 2009). The multiple-case study design allowed for the researcher to formulate an indepth analysis of each individual case with regard to their perception of their leader’s ethical behavior and how the ethical climate of their organization has affected their own ethical decision-making processes. For this study, the data was collected from 16 MBA graduates who graduated within the past 5 years. The majority of the participants work in South Carolina; however, there were participants who currently work in Massachusetts, Maryland, and Washington, D.C. that participated in the study. Their interviews were conducted using Facetime and Facebook Messenger. Each participant completed a brief survey documenting to their business ethics training experience and their knowledge on their leader’s ethical behavior within the workplace. The main question guiding the study was “How do followers perceive their leaders and how will that perception affect their own ethical decision-making processes?” The ethical requirements by Northcentral University Institutional Review Board (IRB) were all met in accordance with their guidelines. All participants signed an informed consent after being made aware of any potential risks and the benefits of being a part of the study. The informed consent forms also included direct contact information to the researcher, the dissertation chair, and Northcentral’s IRB and the dissertation chairman, if they had any questions or concerns. 91 This study included methodological assumptions, limitations, and delimitations. It was assumed that all of the participants would answer all of the interview and questionnaire questions to the best of their ability and honestly. It was also assumed that each participant would not feel forced or enticed to participate in the study and that the interviews and questionnaire was 100% voluntarily. Also, because the participants would be attempting to express their feelings in regards to perception involving their leaders, it was assumed that they would be comprehensive in describing their feelings to the interviewer. There was a limitation to the study because the questions presented and their responses came only from the perceptions of entry-level employees who have recently graduated with their MBA. It is possible that participant responses were simply biased opinions, or their perception of their leaders was not 100% accurate. Therefore, the perception of leaders by other types of employees with higher-level degrees, or without, should be considered in order to compare the results from this specific sample to produce similar results. Also, there were only 16 participants, so the results may not be easily generalized to all entrylevel graduates with MBAs and the perceptions of their leaders. Delimitations of this study included that only 16 entry-level MBA graduates were interviewed. The findings of the study may not be easily generalized to all entry-level MBA graduates and their perceptions of their leaders. Also, the qualitative methodology is not able to establish causal relationships. Therefore, though the study is aimed at studying perception and not cause-and-effect, the results are limited for future research. In the next section of this chapter, the implications of the study will be presented, including logical conclusions of the findings. 92 Implications As briefly noted earlier, in this section, the findings of the four research questions will be presented. The implications of the study are supported by the existing literature described in Chapter 2 in order to validate or show the validity of the reasoning of the study as well as general findings. The themes formulated in Chapter 4 will be addressed in this section. Research Question 1 The first research question (RQ1) was, how do followers perceive their leaders ethical behavior and how will that perception affect their own ethical decision-making processes? Research question one resulted in seven underlying themes, where there were two major themes and five minor themes. It was found that 50% of the participants had a positive perception of their leader’s ethical behavior and that their perception of their leaders had no affect on their own ethical decision-making processes. Identifying ethical leadership, Crews (2015) stated the normative and philosophical perspectives focuses on what leaders ought or should do. In this study, the participants were asked to identify these same perspectives from a subjective point of view as a follower where they were able to articulate if they felt that their leader was doing what they ought to do in regards to their moral and ethical behavior within the workplace. Positive perception of leader’s ethical behavior. The perceptions of followers toward their leaders are an important element of the leadership dynamic (Reiley & Jacobs, 2016). Exactly 50% of the participants perceived their leader’s ethical behavior to be positive. The other 50% of participants had either a negative perception of their leader’s ethical behavior or was stuck in the middle, having no positive or negative 93 perception of their leader. The finding from the analyzed data collected demonstrated some of the participants attributed the ethical climate within their workplace, to be associated with the ethical behavior of their leader or leaders. This finding addressed a identified in literature review where Ho and Lin (2016) noted the gap in the literature lies between the assumption that moral judgments of a leader will affect both the ethical climate and the leadership style within an organization. Participants admitted that they perceived business ethics to be very important and their positive perception of their leader’s ethical behavior is conducive to be appropriate for the work environment. This finding agrees with the literature where Steinbauer et al. (2014) agreed that leaders have the ability to set organizational tones with regard to ethics within the workplace. Based on the data collected from the interviews, positive perception of ethical behavior seemed to bring positive attitudes from each of the participants in regards to their work environment and their willingness to follow their leader. Each of the participant’s in this theme spoke very highly and confidently about their leadership. Even though most of the participants involved in this study said that their leader’s leadership style had no affect on their decision-making skills (see next section), they still believed their leader’s ethical behavior positively influenced the work environment, making it more comfortable for them to uphold their own ethical and moral values. No affect on ethical decision-making process. Though 50% of the participants perceived their leader’s ethical behavior to be positive, the other 50% of the participants also stated that their perception of their leaders, whether positive or negative, did not affect their own ethical decision-making processes. This finding is in agreement with the literature where scholars believe effective leadership and how the effect they might have 94 on their followers has not been easy to confirm empirically (Steinbauer et al., 2014). Steinbauer et al. (2014) also noted only a limited amount of studies exist where scholars empirically confirmed that leaders do have some effect on the decision-making skills and the conduct of their followers. This study met with the same limitation with regards to this matter. Not all of the participants that identified a positive perception of their leader’s ethical behavior said that it also had an affect on their own decision-making skills. Because of the multiple themes that emerged from this research question, it was hard for the researcher to find a direct correlation between the positive perception of ethical behavior and the affects it had on the decision-making skills of the participants. Participants made it clear that regardless of how they perceived their leader’s ethical behavior, it did not necessarily mean it would have an impact on their own decisionmaking processes within the workplace. As they stated, they are their “own individuals” or they have to give an “account for their own actions,” hence, leaders behavior had no direct impact on their own moral and ethical standards and decision-making processes. It may be important to point out that after analyzing the demographics from table one, 87.5% of the participants were over the age of 30. Even though each participant recently graduated with a MBA within the past five years, most of them had already been apart of the workforce for at least 10 years. Future studies involving leader-follower perception, should consider analyzing how age and experience might influence individual decisionmaking skills within the workplace. The researcher could not infer whether age had any affect with the decision-making skills in this study, but based on the responses from each of the participants over the age of 30, they were more likely to make decisions based on their own experiences and ethical training, rather than allowing their leaders to have any 95 influence on their decision-making processes. If age does play apart in how followers respond to their leaders, then it is important for future researchers to study and analyze different age groups and see if there is any significant difference in ethical behavior, based off of the perception of their leaders. Negative perception of leader’s ethical behavior. Though the positive perception of leader’s behaviors by followers resulted in a major theme for the study, the negative perception of a leader’s ethical behavior was also significant. Ho and Lin (2016) noted unethical behavior by leaders might negatively influence the perceptions of their followers, possibly negating the moral and ethical training they previously received in school and on the job. Negative perceptions of ethical behavior by followers with regards to their leaders had a negative impact within business organizations as documented by McCann and Sweet (2014) who noted followers maintain interest in how their leaders behave, seeking to see if their leadership leads to trustworthiness. A little over 31% of the participants involved in the study had a negative perception of their leader and the majority of these individuals associated unethical behavior to their negative perception of their leaders. Also, each participant that perceived his or her leader’s behavior to be negative expressed strong feelings opposing the decision-making processes of their leaders. One participant simply said, “it’s horrible”, in regards to the ethical behavior of her leader. Another participant believed that their leader was more focused on becoming successful, and they were willing to do unethical things to get ahead. This negative perception felt by these followers did not affect their own ethical or moral standards, in or outside of the workplace according to the participants. One participant noted by watching her leader make unethical choices, and then being aware of 96 the consequences of those choices, allowed her to learn what not to do in certain situations. Based on how the participants said they responded to unethical leadership, not all-unethical leadership causes negative impacts on their followers. In these instances, unethical behavior gave the followers the opportunity to maintain their own ethical and moral standards, and according to their responses, that is exactly what they did. Positive affect on ethical decision-making processes. Although 50% of the participants said that their perception of their leader’s ethical behavior had no affect on their decision-making processes, over 37% said that their perception of their leader’s ethical behavior had a positive affect on their ethical decision-making processes. These participants used comments such as, “because my leadership leads by example…” and “it really sets a tone…” with regards to how their leaders impacted their decision-making skills. This finding by Ho and Lin (2016) where they noted the leader-follower relationship is built upon moral judgment, giving the leader the ability to influence the decision-making skills of their followers. Here, the participant, after perceiving ethical leadership by their leader, has found trust in their leader’s ability to lead, which affected their own decision-making processes within the workplace in a positive manner. Not only did the positive perception cause a positive affect on decision-making in regards to the participant’s own behavior, but also when it involved other co-workers. Certain participants said that the positive influence that they received from their leader taught them how to lead others in certain situations. This finding was similar to Baden’s (2014) research where he found that leaders as role models could have a positive impact on the attitudes of their followers. Based on how these participants responded during the interviews, it is feasible to conclude that positive perception of ethical behavior can also 97 have positive affects on an individual’s own ethical behavior and decision-making processes. Research Question 2 Research question number two (RQ2) sought to explore the ethical climates and the leadership styles within the participant’s workplace. The goal was to see how these ethical climates and leadership styles influenced or affected the behavior of the participants when they were faced with moral or ethical dilemmas. Leadership style does contribute to ethical and moral development. Regardless of how the participant’s perceived their leader’s ethical behavior, over 60% admitted that the leadership style of their leaders made some type of contribution to their own ethical and moral development. In the literature, Giessner et al. (2015) said, “leadership can be understood as a process involving specific leader-follower dyads” (p. 3), indicating the affect of leadership and the moral and behavioral outcomes may vary from follower to follower. This was found to be true in this instance as the participants all had different experiences on how their ethical and moral behavior was developed by their leaders. Harris et al. (2014) stated, noting the leader-follower relationship “plays a significant role in shaping important follower attitudes and behaviors” (p. 314). The participants indicated that their leaders do have an impact on their ethical and moral development because they have learned in certain instances how to handle moral and ethical dilemmas they have never faced before. When their leaders were able to set positive tones in the work environment, the followers felt more comfortable learning from their leader’s leadership style. Not all participants said they would mimic their leader’s leadership style, but they could learn from how they handled certain dilemmas, 98 and apply that information to their own decision-making processes. Also, most participants believed they were already developed ethically and morally, but because there are situations and dilemmas that have surfaced within the work environment they were not familiar with, it was best to go to their leaders for advice and guidance on how to handle those dilemmas at that point. Leadership style does not contribute to ethical and moral development. These participants did not believe their leader’s leadership style contributed to their ethical and moral development at all. Most of the participants simply stated “no” with no detailed explanation, however, the ones who did go into details explained their morals, ethics, and moral development came from an outside source, such as their parents. One participant did note that exposure to the workplace helped build their ethical moral values, not just their leader specifically. This upheld findings literature put forth by Taylor and Pattie (2014) where they noted, “intuitively, it seems reasonable to presume that only some-but not all-subordinates would emulate behaviors displayed by a leader,” and different personality traits might be a reason that followers do not all react in like manner to ethical leadership (p. 596). Because each of the participants worked in different work environments, and all were raised differently, they all had their own personality. These personalities did seem to play a huge role in how their moral and ethical standards were developed. As noted earlier, most of the participants were over the age of 30 and only recently received their MBA. The majority of those over 30 was in their second or third career change and had work experiences in other environments. For example, one participant over 30 had been in the military for a certain amount of years before receiving his MBA and making a career change. He indicated that because of his 99 military background and the discipline that was taught to him, along with how he was raised by his parents, his leader had no contribution to his moral and ethical development. This finding indicated that their leaders, regardless of their perception of their ethical behavior, did not easily influence all followers. In this instance, these participants held on to their own moral and ethical standards with no contribution from their leader’s leadership styles. Participants faced ethical dilemmas and handled them on their own. This theme emerged from participants admitting that they have at some point faced some type of ethical dilemma within the workplace, and instead of going to their leader for help or advice on the dilemma, chose to handle it on their own. This was a significant theme that emerged in the study and did not agree with the literature put forth by Brown and Treviño (2014). Brown and Treviño (2014) said, “most adults are not ethically self-sufficient,” but rather rely on external guidance from their “peers and significant others for ethical guidance” (p. 588). However, according to the participants in this study, they believed they were very capable of handling ethical dilemmas on their own for various reasons. One participant simply relayed he felt more qualified than his leader because of his life experiences, where another felt that she had been around her leader long enough to know how she would respond to the dilemma, so decided to respond to the dilemma herself in a similar manner. These participants did feel self-sufficient and did not see any advantage in going to their leader for advice or guidance when they were faced with ethical dilemmas. Another participant said they he wanted to show his leader that he was capable of handling certain situations, and did not want his leader to feel that he needed to come to her for every dilemma. This particular participant said that he worked in a 100 team environment, and that they could work through certain dilemmas together as a team to come up with a solution. He believed that this allowed his leader to concentrate more on other work-related activities where as a whole; they could be more effective for their employer. This finding indicated that not all followers feel the need to go to their leader for advice or guidance when faced with ethical dilemmas. In certain situations, they feel they have the experience and ability to address the dilemma when it surfaces, or that it can be worked through on a subordinate level, giving their leader the freedom to focus on other work-related activities and management. Participants faced ethical dilemmas and did not handle them on their own. Though there were a larger number of participants involved in the study that said they handled their ethical dilemma on their own, 25% of all participants said they went to their leader for help or advice on their dilemmas. There were various reasons for the participants going to their leaders, from ensuring the proper procedure or because it was something they have never faced before. This theme did not line up with Brown and Treviño’s (2014) claim, “most adults are not ethically self-sufficient,” but rather rely on external guidance from their “peers and significant others for ethical guidance” (p. 588). This is likely because in these particular situations, no participant said that they needed to go to their leader for “ethical guidance” (Brown & Treviño, 2014, p. 588), it was likely because they felt they had no other options or because otherwise, they would have attempted to handle the dilemma on their own. These participants were simply inexperienced in the areas of the dilemmas they faced. According to their responses, they saw themselves as being self-sufficient in their position, but when faced with a scenario 101 that they have not faced before, thought it necessary to go to leadership for advice and guidance. Research Question 3 Research question three (RQ3) was designed to see how unethical leadership might negate the ethical training received by workers and if there was any affect on their moral and ethical behavior. Participants who experienced unethical leadership in school or in the workplace. Seventy-five percent of the participants involved in the study said that they have experienced some type of unethical leadership in school or in the workplace. This was important, because the way the question was designed, the researcher had to first know if any of the participants hand any experience under such conditions, to completely answer the question. The majority of the participants simply answered “yes” they have faced unethical leadership at some point in response to the interview question, but with not much substance on the type of unethical dilemmas they faced in school or the workplace. However, one participant said that while she did face unethical leadership while in school, her ethics courses allowed her to approach the situation “in an appropriate matter.” She did not give any other specifics in regards to the situation, but it was important that she pointed out that ethical training did allow her to appropriately handle her unethical dilemma. Another participant did go into some detail as he pointed out that during a lunch meeting, one of his co-workers had drunk some alcohol and was not capable of returning to work. He thought it was unethical for his leader to allow this individual to be relinquished of her work duties for that day, while all the other workers 102 had to go back to work as usual. He did admit that he though it wasn’t fair, but did not view the situation as being a major ethical issue. Because the participants did not go into any major details, it was hard for the researcher to come to any type of substantial conclusion. The significance of this theme was the majority of the participants in the study had at least faced some type of unethical leadership during their tenure at school or in the workplace. Ethical training allowed participants to hold on to their moral and ethical beliefs under unethical leadership. This theme emerged where over 91% percent of the participants fell under these conditions and said that unethical leadership did not negate their ethical training and they were able to hold on to their own moral and ethical values. Only one participant answered in a slightly different manner, but even this individual said that they were able to somewhat hold on to their moral and ethical values under unethical leadership. This theme was significant because there existed a gap in the literature where the researcher was seeking to understand how the ethical climate of an organization and various styles of leadership affected the perceptions and moral development of the followers (Ho & Lin, 2016), in contrast with the ethics training received in school and in the workplace. According to the findings in this study and the responses from the participants, unethical leadership did not negate the ethical training that participants received prior to their careers, resulting in no affect on their moral and ethical behaviors. This presents a valid argument that ethics courses and training does have some type of positive impact on individuals and how they handle moral and ethical dilemmas within the workplace. Every participant said they had some type of ethical training and that it was not negated under unethical leadership. This also points to self-sufficiency of each 103 individual when they face these dilemmas. Each individual had a choice to allow their ethics training to be negated by the unethical behavior of their leader and according to the responses from the participants; this was not the case in this particular study. Research Question 4 The final research question (RQ4) sought to examine what entry-level MBA graduates who received ethical training courses believed about negative or immoral behavior by their leaders and its influence on their own ethical and moral beliefs and behaviors. Out of four themes that emerged from this research question, only one was significant at over 68% of all participants, where three minor themes emerged. The three minor themes that emerged included: negative perception of leader’s behavior with positive influence on participant’s own behavior; negative perception of leader’s behavior with negative influence on participant’s own behavior; and no negative or positive perception of leader’s behavior with no influence on participant’s own behavior. All three of these themes put together only accounted for a little over 31% of all participants, making none of them really significant in this study. Negative perception of leader’s behavior with no influence on participant’s own ethical or moral behavior. As noted earlier, all of the participants in the study did take some type of ethical training or courses prior to their careers. Though all participants did not have a negative perception of their leader, the majority of those who did, said it had no influence on their own ethical or moral behavior within the workplace. This theme finds some validity in the importance of ethics courses as the results showed that the ethical training received was not negated by the perception of unethical behavior by the followers in regards to their leaders. The findings here did not line up with some 104 of the literature presented in Chapter 2, where scholars believed that unethical behavior by leaders may negatively influence the perceptions and behaviors of workers, negating the ethics courses and training provided in collegiate and corporate training (Boddy, 2014). The finding of this study also indicated most of the participants who had a negative perception of their leader’s ethical behavior, were able to hold to their own moral and ethical values because of the way they were raised and not because of ethical courses or organizational training. However, no participant said that a negative perception or unethical behavior by their leader negated the training they did received from ethics courses. These results were in line with a theme that emerged from research question three where ethical training allowed participants to hold on to their moral and ethical beliefs under unethical leadership. The results from both themes indicated that the negative perception of their leaders did not negate the ethical training they received outside of the classroom, nor did it negate the ethical training they received inside of the classroom. The results of this study should close a gap in the literature on understanding the follower-leader relationship and how the ethical climate through various styles of leadership may affect the perception and moral development of their followers. These findings are in contrast with any ethics training the participants received in school or in the job, where the results also indicated that under unethical or immoral leadership, the training received is not negated and individuals are able to hold on to their ethical and moral values when faced with ethical dilemmas. Despite the claim that leaders have the ability to influence the decision-making skills of their followers (Ho & Lin, 2016), this study found this is not always the case. This study did not prove or disapprove that 105 leaders do not have the ability to influence the decision-making skills of their followers, only that not all followers are easily influenced by their leaders, regardless of the ethical or unethical behaviors within the workplace. Based on how the participants responded, it seemed that throughout this study, the participants claimed that their perception of their leader’s did one of two things; allow them to respect their leader’s leadership style or not. Most participants believed they stood on the moral grounds of already knowing what is right and what is wrong, and that they are responsible for their own actions; their leaders had no influence over that. Recommendations Throughout the course of the study, all efforts were made to produce an effective and meaningful study. However, there were still some limitations encountered. In this study, all of the participants were gave their subjective views on how they perceived their leader’s behavior. Within this limitation, their responses and reactions may not easily be generalized for others under the same conditions. Their responses may represent biased or simply skewed perspectives, depending on the true nature of their relationship with their leaders. Consideration must be made that the perceptions of the participants may be the result of experiences outside of the workplace and school, beyond the effects of their leader’s leadership style and ethical training. The researcher minimized the limitations by asking the participants to reiterate what they said or what they meant, when their responses were unclear during the interviews. Also, another limitation is that not all of the participants seemed to respond directly to what they were asked by the interviewer. There were multiple occasions where certain questions from the interview had to be repeated for clarity for the participants, resulting in a “yes” or “no” response, instead of a 106 more detailed response. Another limitation was the number of participants interviewed for the study. The researcher’s goal was to interview up to twenty-five people and only sixteen participated. Even if 25 people had qualified to participate, the study still would have faced this limitation, as 25 people would not be easily generalized to all recent MBA graduated in entry-level positions across the United States. Given that this study did have these limitations amongst others that may have not been mentioned, multiple recommendations were formulated. From the results of the study, the researcher recommends further research by future scholars to study entry-level graduates who have taken ethics courses, but in another area of study in order to compare and contrast with the findings in this study. This will help to better generalize the perception of followers with regard to their leaders and how it might affect the ethical and moral development within the workplace. Also, a more concise study on how unethical leadership does not affect the ethical and moral development of followers may be beneficial for future research. This study concluded that unethical leadership does not negate ethical training, however, the majority of the participants also indicated that it had no affect on their ethical and moral development. This may or may not be true, but only an in depth study can reveal why. If entry-level workers are not easily influenced by the behavior of their leaders, then researchers may seek to understand what is the significance of taking any ethical courses at all, or why does there still exists unethical behavior in the workforce. The researcher also recommends that future researchers study how age and work experience of a follower might affect the follower-leader relationship. The majority of the participants in this study was over the age of 30, and their ethical behaviors all 107 seemed to have been shaped by their former work and ethical experiences, resulting in their leaders not having much influence on their decision-making skills. An in depth study could seek to compare graduates in different age groups and how they perceive their leader’s ethical behavior, and how it affects their own decision-making skills. If age and work experience does indeed make a difference in perception and decision-making process at an entry-level position, the research could benefit businesses in their hiring process based on the results from such a study. It may also give scholars new information in how the follower-leader relationship affects the leader, the follower, and the organization in general. Finally, when future researchers are looking to understand the follower-leader relationship and how the perception of the followers may or may not develop their ethical and moral behavior, it would be beneficial to widely expand the research across the country, including entry-level graduates from various professions. International follower-leader relationship may also be considered, though it may be a huge task in attempting to compare and contrast the similarities and differences across the many cultures that exist in the world. The majority of the participants in this study was from South Carolina, but did include Massachusetts, Maryland and Washington, D.C. However, this is only makes us a small portion of the eastern part of the U.S. and the data should be collected and compared from other regions. Finally, more than sixteen participants should be employed in future studies in order to formulate more generalizable themes from the responses of the participants. 108 Conclusions In conclusion, it can be determined that recent entry-level MBA graduates perceive their leader’s moral and ethical behavior in various ways. From the findings, 50% of the participants perceived their leader’s ethical behavior to be positive and the remaining participants perceived it to be negative, both positive and negative or no positive or negative perception at all. However, two significant findings this study was that the majority of the participants pointed out that regardless of their perception of their leader’s moral and ethical behavior, it did not negate any ethical training that they have received, nor did it affect their own decision-making processes within the workplace. The population gathered in this study may be to small to make any huge generalizations, but it does make room for other researchers to go further than this study did in analyzing the perception of more similar potential participants across various majors and businesses. 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Business Ethics Quarterly, 26(3), 426-429. doi:10.1017/beq.2016.37 117 Appendix A: Interview Guide Hello. Before we begin today, I would like to first thank you for being a part of this study. I would also like to go over the purpose of the study and your rights as participant and answer any questions you might have before we begin. After I have your written consent, I will start the audio recording so we can begin. Do you agree to proceed? [Go over the purpose of the study and the Informed Consent Form.] Do you consent to participate in this study and this interview that will be recorded audibly? [If the answer is yes, obtain the participant’s signature and proceed with the interview. If the answer is no, thank the individual for meeting and conclude the meeting.] Background questions The background questions will be used to build rapport with the participant so that s/he feels comfortable and to gather source information on their organization. Before we begin the interview on moral development and how you perceive your leader’s ethical behavior, I would like to take a few moments to learn about any ethical training or courses you may have taken prior to your new career. (The objective here is to allow the participant to get comfortable with providing me with factual information on their ethical background, then move to more specific questions that may generate larger responses in regards to the purpose of the study). 1. What school or university did you receive your MBA, and when did you graduate? 2. Have you taken any ethics courses prior to employment in your new career? 3. If so, how do you feel these classes affected your ethical or moral development? 118 4. Do you feel like these courses prepared you for the “real world” of business ethics based off what you have experienced up to this point? Perception and ethical behavior questions The next set of questions is intended to fully explore your perception of your manager/leader’s ethical behavior and how ethical climates and leadership styles contribute to your ethical and moral development. 5. Can you tell me how you perceive your leader’s ethical behavior within the workplace? 6. How does your perception of your leader affect your own ethical behavior within the workplace? 7. Do you feel that your leader’s leadership style contribute to your own ethical and moral development? 8. Since you have been employed, have you been faced with any ethical dilemmas within the workplace? If yes, did you go to your leader for advice or did you handle the dilemma on your own? 9. [If the participant did not go to their leader for help] Why did you not go to your leader for advice on the dilemma? [If the participant did go to their leader for help] Why did you go to your leader for advice on the dilemma? 10. Have you ever experienced unethical leadership in school or in the workplace? If yes, did the ethical training you received allow you to hold on to your moral and ethical beliefs? 11. How do you perceive unethical leadership and how does it affect your own moral and ethical beliefs within the workplace? 119 12. Based on your ethical training from school or other courses, do you believe that ethics courses and training is affective for the real world of business? 13. Can you briefly explain how negative or immoral behavior by your leader may influence your own decision-making skills within the workplace? 14. Is there anything you would like to add or say about ethical and moral behavior in regards to what we have already discussed? The next step in this research process is to transcribe this interview. Once completed, I will make available for your review a summary of our conversation that will include the key themes from our conversation and your stated viewpoints. Are you willing to review the summary of our conversation once it is completed? 120 Appendix B: Informed Consent Form Introduction: My name is Brandon M. Glover. I am a doctoral student at Northcentral University. I am conducting a research study on the perception of business ethics by MBA graduates within the workplace. I am completing this research as part of my doctoral degree. I invite you to participate. Activities: If you participate in this research, you will be asked to: 1. Be interviewed for a minimum of 30 minutes not exceeding 1 hour. 2. Answer a brief questionnaire that will provide some background information. Eligibility: You are eligible to participate in this research if you: 1. A recent MBA graduate (graduated within the last five years) 2. Employed at an Entry-level position or report directly to a supervisor (manager). 3. Employment is some how related to your MBA. You are not eligible to participate in this research if you: 1. Have not yet obtained your MBA. 2. Are a high-level or senior manager within your organization (entry-level supervisors and managers ok). I hope to include 25 people in this research. Risks: There are minimal risks in this study. Some possible risks include: the interview questions being a little to personal for your comfort level or you feeling uncomfortable talking in references to the ethical behavior of your leadership. 121 To decrease the impact of these risks, you can: skip or choose not to answer any question at any time and also remove yourself from the study altogether without any backlash or repercussions. Benefits: If you decide to participate, the direct benefits to you are: you will be helping business ethics researchers gather more data on the perception of business ethics and moral behavior. The potential benefits to others are: future researchers, managers and leaders may better understand how perception affects the ethical or moral behavior of others. Confidentiality: The information you provide will be kept confidential to the extent allowable by law. Some steps I will take to keep your identity confidential are: I will use psedynonyms or fake names to identify you. I will not mention the name of the organization in which you work, nor will I mention or even ask for the names of any supervisors or management. The people who will have access to your information are: myself, my dissertation chair and my dissertation committee. The Institutional Review Board may also review my research and view your information. I will secure your information with these steps: storing the data on an encrypted thumbdrive and storing it in a home safe that is equipped with a combination lock. All paper documents will be stored in this safe also. I will keep your data for 7 years. Then, I will delete electronic data and destroy paper data. Contact Information: If you have questions for me, you can contact me at: b.glover2372@email.ncu.edu or (803) 351-6853). My dissertation chair’s name is Dr. Brian Allen. He works at Northcentral University and is supervising me on the research. You can contact him at: brianallen@ncu.edu and he will schedule a call time if needed. 122 If you have questions about your rights in the research, or if a problem has occurred, or if you are injured during your participation, please contact the Institutional Review Board at: irb@ncu.edu or 1-888-327-2877 ext 8014. Voluntary Participation: Your participation is voluntary. If you decide not to participate, or if you stop participation after you start, there will be no penalty to you. You will not lose any benefit to which you are otherwise entitled. Compensation: To thank you for your willingness to participate, you will be given a $10 visa gift card after the interview. Audiotaping: I would like to use a voice recorder to record your responses. You can still participate if you do not wish to be recorded. Please sign here if I can record you: Signature: A signature indicates your understanding of this consent form. You will be given a copy of the form for your information. Participant Signature Printed Name _____________________ ____________ _____________________ Researcher Signature Printed Name _____________________ ____________ _____________________ Date Date 123 Appendix C: Ethical Perception Survey 124 125 126 Appendix D: Recruiting Email to recent MBA graduates Brandon M. Glover Doctoral Candidate Northcentral University 10000 E. University Drive Prescott Valley, AZ 86314 February 21, 2017 Hello, I am a Doctoral Candidate at Northcentral University’s School of Business and Technology and I am conducting research to explore how ethical climates and leadership styles contribute to the ethical and moral development of entry-level MBA graduates. Your MBA graduate group was identified through a search via Facebook or LinkedIn or both. If you and any of the members of your group believe that ethical and moral behavior within the workplace is declining, and would like to better understand the perception of ethics by those entering in the workplace, I am earnestly requesting your participation in this study. As a recent MBA graduate, the information that you and your group members can provide may lead to a better understanding of how the ethical behavior of leaders’ influence the ethical behavior of followers in both positive and negative ways. You and your group members’ participation in this research will be greatly appreciated, as the information given will be a substantial benefit to the purpose of the study. If you and any of your members agree to participate in the research, additional instructions will be sent on how the interview will be conducted and the series of questions on your experiences with your leaders in regards to ethics and perception. In addition, you and your group members who participate will be asked to complete a survey, asking some brief background information regarding ethics courses and training. A survey form will be sent to you to gain your permission to survey your group members about these topics. The survey is anonymous and with multiple choice questions. I believe that the research results will provide valuable information to you, your group members, and many organizations and businesses. To be respectful of your time, a simple yes response is all that is required to start the process. As a bonus, participants will be given a $10 visa gift card after their interview. Thank you in advance for you participation in this research and the valuable contribution you and your group members will make. Respectfully, 127 Brandon M. Glover
DOCTORAL STUDENT EXPERIENCE HANDBOOK Introduction This guide (and the documents referenced within) is a resource outlining major elements of the Northcentral University dissertation process. Candidates and faculty members involved in research and dissertation courses are strongly encouraged to read this Doctoral Student Experience (DSE) Guide and associated documents (rubric and templates) before beginning work on a dissertation. The terms Dissertation Chair and Chair are used interchangeably within this document. If you are a candidate and have questions not answered in this DSE Guide or in any of the supplemental materials, please speak to your Dissertation Chair (academic issues) or Academic and Finance Advisor (program or degree issues). Note: Candidates are responsible for staying current with changes to their program. Check with your Academic and Finance Advisor if you have questions about your program of study. If you are a faculty member and have questions not answered in this DSE Guide or in the supplemental materials, please reach out to the Assistant/Associate Dean of faculty or Department Chair in your school. Doctoral Candidates are doctoral students who have successfully passed their Comprehensive Examinations/ePortfolio/Prospectus course or end of program coursework as denoted in their Program curriculum outlined in the catalog. Candidates are encouraged to identify a researchable topic and their preliminary methods approach by the completion of program coursework. This process should be completed during the last course in a program’s coursework. Based upon the identified topic and methodology, an appropriate Dissertation Chair and Subject Matter Expert (SME) will be aligned with the needs of each individual candidate and assigned accordingly. 2 Section 1: The Dissertation Process The dissertation is the capstone accomplishment in the doctoral candidate’s degree program. The PhD dissertation has a research focus, and the applied degree (e.g. DBA and EdD) is practice based. The doctoral dissertation is a substantial, scholarly work conducted independently by a candidate under the guidance of faculty members comprising the candidate’s Doctoral Dissertation Committee. Committee roles include the Dissertation Chair, Subject Matter Expert (SME), and the Academic Reader (AR). More information on the Committee roles and responsibilities can be found in Section 2 of this guide. In the dissertation process, the candidate:      Identifies a researchable problem substantiated through evidence. Summarizes, analyzes, and integrates recent (generally five years or less) scholarly literature and research relevant to the topic under study, and writes chapters 1, 2 and 3 of the Dissertation Proposal (DP) (Ultimately) Presents original research in an area related to their program and specialization. (While PhD dissertations contribute to the body of research, the applied doctorate dissertations typically contribute to practice). Receives NCU IRB approval to conduct research, collects and analyzes the data and reports the research findings in chapters 4 and 5 of the Dissertation Manuscript (DM). The final manuscript is comprised of five Chapters:  Chapter 1: Introduces the problem and the evidence substantiating the existence of the problem; outlines an initial review of literature on the study topic; articulates the purpose of the study; presents the research questions and theoretical foundation (PhD) or conceptual framework (EdD) and provides an overview of the research methods to be employed.  Chapter 2: Provides a detailed analysis of the theory/conceptual framework used in the study and a detailed synthesis of the available, current, scholarly literature on all aspects of the topic, including all points of view.  Chapter 3: Provides substantiation for the choice of methods and includes details on the planned research approach, design, and analysis.  Chapter 4: Presents the study findings.  Chapter 5: Summarizes the research study and presents the research implications and suggestions for future research. The Dissertation process is generally divided into three broad stages: preparation and approval of the Dissertation Proposal (DP) which includes Chapters 1, 2, and 3; NCU IRB approval to conduct research and conducting the study’s research; and preparation and approval of the final Dissertation Manuscript (DM) which includes all elements of the DP, with the addition of Chapters 4 and 5 to complete the manuscript including the dissertation defense. The Dissertation process is arduous and iterative. As candidates proceed through the dissertation process, they will be required to understand and apply faculty/committee feedback. Successful engagement with faculty requires a high level of conceptual understanding. Dissertation Committee Members review and substantively evaluate work submitted by candidates. Regular, iterative reviews of dissertation sections and drafts are a common - and important - practice in the process. 3 Dissertation Course Overview After doctoral candidates have successfully passed the last course in their scheduled program coursework (e.g. Comprehensive Examination, ePortfolio, Prospectus), they will be enrolled into the dissertation course sequence. There are specific deliverables required for each course. Each course deliverable represents a portion of the overall dissertation process. In order to progress successfully into a subsequent dissertation course, each final deliverable must be completed and meet the minimum standards on the rubric assessment as completed by the committee. Remember, scholarly research is iterative and non-linear (however uncomfortable this may be while you are going through the process). Making a change in a later version to correct an issue in a previous version may reveal new issues that need to be addressed in the subsequently, approved, version. Ultimately, Northcentral University wants all candidates to succeed, but we also have to ensure that our terminal outcomes meet quality standards. To that end, below are the steps of the Dissertation review process designed to facilitate candidate progress. 1. Northcentral University’s Chairs and SMEs provide constructive feedback prior to the DP stage. This is to ensure the candidate has a feasible and realistic plan to develop a wellconceived, substantive, quality dissertation. Individual chapter reviews, throughout the development of the DP, serve to assess if the topic is appropriate and the planned research is sound and practical within the scope of a doctoral program. The Dissertation Proposal ensures the problem is substantiated with evidence, the research methods and design are in alignment and serve the purpose and address the problem of the topic under study. In addition, the proposal allows the candidate to complete an exhaustive review of current scholarly literature addressing all points of view on the topic under study including the theory or conceptual framework used to support the study. 2. The DP must meet the minimum standards on all rubric criteria assessed by the Dissertation Chair and Subject Matter Expert to proceed to the next course in the dissertation sequence and begin the NCU Institutional Review Board (IRB) application process. 3. Upon final approval of the DP, the candidate applies to NCU IRB for approval to collect data. No data may be collected until IRB approval is obtained. Failure to observe this rule may result in dismissal from Northcentral University. 4. Following IRB approval, the candidate conducts his/her research and writes the DM in the required manner. The DM is approved by the Dissertation Chair and SME. The approved DM is then sent to the AR for review against the checklist, which may result in the candidate having to make changes for improvement. 5. Upon final approval of the DM, the Oral Defense is scheduled. To pass this oral examination, the candidate must be able to explain and justify what was accomplished by the dissertation research. Dissertation Course Sequence The dissertation courses have been structured into discrete courses with specific deliverables at the end of each course. Additionally, each course requires weekly engagement between the candidate and the Chair through weekly assignment submissions, similar to the current coursework requirements. These weekly submissions are scaffolded to build the entire deliverable to meet the minimum standards of the evaluation process by the end of the course. A few times throughout each course, candidates submit assignments to the Chair and SME, as noted in the syllabus, to receive feedback on these components based on the rubric criterion. 4 The dissertation sequence of courses has been designed to assist the candidate in scaffolding the development of the individual chapters of the dissertation in a timely and scholarly approach. There are four 12-week courses. The deliverables to be evaluated at the end of each course include: Dissertation course DIS-9901A – Chapter 1 Dissertation course DIS-9902A – Chapter 2, Chapter 3, and final DP Dissertation course DIS-9903A – IRB approval, and final Study Closure Form after data are collected Dissertation course DIS-9904A – Chapter 4, Chapter 5, final DM, and Oral Defense Candidates not meeting the minimum standards on the required deliverable at the end of the 12-week course will be assigned to an 8-week supplemental course. The 8-week supplemental course provides additional committee collaboration and support, University support, and a higher ‘hands-on’ process to expedite the candidate through the areas needing to be addressed in meeting the minimum standards for each deliverable. These supplemental courses also allow for candidates to continue to work on subsequent chapters and deliverables in advance of starting the next 12-week course once the minimum standards have been met on the current course requirements. If the candidate does not meet the minimum criteria of the required course deliverable within the 8week supplemental course, the candidate is allowed to retake the 8-week supplemental course two more times. The third retake of the original dissertation sequence course is the final opportunity for the candidate to meet the minimum standards for the required course deliverable. Not meeting minimum standards on all rubric criteria for an end of course deliverable indicates candidates must progress to a supplemental course to work on the criterion. As a reminder, the iterative process in developing a dissertation may require the candidate go back and revise previously approved chapters before a final DP or DM can be approved. This must be reiterated to the candidate throughout the development of their dissertation. In the following diagram, the dissertation course sequences are displayed. Each course sequence block has the required deliverable to meet minimum standards displayed to progress into the next course sequence block. The table below illustrates the course sequence: 5 Candidates must complete a minimum of 12-credit hours of dissertation coursework with a grade of “B” or better to satisfy degree program requirements. Students may be eligible to overlap the last 3-credit hours in order to meet the minimum required dissertation credit hours after they have achieved an approved Chapter 5. Please see the catalog for additional information on specific degree program requirements. Candidates should contact their Academic and Finance Advisor if they need additional assistance Dissertation 12-week course learning outcomes and descriptions Below are the course descriptions and learning outcomes for the four 12-week courses. DIS-9901A Components of the Dissertation Students in this course will be required to complete Chapter 1 of their dissertation proposal including a review of literature with substantiating evidence of the problem, the research purpose and research questions, the intended methodological design and approach, and the significance of the study. A completed, committee approved (against the minimum rubric standards) Chapter 1 is required to pass this course successfully. Students who do not receive approval of Chapter 1 to minimum standards will be able to take up to three supplemental 8week courses to finalize and gain approval of Chapter 1. Course Learning Outcomes 1. Justify a research-worthy topic with current, relevant literature related to professional interests and chosen Doctoral degree. 2. Develop an evidence-based problem statement in need of further research, a related purpose statement, research question(s), or applicable hypotheses. 3. Formulate a research methodology and corresponding design to accurately address the study’s research question(s) or applicable hypotheses. 4. Integrate a theoretical foundation/conceptual framework with which to ground the study. DIS-9902A The Dissertation Proposal Students in this course will be required to work on completing Chapters 1-3 of their dissertation proposal and receive committee approval for the Dissertation Proposal (DP) in order to pass the class. Chapter 2 consists of the literature review. Chapter 3 covers the research methodology method and design and to includes population, sample, measurement instruments, data collection and analysis, limitations, and ethical considerations. In this course, a completed, committee-approved Chapters 2 and 3 are required and, by the end of the course, a final approved dissertation proposal (against the minimum rubric standards). Students who do not receive approval of the dissertation proposal will be able to take up to three supplemental 8week courses to finalize and gain approval of these requirements. Course Learning Outcomes 1. Formulate an exhaustive, balanced, objective review of relevant and current literature relative to the discipline under study which will result in an approved Chapter 2. 2. Demonstrate mastery of the current research base relevant to the discipline under study. 3. Substantiate through current and seminal literature the relevant 6 theoretical foundation/conceptual framework used to frame the study. 4. Formulate a detailed research design and methodology substantiating the alignment of the problem statement, purpose, research questions and/or hypotheses relevant to the discipline under study which will result in an approved Chapter 3. 5. Assemble all ancillary materials, appendices and references necessary to complete their dissertation proposal. DIS-9903A Institutional Review Board (IRB) and Data Collection Students in this course will be required to prepare, submit, and obtain approval of their IRB application, collect data, and submit a final study closure form to the IRB. Students still in data collection at the end of the 12-week course will be able to take up to three supplemental 8-week courses to complete data collection and file an IRB study closure form. Course Learning Outcomes 1. Generate an IRB Application meeting federal requirements for ethical treatment of human subjects and all NCU IRB Guidelines. 2. Develop materials and procedures to meet all levels of required site permissions, including non-NCU IRB approval, and DoD, military, VA, or international approvals, as required. 3. Create appropriate materials and procedures for the ethical recruitment of participants, informed consent, data collection, de-identified data analysis, and secure data storage including reporting any modification or anomaly discovered throughout all phases of the research project until it has been closed with the IRB. 4. Conduct data collection upon approval of IRB Application. DIS-9904A The Dissertation Manuscript and Defense In this dissertation course students work on completing Chapters 4 and 5 and the final dissertation manuscript. Specifically, students will complete their data analysis, prepare their study results, and present their findings in an oral defense and a completed manuscript. A completed, committee approved (against the minimum rubric standards) Dissertation Manuscript and successful Oral Defense are required to complete the course and graduate. Students who do not receive approval for either or both their dissertation manuscript or defense can take up to three supplemental 8-week courses to finalize and gain approval of either or both items as needed. Course Learning Outcomes 1. Present study results aligned to the research design including the research questions and/or hypotheses, ensuring aligned with the doctoral degree discipline. 2. Compile study implications, recommendations, and conclusions based on study findings. 3. Generate a final Dissertation Manuscript consisting of all requisite components and revisions. 4. Synthesize research study and design, findings, recommendations, and conclusions in oral defense of their completed study. An overview of the four 12-week courses and weekly expectations can be found in the individual course syllabi. 7 Dissertation 8-week course learning outcomes and descriptions An overview of the eight 8-week courses and weekly expectations can be found in the individual course syllabi. DIS-9901B Components of the Dissertation Supplemental Students enrolled in this course are required to complete Chapter 1 of their dissertation proposal, which includes the research problem to be investigated, its background the study’s purpose, and supporting evidence for the study’s significance. A completed, committeeapproved (against the minimum rubric standards) Chapter 1 is required before student may advance to DIS-9902A. Students who do not receive approval of Chapter 1 will take DIS-9901C to finalize and gain approval of Chapter 1. Course Learning Outcomes 1. Justify a research-worthy topic with current, relevant literature related to professional interests and chosen Doctoral degree. 2. Develop an evidence-based problem statement in need of further research, a related purpose statement, research question(s), or applicable hypotheses. 3. Formulate a research methodology and corresponding design to accurately address the study’s research question(s) or applicable hypotheses. 4. Integrate a theoretical foundation/conceptual framework with which to ground the study. DIS-9902B The Dissertation Proposal Supplemental Students enrolled in this course will be required to complete Chapters 1-3 of their dissertation proposal and receive committee approval for the Dissertation Proposal (DP). Chapter 2 consists of the literature review. Chapter 3 covers the research methodology to include population, sample, measurement instruments, data collection and analysis, limitations, and ethical considerations. In this course, a completed, committee approved Chapters 2 and 3 are required in addition to a completed, approved dissertation proposal (against the minimum rubric standards) before students may move to DIS-9903A. Students who do not receive approval of the dissertation proposal will be enrolled in DIS-9902C to finalize and gain approval of these requirements. Course Learning Outcomes 1. Formulate an exhaustive, balanced, objective review of relevant and current literature relative to the discipline under study which will result in an approved Chapter 2. 2. Demonstrate mastery of the current research base relevant to the discipline under study. 3. Substantiate through current and seminal literature the relevant theoretical foundation/conceptual framework used to frame the study. 4. Formulate a detailed research design and methodology substantiating the alignment of the problem statement, purpose, research questions and/or hypotheses relevant to the discipline under study which will result in an approved Chapter 3. 5. Assemble all ancillary materials, appendices and references necessary to 8 complete their dissertation proposal. DIS-9903B Institutional Review Board (IRB) and Data Collection Supplemental Students enrolled in this course will be required to prepare, submit, and obtain approval of their IRB application, collect data, and submit a final study closure form to the IRB. They then will be enrolled in DIS-9904A. Students still in data collection at the end of this course will be enrolled in DIS-9903C to complete data collection and file a study closure form. Course Learning Outcomes: 1. Generate an IRB Application meeting federal requirements for ethical treatment of human subjects and all NCU IRB Guidelines. 2. Develop materials and procedures to meet all levels of required site permissions, including non-NCU IRB approval, and DoD, military, VA, or international approvals, as required. 3. Create appropriate materials and procedures for the ethical recruitment of participants, informed consent, data collection, de-identified data analysis, and secure data storage including reporting any modification or anomaly discovered throughout all phases of the research project until it has been closed with the IRB. 4. Conduct data collection upon approval of IRB Application. 5. Synthesize collected data to begin analyzing results. DIS-9904B The Dissertation Manuscript and Defense Supplemental Students enrolled in this course will work on completing Chapters 4 and 5 and the final dissertation manuscript. Specifically, students will complete their data analysis, prepare their study results, and present their findings in an oral defense and a completed manuscript. A completed, committee approved (against the minimum rubric standards) Dissertation Manuscript and Defense are required to complete the course and graduate. Students who do not receive approval for either or both of their dissertation manuscript or defense will be enrolled in DIS-9904C to finalize and gain approval of either or both items as needed. Course Learning Outcomes 1. Present study results aligned to the research design including the research questions and/or hypotheses, ensuring aligned with the doctoral degree discipline. 2. Compile study implications, recommendations, and conclusions based on study findings. 3. Generate a final Dissertation Manuscript consisting of all requisite components and revisions. 4. Synthesize research study and design, findings, recommendations, and conclusions in oral defense of their completed study. DIS-9901C Components of the Dissertation Supplemental Students enrolled in this course are required to complete Chapter 1 of their dissertation proposal, which includes the research problem to be investigated, its background the study’s purpose, and supporting evidence for the study’s significance. A completed, committeeapproved (against the minimum rubric standards) Chapter 1 is required before student may advance to DIS-9902A. Students who do not receive approval of Chapter 1 will take DIS-9901D to finalize and gain approval of Chapter 1. Course Learning Outcomes 9 1. Justify a research-worthy topic with current, relevant literature related to professional interests and chosen Doctoral degree. 2. Develop an evidence-based problem statement in need of further research, a related purpose statement, research question(s), or applicable hypotheses. 3. Formulate a research methodology and corresponding design to accurately address the study’s research question(s) or applicable hypotheses. 4. Integrate a theoretical foundation/conceptual framework with which to ground the study. DIS-9902C The Dissertation Proposal Supplemental Students enrolled in this course will be required to complete Chapters 1-3 of their dissertation proposal and receive committee approval for the Dissertation Proposal (DP). Chapter 2 consists of the literature review. Chapter 3 covers the research methodology to include population, sample, measurement instruments, data collection and analysis, limitations, and ethical considerations. In this course, a completed, committee approved Chapters 2 and 3 are required in addition to a completed, approved dissertation proposal (against the minimum rubric standards) before students may move to DIS-9903A. Students who do not receive approval of the dissertation proposal will be enrolled in DIS9902D to finalize and gain approval of these requirements. Course Learning Outcomes 1. Formulate an exhaustive, balanced, objective review of relevant and current literature relative to the discipline under study which will result in an approved Chapter 2. 2. Demonstrate mastery of the current research base relevant to the discipline under study. 3. Substantiate through current and seminal literature the relevant theoretical foundation/conceptual framework used to frame the study. 4. Formulate a detailed research design and methodology substantiating the alignment of the problem statement, purpose, research questions and/or hypotheses relevant to the discipline under study which will result in an approved Chapter 3. 5. Assemble all ancillary materials, appendices and references necessary to complete their dissertation proposal. DIS-9903C Institutional Review Board (IRB) and Data Collection Supplemental Students enrolled in this course will be required to prepare, submit, and obtain approval of their IRB application, collect data, and submit a final study closure form to the IRB. They then will be enrolled in DIS-9904A. Students still in data collection at the end of this course will be enrolled in DIS-9903D to complete data collection and file a study closure form. Course Learning Outcomes 1. Generate an IRB Application meeting federal requirements for ethical treatment of human subjects andall NCU IRB Guidelines. 2. Develop materials and procedures to meet all levels of required site permissions, including non-NCU IRB approval, and DoD, military, VA, or international 10 approvals, as required. 3. Create appropriate materials and procedures for the ethical recruitment of participants, informed consent, data collection, de-identified data analysis, and secure data storage including reporting any modification or anomaly discovered throughout all phases of the research project until it has been closed with the IRB. 4. Conduct data collection upon approval of IRB Application. 5. Synthesize collected data to begin analyzing results. DIS-9904C The Dissertation Manuscript and Defense Supplemental Students enrolled in this course will work on completing Chapters 4 and 5 and the final dissertation manuscript. Specifically, students will complete their data analysis, prepare their study results, and present their findings in an oral defense and a completed manuscript. A completed, committee approved (against the minimum rubric standards) Dissertation Manuscript and Defense are required to complete the course and graduate. Students who do not receive approval for either or both of their dissertation manuscript or defense will be enrolled in DIS-9904D to finalize and gain approval of either or both items as needed. Course Learning Outcomes 1. Present study results aligned to the research design including the research questions and/or hypothees, ensuring aligned with the doctoral degree discipline. 2. Compile study implications, recommendations, and conclusions based on study findings. 3. Generate a final Dissertation Manuscript consisting of all requisite components and revisions. 4. Synthesize research study and design, findings, recommendations, and conclusions in oral defense of their completed study. DIS-9901D Components of the Dissertation Supplemental Students enrolled in this course are required to complete Chapter 1 of their dissertation proposal, which includes the research problem to be investigated, its background the study’s purpose, and supporting evidence for the study’s significance. A completed, committeeapproved (against the minimum rubric standards) Chapter 1 is required before student may advance to DIS-9902A. Students still in data collection at the end of this course will be removed from the program. Course Learning Outcomes 1. Justify a research-worthy topic with current, relevant literature related to professional interests and chosen Doctoral degree. 2. Develop an evidence-based problem statement in need of further research, a related purpose statement, research question(s), or applicable hypotheses. 3. Formulate a research methodology and corresponding design to accurately address the study’s research question(s) or applicable hypotheses. 4. Integrate a theoretical foundation/conceptual framework with which to ground the study. DIS-9902D The Dissertation Proposal Supplemental Students enrolled in this course will be required to complete Chapters 1-3 of their dissertation proposal and receive committee approval for the Dissertation Proposal (DP). Chapter 2 consists 11 of the literature review. Chapter 3 covers the research methodology to include population, sample, measurement instruments, data collection and analysis, limitations, and ethical considerations. In this course, a completed, committee approved Chapters 2 and 3 are required in addition to a completed, approved dissertation proposal (against the minimum rubric standards) before students may move to DIS-9903A. Students still in data collection at the end of this course will be removed from the program. Course Learning Outcomes 1. Formulate an exhaustive, balanced, objective review of relevant and current literature relative to the discipline under study which will result in an approved Chapter 2. 2. Demonstrate mastery of the current research base relevant to the discipline under study. 3. Substantiate through current and seminal literature the relevant theoretical foundation/conceptual framework used to frame the study. 4. Formulate a detailed research design and methodology substantiating the alignment of the problem statement, purpose, research questions and/or hypotheses relevant to the discipline under study which will result in an approved Chapter 3. 5. Assemble all ancillary materials, appendices and references necessary to complete their dissertation proposal. DIS-9903D Institutional Review Board (IRB) and Data Collection Supplemental Students enrolled in this course will be required to prepare, submit, and obtain approval of their IRB application, collect data, and submit a final study closure form to the IRB. They then will be enrolled in DIS-9904A. Students still in data collection at the end of this course will be removed from the program. Course Learning Outcomes: 1. Generate an IRB Application meeting federal requirements for ethical treatment of human subjects and all NCU IRB Guidelines. 2. Develop materials and procedures to meet all levels of required site permissions, including non-NCU IRB approval, and DoD, military, VA, or international approvals, as required. 3. Create appropriate materials and procedures for the ethical recruitment of participants, informed consent, data collection, de-identified data analysis, and secure data storage including reporting any modification or anomaly discovered throughout all phases of the research project until it has been closed with the IRB. 4. Conduct data collection upon approval of IRB Application. 5. Synthesize collected data to begin analyzing results. DIS-9904D The Dissertation Manuscript and Defense Supplemental Students enrolled in this course will work on completing Chapters 4 and 5 and the final dissertation manuscript. Specifically, students will complete their data analysis, prepare their study results, and present their findings in an oral defense and a completed manuscript. A completed, committee approved (against the minimum rubric standards) Dissertation Manuscript and Defense are required to complete the course and graduate. Students still in data 12 collection at the end of this course will be removed from the program. Course Learning Outcomes 1. Present study results aligned to the research design including the research questions and/or hypotheses, ensuring aligned with the doctoral degree discipline. 2. Compile study implications, recommendations, and conclusions based on study findings. 3. Generate a final Dissertation Manuscript consisting of all requisite components and revisions. 4. Synthesize research study and design, findings, recommendations, and conclusions in oral defense of their completed study. Dissertation Template A template, formatted to APA standards, is available for use by candidates. Differentiation is noted throughout the document for completing an applied (EdD and DBA) or research (PhD) dissertation. Candidates should only use this template to complete their dissertation course deliverables. Remember, Candidates are to remove the explanation sections of the template when developing their work. DSE Dissertation Grading Candidates must submit something every week in their dissertation course for their Chair to review. Each course contains Committee reviews for candidates to submit the assigned deliverable. Multiple times throughout the courses this deliverable will be reviewed by the Chair and SME against the stated rubric criteria in the Doctoral Record. The final submitted deliverable(s) for the course must receive the minimum passing score of ‘meets’ for all rubric criteria to receive a passing course grade (A or B). If any one of the criteria reflects ‘does not meet’, the candidate receives a ‘C’ for the course and will be enrolled in the associated 8-week supplemental course. Students who have not made any academic progress as determined by faculty and have not made any Doctoral Record submissions to grade using the rubric may be awarded an ‘F’ as the final grade. Students receiving an ‘F’ would be enrolled in the associated 8-week supplemental course. The Chair will make the determination between A or B by using an additional Final Grade rubric in the dissertation course that considers items such as communication with Chair and response to feedback, weekly coursework performance and progress, and scholarly writing. The supplemental course allows the candidate additional time to complete the expected deliverable(s) to meet minimum rubric criteria for the dissertation course. In order to receive a passing score in the supplemental course the candidate must receive the minimum acceptable criteria on the rubric, assessed by the Chair and SME. If the candidate receives a ‘C’ or ‘F’ in the first supplemental course (DIS-990xB), they will be allowed to take supplemental courses (DIS-990xC & D) to satisfactorily complete the course deliverable(s). Any candidate who receives ‘C’ or ‘F’ grades in all supplemental courses (DIS-990xB, C, &D) will not be eligible to enroll in additional courses and will be subject to dismissal from the University. Dissertation Deliverable Rubric A rubric has been developed for all individual Chapters (1-5), the Dissertation Proposal (DP), and the Dissertation Manuscript (DM). Course grades will be determined by the rubric for DIS-9901X (Chapter 1 meeting minimum criteria), DIS-9902X (Dissertation Proposal meeting minimum criteria), and DIS9904X (Dissertation Manuscript meeting minimum criteria). Grading will be completed by the Chair 13 and the Subject Matter Expert (SME) and the final scores will be reconciled to determine the final grade. The individual Chapter rubrics are in the courses and in the Doctoral Record. The Doctoral Record will be used as the evaluation tool for assessing student work by the Committee. The final DP and DM will be read by the Academic Reader (AR) and comments and suggestions from the AR should be incorporated into the final papers under the direction of the Chair. The rubrics are to be used to evaluate the work completed for Dissertation Manuscript against institutional expectation criteria. Candidates should use the rubrics to self-evaluate their work before submitting to their Chair and Committee. All criteria must be designated as ‘Meets’ in order for a successful grade to be achieved. The nature of the dissertation may require revisions to previously approved Chapters to better align with changes made in subsequent Chapters. The five Chapters (1, 2, 3, 4, and 5) will not be considered as final until a Committee approved (meeting minimum criteria) Dissertation Manuscript has been completed. The Dissertation Proposal and the Dissertation Manuscript will be automatically submitted to TurnItIn in the Doctoral Record for originality before the Manuscript can be considered final. Target originality should be below 15% (excluding references, TOC, and template criteria). The final manuscript will be read by a full-time faculty member (Academic Reader - AR) for methods and findings quality, rigor, and alignment to institutional guidelines. Changes may be requested from the AR to improve upon key manuscript components. Be sure to visit the Dissertation Center for the current rubrics. Using the Deliverable Rubric Each rubric has specific criteria outlined based on the submitted deliverable. There are criteria are weighted ‘Meets’ and ‘Does Not Meet’. Students are graded (for A or B grades) based only on the criterion allowing the scoring of a ‘Meets’ on all rubric criteria for final course deliverable. The grading scale includes an ‘A’, ‘B’, or ‘C’, or F. Any reconciled rubric scoring a single ‘Does Not Meet’ and the deliverable will be considered as not passing and the course grade must be marked as a ‘C’ grade and the student will be enrolled in the 8-week supplemental course DIS-990XB/C/D. If the deliverable has been scored with a ‘Meets’ on all rubric criteria, the course grade will be marked as an ‘A’ or ‘B’ and the student will move on to the next DIS-990XA course in the dissertation sequence. If no progress on any of the required components has been demonstrated or communicated, the course will be graded as ‘F’ and the student will be enrolled in the next in the 8-week supplemental course DIS-990XB/C/D. Final course grades are not to be submitted before the last day of the course and must be submitted by COB MST on the Thursday following the course completion. The University awards letter grades in recognition for academic performance in each course. Grade 14 points are assigned to each academic performance grade, with the exception of S, U, R, and RD grades and are used to calculate a Grade Point Average (GPA) for each candidate. Submission Timeframes for Faculty Feedback The dissertation course structure requires candidates to turn in an assignment every week. Assignment deadlines are Sunday at midnight, Mountain Standard Time. Candidates will upload their work in the Dropbox of each week. Chairs will access the paper and download it from the Dropbox. Chairs will provide feedback within the document and upload it in the Dropbox within the stated guidelines for feedback timeframes. Candidates failing to submit assignments weekly will be identified as ‘at-risk’ (missing two weeks in a row) by the Chair which may result in outreach by the Academic and Finance Advisor, School designee, or other University representative. Course, institutional, or other consequences may be instituted for candidates’ failure to follow academic submission and course requirements. Chairs have 7 calendar days to provide feedback to candidates on weekly submissions. Chairs and Subject Matter Experts (SMEs) have 7 calendar days to return feedback on work submitted in the Doctoral Record. The exceptions to this rule include full Chapter 2 submissions in the Doctoral Record, the submission of the Dissertation Proposal in the Doctoral Record, and the Dissertation Manuscript in the Doctoral Record all which allow a 14-day turnaround time for feedback in the Doctoral Record. Final course grades should be submitted by the Thursday following the last day of the course in order to allow for continuous enrollments for students. Chairs should know (for the most part) how a student is performing based on previous submissions in the Doctoral Record and from feedback from the SME and should submit the appropriate grade. Assignments submitted after the course end date will not be included in the end of course grade. Doctoral Record turnaround times (calendar – midnight Sunday submission MST*) Chapter 1 (7 days) Chapter 2 (14 days) Chapter 3 (7 days) Dissertation Proposal Draft (14 days) Final Dissertation Proposal AR (14 days) IRB Approval Form (7 days) IRB Closure /NHSR Closure (7 days) Chapter 4 (7 days) Chapter 5 (7 days) Dissertation Manuscript Draft (14 days) Dissertation Oral Defense (7 days) Final Dissertation Manuscript AR (14 days) Doctoral Record Submissions Twice in every course, all work completed throughout the dissertation courses should be submitted to the Doctoral Record for review by the Chair and the SME. The Chair and the SME will use the rubric to evaluate each component of the submitted document. The completed rubric and edited document will be submitted back into the Doctoral Record by the Chair and SME. The Chair will then reconcile the scores. All criteria on the rubric must be marked as ‘Meets’ by the Committee in order for the candidate to move onto the next dissertation course in the sequence following completion of their 15 current course. The final draft of the DP and DM will be submitted to the AR by the Chair to be reviewed against a checklist of University criteria in the Doctoral Record once the document has passed all the rubric criteria by the Chair and the SME. The suggested Doctoral Record submission timeframes are noted throughout the syllabi of the courses. Additional submissions can occur if the candidate completes a deliverable, and the Chair believes the deliverable is ready for evaluation by the Committee. A student should submit a course deliverable no later than week 5 of a 12-week course and week 2 of an 8-week course in order to obtain feedback against the rubric criteria by all Committee Members. The rubric has been developed for all Chapters, the Proposal, the Manuscript, and front and back matter. Candidates are reminded while their submitted documents are being evaluated they are expected to continue conducting appropriate activities to advance their research. Resources and next steps are outlined in all the doctoral courses. Candidates are expected to continue working on subsequent Chapter components advancing their work towards a timely completion. Doctoral research is an ongoing, iterative learning process requiring extensive and continual effort. All available information for progressing through the doctoral dissertation courses are in the dissertation courses, allowing the candidate to work ahead while the Committee works on evaluating the current paper. 16 Section 2: The Dissertation Committee Dissertation Committee Composition The Dissertation Committee provides a candidate with the direction, guidance, support, and feedback needed to complete all phases and chapters of the dissertation. The Dissertation Committee consists of three Northcentral University faculty members. The Dissertation Chair has significant expertise in research processes, procedures, methodology, and proficiency in guiding the candidate through the dissertation process. The second Committee member serves in the role of Subject Matter Expert (SME) bringing expertise in the field of study while also supporting the candidate in any methods approach. The Academic Reader (AR) has expertise in research methods and familiarity with the field of study and ensures the dissertation aligns to University standards of academic integrity, rigor, research methods, and quality. This model allows continued support to candidates throughout the development of their dissertation components, even during times of Committee time off. Chair Subject Matter Expert (SME) Academic Reader (AR) The Chair works with students in each of your Dissertation Courses and guides students toward completion, serving as a mentor and consult. The Dissertation Chair is available via phone calls, Skype conversations, and emails. The SME reviews work that students submit to the Doctoral Record (at least twice per course). The SME uses the rubric to evaluate work and provides feedback to assist students on their dissertation journey. The Academic Reader reviews the Dissertation Proposal (DP) and Dissertation Manuscript (DM) when submitted to the Doctoral Record. The AR uses the rubric to evaluate student work and provides feedback to assist students on their dissertation journey. The DSE sequence of courses requires the Chair and the SME to apply their methodological expertise to every course to support the candidate through their doctoral journey. The AR will perform a review, at transitional points and through consultation as needed, ensuring compliance to both methodological rigor and University scholarship standards, allowing a more streamlined and systematic approach to the completion of the dissertation. The required qualifications of the Dissertation Chair, SME, and AR are as follows: 17 Chair of Dissertation Committee     Member of Dissertation Committee (Subject Matter Expert - SME)     Academic Reader (AR) Expertise in research processes, methods, and approaches and proficiency in guiding the dissertation process Successful completion of a dissertation and terminal degree from a regionally accredited institution Demonstrated record of research and doctoral level teaching Publications in peer reviewed or scholarly journals, books, edited, or otherwise Academic preparation and proficiency within the field of study for their assigned candidates Solid understanding in research processes, methodologies, and experience in supporting candidates through completion of their dissertation Successful completion of a dissertation and terminal degree from a regionally accredited institution Demonstrated record of research and/or doctoral level teaching and/or practical experience appropriate to the program and degree specialization  Full-time faculty member  Expertise with the methodology for their assigned candidates  Strong understanding of University research and dissertation   guidelines, academic rigor requirements, and quality research processes Successful completion of a dissertation and terminal degree from a regionally accredited institution Demonstrated record of research and/or doctoral level teaching and/or practical experience appropriate to the program and degree specialization Selection of Committee Members All candidates who are enrolling in their first dissertation (DIS) course will be assigned a Dissertation Chair, a SME, and AR. The selection of a SME will depend on faculty knowledge, availability, and topic experience in the candidates’ field of study. All committee members will be assigned by the disciplinary School. Committee Responsibilities The ultimate responsibility of the Chair of the Dissertation Committee is to determine whether the candidate has demonstrated the competencies required. The Chair is supported by the SME and AR in helping the candidate to complete their dissertation. Each member has a specific role in the dissertation committee, contributing to the success of the candidate. The Committee Members support the candidate through the dissertation process. The SME engages and supports both the Chair and the candidate throughout each course in the dissertation sequence by serving as the subject matter expert as well as an additional resource in verifying proper use of research methods, design, and procedures. The AR provides a quality check for key deliverables (the dissertation proposal (DP) and manuscript (DM)) and consultation for the other Committee Members 18 as needed throughout the dissertation journey. The AR is not a gate-keeper to final deliverables but a reviewer to ensure alignment to University scholarship requirements, research methods, design, procedures, and scholarly expectations. The AR will be responsible for reviewing the Proposal and Manuscript when considered final by the Committee through the use of a checklist in the Doctoral Record. The AR will go into the Doctoral Record and retrieve the final Proposal or Manuscript and review the document against a quality checklist to ensure compliance with the University’s standards of academic rigor and quality in both scholarly writing and research design and approach. Documents with any AR feedback will be uploaded into the Doctoral Record by the AR with a completed checklist. Changes requested by the AR need to be discussed and revised in the documents by the candidate under direction of the Chair. Specifically, the responsibilities of the committee members are included below. The Dissertation Chair – (12-week courses):  Primary arbiter of satisfactory candidate progress for dissertation deliverables;  Directs a candidate’s entire dissertation process and ensures all relevant policies, procedures, and standards are followed;  Manages the course and course related activities and weekly deliverables;  Ensures candidate completely aligns all work on the required, appropriate dissertation template;  Expects weekly student participation as required for financial aid and University attendance requirements;  Reports ‘at-risk’ student progress for missing two weekly submissions;  Ensures proper and ethical application of research methods, design, procedures, and topic alignment throughout the dissertation process;  Coordinates activities so that the work of the Dissertation Committee proceeds in a timely fashion (it is the responsibility of the Chair to ensure feedback from Committee Members is completed within the stated deadlines);  Facilitates communication between candidate and Committee and the disciplinary School;  Follows course syllabi in directing the candidate’s weekly submissions as required;  Provides substantial formative and summative feedback through the use of the appropriate dissertation rubric (detailed feedback is required for all areas not meeting minimum standards on the rubric);  Reviews TurnItIn reports in the Doctoral Record for the Proposal and the Manuscript focusing on a goal of less than 15% originality; and  Complies with the expectations articulated in the faculty handbook and appointment letter requirements. The Dissertation Chair – (8-week supplemental courses): The premise on the completion of the 8-week supplemental courses is the bulk of the actual deliverables have been completed and there are areas in need of special attention. Weekly deliverables are still expected in line with the course syllabus as noted by the Chair and are designed to support the development and refinement of key components as noted from the 12-week course. The exact same deliverables are expected to be completed at the end of these supplemental courses (from the associated 12-week course) with the support of additional University resources as required by the Chair to meet minimum rubric standards and progress to the next 12-week dissertation course 19 in the sequence.  Primary arbiter of satisfactory candidate progress for dissertation deliverables;  Directs a candidate’s entire dissertation process and ensures that all relevant policies, procedures, research design and methods; and standards are followed;  Expects weekly student participation as required for financial aid and University attendance requirements;  Reports ‘at-risk’ student progress for missing two weekly submissions;  Ensures candidate completes interventions as required by the Chair or Committee Members;  Facilitates changes as required by committee members to meet minimum rubric standards;  Manages course and course related activities and weekly deliverables;  Ensures candidate completely aligns all work on the required, appropriate dissertation template;  Completes rubric components as required;  Reviews TurnItIn reports in the Doctoral Record for the Proposal and the Manuscript focusing on a goal of less than 15% originality; and  Complies with the expectations articulated in the faculty handbook and appointment letter requirements. The Subject Matter Expert (SME) - (12-week courses):  Advises and supports the candidate as needed throughout the dissertation course sequence processes related to all areas of the dissertation process;  Reviews and provides formative and summative written, constructive feedback of candidates’ submissions through the use of the dissertation rubric for the requisite components as noted in the course syllabus (feedback is required for all areas of the paper not meeting minimum standards on the rubric);  Ensures alignment to discipline specific approaches and that all points of view are addressed in the literature review through the development of topic depth; scope, currency, and relevance to the field;  Maintains communication and responds to all messages sent by the Dissertation Chair or candidate within 48 hours;  Participates in teleconferences or other interactive modes of communication when requested by the Dissertation Chair or the Dean (or designee) of the disciplinary School;  Provides support specifically addressing rigor in methods, topic development, appropriate use of theoretical or conceptual context; and  Complies with the expectations articulated in the faculty handbook and appointment letter requirements. The Subject Matter Expert (SME) - (8-week supplemental courses): The premise on the completion of the 8-week supplemental courses is that the bulk of the actual deliverables have been completed and there are areas in need of special attention. Weekly deliverables are still expected in line with the course syllabus as noted by the Chair and are designed to support the development and refinement of key components as noted from the 12-week course. The exact same deliverables are expected to be completed at the end of these supplemental courses (from the associated 12-week course) with the support of additional University resources as required by the Chair to meet minimum rubric standards and progress to the next 12-week dissertation course 20 in the sequence.         Advises and supports the candidate as needed throughout the dissertation course sequence processes related to all areas of the dissertation process; Provides support specifically addressing rigor in methods, topic development, appropriate use of theoretical or conceptual context; Checks alignment to discipline specific approaches and relevance to the field; Completes rubric components as required; Participates in teleconferences or other interactive modes of communication when requested by the Dissertation Chair or the Dean (or designee) of the content School; Reviews revisions made by candidate as requested; Supports the candidate throughout any time off taken by the Chair; and Complies with the expectations articulated in the faculty handbook and appointment letter requirements. The Academic Reader (AR):  Reviews and provides written, constructive feedback both formative and summative of candidates’ submissions through the use of a checklist (feedback is required for all areas in need of improvement);  Provides a review of the final draft (Chair and SME indicate the deliverable meets the minimum standards of all criteria of the rubric) of the Dissertation Proposal and Dissertation Manuscript (courses 2 and 4);  Reviews the final drafts, with an eye towards approval, focusing on evidence of the problem, alignment of methods, ethical research guidelines and procedures, conformance to University policies, scholarly rigor, template guidelines, and rubric criteria;  Provides support, as needed, to the Chair or SME in addressing any concerns or issues related to the development of the dissertation course sequence deliverables;  Maintains communication and responds to all messages sent by the Dissertation Chair within 48 hours;  Complies with the expectations articulated in the faculty handbook and appointment letter requirements; and  Completes the time allocation sheet for tracking and data decisions for all interactions with candidates or the other committee members. Working with a Committee All communication among candidates and Committee Members must be timely, open, and honest. All concerned should maintain positive, respectful, and professional relationships. The candidate must take responsibility to notify their Chair of any and all academic concerns prior to notifying anyone else in the institution. If the Chair has not been notified, the concern will not be considered. Examples of academic issues include, but are not limited to: document contents, structure and format; results of reviews by SMEs and ARs; alignment of SMEs to candidate discipline or topic; and, changing degree program track. Candidates and their Dissertation Chairs should communicate regularly with one another using NCU provided communication tools. Chairs may also choose to communicate with candidates via telephone, teleconference, or videoconference. All communications outside the NCU learning management system or communication tools must be documented by the Dissertation Chair in the 21 course and/or other NCU systems as appropriate. Changes in Committee Assignments Candidates may request to replace a Committee Member only in unusual situations and only after consulting with their Academic and Finance Advisor. Candidates must contact their Academic and Finance Advisor to discuss the process to change a Committee Member. Prior to requesting any such change, candidates are expected to use conflict management strategies to resolve issues surrounding communication and feedback. The scholarly journey is an iterative process and although candidates may not always agree with feedback they are expected to listen actively, reflect, and pose clarifying questions to overcome normal communication and personality differences. Given the length of time it takes to complete dissertation research; it is not unlikely a candidate will experience changes to their Committee during their program. If such changes do occur, the candidate’s disciplinary school will work to make the transition as smooth and possible for the candidate. Such changes are not expected to negatively impact progress towards degree completion. In all situations involving requests for Committee changes, the decision of the Dean of the candidate’s disciplinary School (or designee) as to what is in the candidate’s best interest is final. 22 Section 3: Considerations and Policies (Refer to the NCU Catalog for most current information and specific policy language) Time Limits For current time limits, please review the Satisfactory Academic Progress policy in the NCU Catalog. Academic Integrity Northcentral University’s reputation depends on an uncompromising commitment to standards of academic integrity. The Northcentral University Academic Integrity Policy, to which all candidates and faculty members are bound, is available in the NCU Catalog and in the University Services Module in NCUOne. Doctoral candidates are expected to follow the highest standards of professional ethics, intellectual honesty, and academic integrity. All work submitted to a faculty member in any course is subject to originality confirmation. Faculty members have the responsibility to reject work that fails to meet the standards outlined in the Northcentral University Academic Integrity Policy. Northcentral University dissertation-related work is checked to ensure they meet Northcentral University standards of Academic Integrity. Plagiarism, misrepresentation, or fabrication of information or research results will not be tolerated and may be grounds for immediate dismissal from the University. Code of Conduct All members of the Northcentral University community are bound by the Northcentral University Code of Conduct (COC) contained in the current Northcentral University Course Catalog and thus are expected to act in a professional manner at all times. Failure to adhere to the COC may lead to disciplinary action up to and including dismissal from NCU. Satisfactory Academic Progress For additional information regarding Satisfactory Academic Progress, please review the Satisfactory Academic Progress policy in the Catalog. Minimum Passing Grades The University considers the following to be the minimum passing grade by dissertation course-level: Doctoral Sequence (CMP9600+ and DIS9901A+) B = 3.00 NOTE: Doctoral candidates are required to have a minimum of a 3.0 GPA before entering into CMP courses (comprehensive exam, portfolio, or prospectus). Assignment Deadlines and Final Course Grades Assignments submitted after the course end date will not be graded and calculated in the final grade for the course. 23 Incomplete Grades Candidates may request an incomplete grade extension if they meet the following requirements:  An unforeseen circumstance threatens a student’s ability to complete a course by the scheduled course end date.  The student has completed 75% of the course  The student has a “C” average for the assignments submitted thus far  The student is earning a passing grade in the course at the time the "I" grade is requested NOTE: The following Doctoral courses are not eligible for an incomplete grade:  CMP course prefixes  DIS-9901A/B/C; DIS-9902A/B/C; DIS-9903A/B/C; DIS-9904A/B/C Incomplete grade extension requests are submitted to faculty for review. Faculty may approve a request at their discretion if candidates meet the eligibility criteria listed above. Incomplete grade request decisions are final and cannot be appealed. ADA Course Accommodations Candidates receiving ADA accommodations that extend their original course completion date are also eligible for Dean approved course modifications and incomplete grade extensions beyond approved ADA accommodation date. Unsatisfactory Grades for Dissertation Courses  DIS-9901A-9904D – Candidates who are unable to earn a grade of “B” or better by the fourth course within in a dissertation block (DIS-9901, DIS-9902, DIS-9902, and DIS-9904) are subject to dismissal from the University. Repeating Doctoral Sequence Courses Candidates enrolled in course codes CMP9600 through CMP9799 and DIS-9901A through DIS-9904C may be eligible to earn a repeated Doctoral Sequence (“RD”) grade for courses that were originally completed with a non-passing grade of “C” or “F” if subsequent attempts are completed with a “B” or better. Courses awarded an “RD” grade will not be used in GPA calculations. Some courses may not be eligible for a repeated dissertation grade; candidates should work with their Academic and Finance Advisor to determine course repeat eligibility. NOTE: A dissertation block consists of a 12-week dissertation course (DIS-990XA) and three 8-week supplemental courses (DIS-990XB, DIS-990XC, and DIS-990XD). For non-passing grades to be replaced, candidates must successfully complete the dissertation block with a grade of “B” or better by the end of the third supplemental dissertation course (DIS-990XD). Maximum “RD” Grade Policy for Doctoral Sequence A candidate may utilize the “RD” grade a maximum of ten times during the Doctoral Sequence (CMP9600+ and DIS-9901A+). Dean permission is needed prior to attempting the CMP course for a third and final time. During the dissertation, a candidate will be allowed a maximum of two RD grades per dissertation block. 24
[Title] Prospectus Paper Submitted to Northcentral University Graduate Faculty of the School of Business in Partial Fulfillment of the Requirements for the Degree of DOCTOR OF BUSINESS ADMINISTRATION by San Diego, CA January 2019 Table of Contents Introduction ......................................................................................................................... 1 Statement of the Problem .............................................................................................. 1 Purpose of the Study ..................................................................................................... 2 Research Questions ....................................................................................................... 2 Brief Review of the Literature ............................................................................................ 3 Theme 1: Description of the significant challenges faced by the construction industry in Nigeria ...................................................................................................................... 3 Theme 2. Impact of the policies and guidelines on the development and performance of the civil construction industry .................................................................................. 7 Summary ....................................................................................................................... 7 Research Method ................................................................................................................ 7 Operational Definition of Variables.............................................................................. 8 Measurement ................................................................................................................. 9 Summary ....................................................................................................................... 9 References ......................................................................................................................... 11 1 Introduction The construction industry plays an essential role in ensuring the success of a nation (Myers, 2016). This industry helps in the attainment of stable economic growth as well as assisting in improving the GDP of a given country (Myers, 2016). Among the various accomplishments, an improved civil engineering sector helps in distinguishing between a developed, developing, and underdeveloped economy (Mu'awiya Abubakar & Bala, 2018). The construction industry is a highly sensitive industry in the sense that it is closely linked to the financial situation of the company. From this point of view, it is necessary to develop and apply different methods that will boost the civil engineering industry even during periods of financial crises, decreasing its dependence on the economic situation of a given nation. Providing affordable training to practitioners in this sector serves as one of the most effective methods to succeed in implementing an appropriate procurement system at the construction site (Hardin & McCool, 2015). This strategy may help in improving the knowledge among practitioners in this field as well as improving the measures that the community may handle the arising problems in this field. The failure to implement some of these approaches may result in increased issues among the industry which may significantly influence service delivery as well as the economic status of the respective nation (Johanson & Mattsson, 2015). The above issues illustrate how the civil engineering industry has so far failed to optimize the material procurement, which is currently hampering its full performance in countries like Nigeria. Statement of the Problem There is a problem in the civil engineering construction industry projects in Nigeria concerning time-critical materiel deliveries (Naoum & Egbu, 2016). These 2 material delivery delays result in 12.9 billion dollars of lost revenue annually and result in project cost overruns affecting 33% of projects annually (Chen et al., 2015). Despite basic credentialed training for project managers and published research and guidelines on procurement, losses continue (Pasquire, Sarhan, & King, 2015). This problem negatively impacts the governments and taxpayers because of financial injuries of revenue result in lost opportunities (Leite et al., 2016). A possible cause of this problem is the lack of comprehensive and usable applied knowledge about procurement and procurement routes available to the construction industry (Malalgoda et al., 2016). Perhaps a study which investigates the material procurement and delivery risk mitigation and project manager awareness of training by a qualitative method could remedy the situation. Purpose of the Study The aim of this research is to evaluate the different methodologies for the material procurement and delivery risk mitigation to decrease waste and improve the project performance and completion. The goal is to evaluate how the failure to apply modern and reliable means of production within the civil engineering sector may result in unpredicted shortcomings in the construction industry. Additionally, the research evaluates the most appropriate and effective method that the government of Nigeria and other involved stakeholders within the civil engineering department may need to apply to mitigate the risks that may arise within the industry. Research Questions Every research requires the researcher to formulate research questions that may help in increasing their knowledge about the topic at hand. The formulation of valid research questions helps the researcher to obtain accurate data that may help in making a 3 logical conclusion about the involved topic. In this research, the concerned interviewer will refrain from engaging the selected subjects with biased and sensitive questions that may negatively influence the investigation. In that case, the researcher will choose five items that will help in increasing their knowledge about the situation in hand. Some of the questions involved in this research include: RQ1. Which material delivery approaches do the practitioners in the construction industry identify as most effective? RQ2. Is there increased application of technological appliances such as programs used in the better management of the existing resources (e.g., automated inventory management tools) in performing various tasks within the material procurement, waste management, and delivery risk reduction compared to traditional methods? RQ3. What approach do most engineers identify as the most effective in selecting an appropriate procurement route during construction? Brief Review of the Literature The present literature review highlights the main challenges faced by civil engineers in the procurement of construction projects. The focus of such analysis is set at the evaluation of the construction industry in Nigeria, which represents a model scenario in which to evaluate the impact that the different guidelines and policies have had on the development of a highly profitable industry despite the multiple challenges. Theme 1: Description of the significant challenges faced by the construction industry in Nigeria Sub-theme 1.1. 4 The first significant challenge refers to the definition of the different metrics used in the evaluation of the quality of the civil engineering projects (Naoum & Egbu, 2015). In this regard, it is noteworthy how the scholars have repeatedly warned about the impossibility of directly applying the criteria commonly used in the developed countries. Such difficulty arises from the different construction methods used and the constrained availability of certain building materials. Eyitope & Ajibola (2012) evaluated the critical selection criteria that any project delivery should have in Nigeria. As per their analysis, the appropriate procurement strategy requires the researcher to investigate whether or not different factors affecting infrastructural projects are significant both for the project consecution and the economic development in the region. Such economic development is highly relevant in the case that the construction project takes place in locations that, like Nigeria, are currently working towards the economic growth and the creation of the necessary infrastructures. As per their evaluation, the failure of the assessment of such factors is likely to fail the construction project, hence being a critical step in the management of any construction project. Moreover, the results obtained from the different qualitative and quantitative tests conducted by Eyitope and Ajibola (2012) indicated how there is generally not a significant difference on the quality criteria requested by the customers and those offered by the consultants. This conclusion is essential considering how in many cases, the primary decision criteria used by customers for the selection of the most appropriate project procurement strategy is often not adequately defined due to the lack of experience that customers may have in the topic (Oyedele et al., 2015). In this regard, considering how the comparisons carried out by Eyitope and Ajibola have indicated that these 5 decision criteria, whenever defined, seem to resemble those of consultants, it is possible for the researcher to rely on the higher experience of construction consultants in the evaluation of the quality of the different procurement strategies and decisions in the construction industry (Eyitope & Ajibola, 2012). The methodology designed by Eyitope and Ajibola (2012) may thus serve as an appropriate starting point for the evaluation of the impact that the different project decisions have on the success of the construction projects and the economic and social growth in countries like Nigeria. A similar conclusion is derived from the analysis carried out by Naoum et al., (2016), which pointed out how the decision-making process involved in the evaluation of the best procurement strategies requires from the analysis of multiple variables and issues, thus being an extremely complicated process. As an approximation, Naoum et al. (2016) suggest the use of different models to try to exemplify the different scenarios considering how it is impossible to design a procurement strategy that works for all the construction projects, as they will depend on the exact decision criteria used by both the customers and the consultants (Naoum et al., 2016). 6 Sub-theme 1.2. Another major problem related to the selection of the best procurement strategy for the management of construction projects is that of the existing barriers and limitations when it comes to using and purchasing the appropriate building materials (Akadiri, 2015). Such an issue becomes even more relevant in the case of projects carried out in underdeveloped or developing countries, where the supply of sustainable materials is constrained by the access of enough financial resources (Zakari et al., 2017). Sub-theme 1.3. Risk management represents an additional challenge faced in the procurement of civil engineering projects. In developed countries, the industry uses a series of critical success factors with which to evaluate whether a civil engineering project meets the necessary standards of safety during both the construction of the project itself and during the lifetime of the constructed element. However, as pointed out by Fadun and Saka (2018), it is necessary to verify whether such critical decision factors apply to underdeveloped and developing countries as Nigeria. One of the significant challenges that may limit the application of such essential elements of success and may result in the failure of the project in such countries is the fact that the construction managers may lack sufficient expertise regarding technical and administrative skills, thus limiting their possibility of handling complex civil engineering projects (Fadun & Saka, 2018). 7 Theme 2. Impact of the policies and guidelines on the development and performance of the civil construction industry It is essential to consider the effect that the policy has on the procurement of civil engineering projects in countries that, like Nigeria, rely heavily on the strength of their construction industry. In this regard, Abdullahi, Hussin, and Osmadi (2017) suggest how the development of the Public Procurement Guidelines in Nigeria on 2007 had had a significant impact on the civil engineering and construction industry, resulting in a substantial factor determining the success of the construction projects focused at the sustainable urban planning. Summary As illustrated previously, the construction industry has flourished in Nigeria despite the multiple challenges faced by the companies undergoing such civil engineering projects. In this regard, the literature review illustrates the main challenges faced by the industry and how the industry has tried to respond to them. Research Method The research method employed will combine both qualitative and quantitative designs. The goal of implementing both design methods is that of obtaining the broadest possible point of view in the evaluation of the different variables affecting the problem statement. In this regard, the proposed research method addresses the different variables affecting the time and materials required for the civil engineering works in Nigeria and the quality of the construction projects. For this purpose, information about the compliance with the different critical success factors and the Public Procurement Guidelines will be collected from different 8 civil engineering projects carried out in the country. The specific projects included in the survey will be selected through a random sampling approach to minimize the potential threats to the validity of the obtained results by preventing any selection bias. While the use of other sources will be evaluated from the actual availability, most of the data used in the research project will be collected through the evaluation of the construction project planning and the interviewing of both the project manager and the construction crew. Operational Definition of Variables The variables used in the present project will be based on those established by both commonly accepted critical success factors (Fadun & Saka, 2018) and the Public Procurement Guidelines (Abdullalhi et al., 2017). The objective of using such variables is that of using standardized variables that have proven effective in the evaluation of the quality of the procurement projects. Moreover, as stated by Fadun and Saka (2018), the use of these variables will enable the prediction of whether the project will be completed on time with the existing materials or if there is a high risk of a delay in the construction process. Specifically, the variables that will, at least, be included in the analysis refer to: • The technical skills and experience of the project or construction manager and the civil engineers in charge of coordinating the construction works • The types of materials used in the construction process and whether or not these materials are available locally. • The time required by the materials to arrive at the construction site once ordered 9 • The use of advanced technologies that facilitate the construction works, such as the number of elevators available on site • The number and nature of the electric appliances that will be included in the construction project, and whether these appliances are available locally Measurement As illustrated previously, the collection of the data required for the project will mainly rely on the evaluation of the procurement project book and the interviews of both the construction manager and the construction crew. From this point of view, instruments such as standardized checklists and questionnaires will be used as the primary data collection instruments throughout the project. The collected data will be coded to preserve the traceability of the different data back to each particular construction project. Statistical tools such as hypothesis tests, frequency analysis, and comparative analysis will be used in the study of the collected data. Summary The proposed research method involves both a qualitative and a quantitative research design, through which to obtain the broad point of view necessary for the evaluation of the identified research questions. In this regard, a series of data collection methods involving the use of standardized checklists and questionnaires will be used as the primary instrument to collect the necessary data. These data are required to evaluate the types of materials predominantly used in the construction projects in Nigeria and their availability. They will also be used in the assessment of the impact that the Public Procurement Guidelines have had on the control and execution of construction projects in 10 the country, the number and nature of the electric appliances included in the construction projects in Nigeria, and the availability of qualified project managers and construction crew. The statistical analysis of the collected data will assist in the identification of the critical success factors that determine whether or not the construction project will be finished on time with the desired safety and quality levels. 11 References Abdullahi, N. Z., Hussin, A. A., & Osmadi, A. (2017). Mediation Effects Of Innovative Procurement Practices Between The Determinants Of Non-compliance With Public Procurement Guidelines And Construction Project Cost Performance In The Nigerian Construction Industry. WIT Transactions on Ecology and the Environment, 210, 99-109. Akadiri, P. O. (2015). Understanding barriers are affecting the selection of sustainable materials in building projects. Journal of Building Engineering, 4, 86-93. Creswell, J. W., & Creswell, J. D. (2017). Research design: Qualitative, quantitative, and mixed methods approaches. Sage publications. Chen, Q., Jin, Z., Xia, B., Wu, P., & Skitmore, M. (2015). Time and cost performance of design-build projects. Journal of Construction Engineering and Management, 142(2), 04015074 Eyitope, O.A., & Ajibola, G.M., (2012). Critical selection criteria for appropriate procurement strategy for project delivery in Nigeria. Journal of Emerging Trends in Economics and Management Sciences (JETEMS), 3(5), 422-428. Fadun, O. S., & Saka, S. T. (2018). Risk management in the construction industry: Analysis of critical success factors (CSFS) of construction projects in Nigeria. International Journal of Development and Management Review, 13(1) 108-139. Fellows, R. F., & Liu, A. M. (2015). Research methods for construction. John Wiley & Sons. Hardin, B., & McCool, D. (2015). BIM and construction management: proven tools, methods, and workflows. John Wiley & Sons. Johanson, J., & Mattsson, L. G. (2015). Internationalization in industrial systems—a network approach. In Knowledge, networks, and power (pp. 111-132). Palgrave Macmillan, London. Leite, F., Cho, Y., Behzadan, A. H., Lee, S., Choe, S., Fang, Y., ... & Hwang, S. (2016). Visualization, information modeling, and simulation: Grand challenges in the construction industry. Journal of Computing in Civil Engineering, 30(6), 04016035. Malalgoda, C., Amaratunga, D., Keraminiyage, K., & Haigh, R. (2016). Knowledge gaps in the construction industry to increase societal resilience: a local and national government perspective. The Tampere University of Technology. Department of Civil Engineering. 12 Mu'awiya Abubakar, M. A., & Bala, K. (2018). Analysis of the Causality Links between the Growth of the Construction Industry and the Growth of the Nigerian Economy. Journal of Construction in Developing Countries, 23(1), 103-113. Naoum, S. G., & Egbu, C. (2016). Modern selection criteria for procurement methods in construction: A state-of-the-art literature review and a survey. International Journal of Managing Projects in Business, 9(2), 309-336. Naoum, S., & Egbu, C. (2015). A critical review of procurement method research in construction journals. Procedia Economics and Finance, 21, 6-13. Oyedele, L. O., Jaiyeoba, B. E., Kadiri, K. O., Folagbade, S. O., Tijani, I. K., & Salami, R. O. (2015). Critical factors affecting construction quality in Nigeria: evidence from industry professionals. International Journal of Sustainable Building Technology and Urban Development, 6(2), 103-113. Pasquire, C., Sarhan, S., & King, A. (2015). A critical review of the safeguarding problem in construction procurement: unpicking the coherent current model. In 23rd Annual Conference of the International Group for Lean Construction (pp. 309-318). IGLC. Zakari, I., Awal, A. A., Zakaria, R., Abdullah, A. H., & Hossain, M. Z. (2017). Application of industrialized building system: A case study in Kano State, Nigeria. International Journal, 13(39), 80-86.

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Please let me know if there is anything needs to be changed or added. I will be also appreciated that you can let me know if there is any problem or you have not received the work. Please let me know if there is anything needs to be changed or added. I will be also appreciated that you can let me know if there is any problem or you have not received the work Good luck in your study and if you need any further help in your assignments, please let me know Can you please confirm if you have received the work? Once again, thanks for...

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