I have attached 2 business research. Write a 700- to 1,050-word paper in which you practice identifying the critical first stage of developing any research study: State the purpose of the business research for each article. Determine the research questions and hypotheses being researched in each article. Identify the dependent and independent variables being manipulated or measured in each article. Format your paper consistent with APA guidelines.

Journal of Athletic Training 2014;49(1):68-74 doi: 10.4085/1062-6050-48.6.12 by the National Athletic Trainers' Association, Inc www.natajournals.org original research Perceived Levels of Frustration During Clinical Situations in Athletic Training Students Scott Heinerichs, EdD, ATC; Neil Curtis, EdD, ATC; Alison Gardiner-Shires, PhD, ATC Department of Sports Medicine, West Chester University, PA Context: Athletic training students (ATSs) are involved in various situations during the clinical experience that may cause them to express levels of frustration. Understanding levels of frustration in ATSs is important because frustration can affect student learning, and the clinical experience is critical to their development as professionals. Objective: To explore perceived levels of frustration in ATSs during clinical situations and to determine if those perceptions differ based on sex. Design: Cross-sectional study with a survey instrument. Setting: A total of 14 of 19 professional, undergraduate athletic training programs accredited by the Commission on Accreditation of Athletic Training Education in Pennsylvania. Patients or Other Participants: Of a possible 438 athletic training students, 318 (72.6%) completed the survey. Main Outcomes Measure(s): The Athletic Training Student Frustration Inventory was developed and administered. The survey gathered demographic information and included 24 Likert-scale items centering on situations associated with the clinical experience. Descriptive statistics were computed on all items. The Mann-Whitney U was used to evaluate differences between male and female students. Results: A higher level of frustration was perceived during the following clinical situations: lack of respect by studentathletes and coaching staffs, the demands of the clinical experience, inability of ATSs to perform or remember skills, and ATSs not having the opportunity to apply their skills daily. Higher levels of frustration were perceived in female than male ATSs in several areas. Conclusions: Understanding student frustration during clinical situations is important to better appreciate the clinical education experience. Low levels of this emotion are expected; however, when higher levels exist, learning can be affected. Whereas we cannot eliminate student frustrations, athletic training programs and preceptors need to be aware of this emotion in order to create an environment that is more conducive to learning. Key Words: scaffolding, professional socialization, athletic training education Key Points \u000f \u000f Athletic training students perceived having higher levels of frustration about how they are respected by various constituents, their performance of and ability to remember skills and information, the opportunity to apply skills daily, and the demands of the clinical obligation. Whereas frustration cannot be eliminated, athletic training programs and preceptors should recognize these frustrations, discuss strategies to help mitigate their occurrences, and help create more conducive environments for learning and student success. M ore than half of the entry-level professional development of athletic training students (ATSs) is perceived to be attributed to the clinical setting.1 However, the transition from the preclinical to clinical years can be difcult for them. They are expected to be active participants during this time and to apply what they learn each day in the classroom with the people they treat.2 In addition, ATSs are learning various behaviors pertaining to the complex demands of the profession, such as time management, communication, and administrative tasks, through mentorship from their preceptors.2 These transitions and social interactions have been shown to cause differing levels of negative emotional responses by students in other allied health professions.3-7 Understanding students' perceived levels of emotional response during clinical situations is important because researchers have found that negative emotional responses may affect student learning, decision-making, and caring capabilities.4,8-10 In 68 Volume 49 \u000f Number 1 \u000f February 2014 addition, understanding the clinical experience from the perception of students is important because students can provide insightful information.11 In a qualitative study, Heinerichs and Curtis12 showed that frustration exists within ATSs during the clinical experience. However, the level of frustration during this time has not been evaluated in ATSs. Researchers3-6,13 in other health professions, such as medicine and nursing, have examined levels of emotion in clinical students using the descriptors of stress and anxiety. Stress is something that happens to someone, whereas anxiety and frustration are the emotions experienced due to the stressor. Anxiety is the emotion experienced when a person feels threatened by a stressor, and frustration is the emotion that occurs when a person cannot manage the stressor. ATSs have many responsibilities and daily interactions during the clinical experience, and we believed frustration best describes what a student may perceive during this time. The perceived Table 1. Operational Definitions for the Constructs of the Athletic Training Student Frustration Instrument Construct Demand Interaction Respect Skill Supervision Definition Ability of ATSs to balance clinical, schoolwork, and personal obligations, as well as daily responsibilities, during the clinical experience Communication with student-athletes and ATSs and the performance of tasks Ability of coaches, student-athletes, or preceptors to value a student's role as an ATS Confidence of ATS in performing a skill or skills or ability to perform, remember, or recognize a previously learned skill or skills Ability of preceptor to provide feedback, explanations, and opportunities for ATSs to apply knowledge or skills and to respond to athletes' needs Abbreviation: ATS, athletic training student. level of frustration is important to explore because higher levels of negative emotions can affect student learning.14,15 Social cultural learning theory can be used to appreciate how frustration affects learning.16 This theory states that learning is a process that results through the development of social interactions with others and within oneself.16 Athletic training programs (ATPs) and preceptors have a responsibility to promote interactions that allow students to build on their previous experiences through guided autonomy (ie, scaffolding)17 and to professionally socialize18 them into athletic training so they can understand what is expected. The ATSs are involved in social interactions during the clinical experience that expose them to the demands of the profession while promoting the use of higher-order thinking skills (ie, evaluation and synthesis) as they apply their knowledge and abilities each day. These interactions can cause students to experience frustration that can affect their performances because it activates the ight-or-ght response,14 resulting in a positive or negative outcome. Students perform well with a moderate level of negative emotion, such as frustration; however, when frustration levels are too high or low, performance is decreased.15 Given that negative emotions can be detrimental to learning and performance, it is critical to understand students' level of frustration during clinical experiences, which occur when more than half of an ATS's entry-level professional development is achieved.1 Frustration will always exist; however, understanding when higher levels of this emotion exist during clinical situations can help ATPs, preceptors, and ATSs create an environment more conducive to learning. Therefore, the purpose of our study was to determine perceived levels of frustration in ATSs during specic clinical situations and whether those perceptions differ based on sex. METHODS A cross-sectional, descriptive survey study design was used to explore perceived levels of frustration in ATSs. Participants We used a convenience-sampling technique to recruit participants from 14 of 19 undergraduate programs accredited by the Commission on Accreditation of Athletic Training Education (CAATE) in Pennsylvania. All ATSs enrolled in a clinical education experience during the spring of 2008 were invited to participate. A clinical education experience was dened as an experience that is associated with a course grade and involves the application of athletic training skills under the supervision of a preceptor. All participants provided written informed consent, and the study was approved by the West Chester University Institutional Review Board. Instrumentation Creation of the Athletic Training Student Frustration Instrument. We reviewed similar surveys on negative emotions from nursing,3,5,6,13,19 medicine,4,7,20,21 and physical therapy22 to gain a sense of their relative descriptors. However, we needed to develop the Athletic Training Student Frustration Instrument (ATSFI) in the context of athletic training. Qualitative data on a relatively unexplored topic can be used to design a subsequent quantitative phase of a study.23 Therefore, we used the qualitative study by Heinerichs and Curtis12 to develop the ATSFI. Content validity was established by consulting a panel of 4 experts in the eld of athletic training education. Three experts had published articles on educational topics, and one was an expert in survey research in athletic training education. The modications from the experts included a revision of the Likert scale from a 5-point to a 4-point scale, with 4 indicating extremely frustrated; 3, very frustrated; 2, slightly frustrated; and 1, not at all frustrated. This revision was made to avoid a neutral response.24 Several question stems were also reworded to ensure clarity of the question being asked. Construct validity was established by performing a principle component analysis. The factor analysis enabled us to understand which items grouped around certain concepts. The factor analysis revealed 5 loadings ranging from 0.739 to 0.416. The cutoff value for the factor loadings was 0.400 because values less than this are known to not be different. After reviewing the items, we operationally dened 5 constructs (Table 1). The constructs that compose the ATSFI are items centering on 5 types of clinical situations: demand (6 items), interaction (5 items), respect (5 items), skill (4 items), and supervision (9 items). The overall internal consistency of the survey instrument was 0.90. After the expert panel review, the ATSFI was piloted with 21 ATSs. The purpose of the pilot was to ensure the clarity and readability of the instrument and to determine the length of time needed to complete it. Several modications were made after the pilot, such as clarifying the instrument's instructions and placing the Likert scale at the top of each page so participants could easily refer to it. Journal of Athletic Training 69 Table 2. Survey Responses by Year in School (n 314)a Year in School Respondents, n (%)b Freshman Sophomore Junior Senior a b 1 66 153 94 (0.003) (21.02) (48.72) (29.93) Four respondents did not indicate their year in school. Percentages are rounded. Procedures Fourteen directors of undergraduate ATPs in Pennsylvania indicated their willingness to help recruit participants and indicated the number of students that would be enrolled in courses that contained a clinical experience for spring 2008. The maximum possible sample size was 438. Each program director who agreed to facilitate the data collection was sent a packet containing instructions for distributing and collecting the survey; informational letters (informed consent) for each participant; a survey for each participant; and a self-addressed, stamped envelope for the return mailing of completed surveys. Each return envelope was coded to indicate the program so we could identify the source. Program directors were instructed to conduct the survey in a classroom at a time that was convenient for them. Statistical Analysis After the survey instruments were completed and returned, we calculated descriptive statistics for each item. Given the ordinal data collected, a Mann-Whitney U test was calculated to identify any differences in levels between male and female ATSs. For all statistical comparisons, the a level was set a priori at less than .05. Data were analyzed using the Statistical Package for the Social Sciences (version 11.0, SPSS, Chicago, IL). RESULTS Participants A total of 318 of 438 (72.6%) surveys were returned. Ages of respondents ranged from 19 to 43 years, with the ages of 288 respondents (90.6%) ranging from 19 to 22 years. Respondents included 208 women (66.20%) and 106 men (33.80%). Four respondents did not indicate their sex. This breakdown of sex is similar to the breakdowns of national statistics reported from a survey published by the CAATE from 2005 to 2006.25 The respondents by year in school are shown in Table 2. Most respondents (n 247, 77.7%) were upper-level students (juniors and seniors). More than half of those surveyed (n 184, 57.9%) reported having completed 3 or more semesters of clinical experiences. Student Perceived Level of Frustration The perceived level of frustration reported by the students for various clinical situations is illustrated in Table 3. The situations producing the highest levels of perceived frustration in ATSs were not being respected by coaching staff (2.90 6 0.913), student-athletes (2.90 6 0.907), and preceptors (2.84 6 0.953); balancing clinical 70 Volume 49 \u000f Number 1 \u000f February 2014 obligations with school work (2.74 6 0.943); inability to recall previously learned information (2.73 6 0.747); performing a previously learned skill incorrectly (2.65 6 0.782); and preceptors not allowing them to perform skills associated with their educations (2.61 6 0.905). Respondents experienced the lowest levels of frustration when they had too much responsibility during the clinical experience (1.80 6 0.849), had a high volume of athletes for whom to provide care on a given day (1.70 6 0.785), and did not speak to their preceptors daily (1.56 6 0.758). The remaining items were found to be neither high nor low with regard to ATS-perceived level of frustration (Table 3). Sex Differences in Perception of Frustration The level of frustration reported by students for their respective sex is displayed in Table 4. In 13 of the 24 items, female ATSs had higher levels of frustration than male ATSs (P , .05). DISCUSSION Athletic Training Students' Perceived Levels of Frustration Exploring the levels of frustration ATSs perceived in this study contributes to the understanding of the nature of the clinical experience. Athletic training programs should be concerned about the nature of the clinical experience because more than half of ATSs' professional development takes place during this time.1,26 As ATSs have their clinical experiences, they are involved in various social interactions that allow them to learn about themselves as aspiring clinicians.16 Some of these interactions may cause differing levels of frustration within ATSs. Identifying levels of ATS frustration allows researchers to understand how they internalize their emotions. By understanding ATS emotions, ATPs and preceptors can respond to situations that cause higher levels of this emotion and can positively affect ATS learning, decision-making, and caring capabilities during this time.4,8-10 Frustrating experiences relating to respect elicited the highest levels of frustration within ATSs. These experiences centered on such issues as lack of respect by coaches, student-athletes, and preceptors. This nding is similar to the nding that nursing students perceived their nonacceptance by staff or being demeaned as high-anxiety events.5 The preceptors need to understand the power structure of the athletic training clinical setting,5 which includes coaches, student-athletes, athletic administrators, parents, preceptors, and ATSs. As newcomers to this structure, ATSs are aware of their inexperience and may believe others want their position to be peripheral rather than central.5 When students become more central in their daily responsibilities, they believe they are more empowered.5 However, if denied and left on the periphery, they believe they are powerless.5 To help mitigate this situation, ATSs need to be assimilated appropriately into the profession by their preceptors.27 Specically, constituents within this structure beyond the preceptor, such as the athlete, coach, and athletic administrator, must clearly understand the role of the ATS as a health care provider and not as a person with Table 3. Athletic Training Students' Perceived Levels of Frustrations in the Clinical Setting (N 318)a Response, n (%)a Construct Skill Supervision Interaction Respect Demand a b Statement of Frustration I I I I I am not confident in performing skills. cannot recall previously learned information. do not recognize injuries that occur. perform a previously learned skill incorrectly. feel my clinical experience lacks opportunities to apply my education and skills. My preceptor does not allow me to perform skills associated with my education. My preceptor does not provide me verbal feedback on my knowledge and skills during my first year as an athletic training student. My preceptor does not provide me verbal feedback on my knowledge and skills as an experienced athletic training student. My preceptor does not respond to athletes' needs seriously. My preceptor does not want to know what I already know. My preceptor provides no explanation for the type of care that he or she wants me to perform. I do not speak with my preceptor on a daily basis. My fellow students compete with me for learning opportunities during the clinical experience. Student-athletes complain of being injured when they do not appear to be. Student-athletes do not report their injuries to the athletic training staff and/or athletic training students. I am asked to perform tasks that are not associated with my direct responsibilities as an athletic training student. Athletes express a negative attitude toward me in my role as an athletic training student. Student-athletes do not respect my role as an athletic training student. The preceptors do not respect my role as an athletic training student. The coaching staff does not respect my role as an athletic training student. I cannot balance my clinical obligations with my personal life. I cannot balance my clinical obligations with my schoolwork. I have too much athletic training responsibility during my clinical experience. There is a high volume of athletes to provide care for on a given day.b Mean 6 SD 2.45 2.73 2.49 2.65 2.46 6 6 6 6 6 0.725 0.747 0.777 0.782 0.984 Not at All Frustrated 17 7 24 14 64 (5.3) (2.2) (7.5) (4.4) (20.1) Slightly Frustrated Very Frustrated Extremely Frustrated 167 122 145 128 95 107 139 117 129 109 27 50 32 47 50 (52.5) (38.4) (45.6) (40.3) (29.9) (33.6) (43.7) (36.8) (40.6) (34.3) (8.5) (15.7) (10.1) (14.8) (15.7) 2.61 6 0.905 31 (9.7) 124 (39.0) 102 (32.1) 61 (19.2) 2.47 6 0.929 45 (14.2) 129 (40.6) 92 (28.9) 52 (16.4) 2.52 6 0.925 44 (13.8) 115 (36.2) 107 (33.6) 52 (16.4) 2.36 6 0.991 69 (21.7) 116 (36.5) 83 (26.1) 50 (15.7) 2.20 6 0.866 67 (21.1) 145 (45.6) 80 (25.2) 26 (8.2) 2.55 6 0.903 39 (12.3) 116 (36.5) 112 (35.2) 51 (16.0) 1.56 6 0.758 2.04 6 0.979 185 (58.2) 115 (36.2) 93 (29.2) 107 (33.6) 34 (10.7) 65 (20.4) 6 (1.9) 31 (9.7) 2.34 6 0.872 46 (14.5) 158 (49.7) 75 (23.6) 39 (12.3) 2.21 6 0.802 57 (17.9) 153 (48.1) 90 (28.3) 18 (5.7) 2.37 6 0.960 61 (19.2) 126 (39.6) 83 (26.1) 48 (15.1) 2.58 6 0.929 42 (13.2) 105 (33.0) 115 (36.2) 56 (17.6) 2.90 6 0.907 24 (7.5) 76 (23.9) 126 (39.6) 92 (28.9) 2.84 6 0.953 29 (9.1) 86 (27.0) 109 (34.3) 94 (29.6) 2.90 6 0.913 23 (7.2) 80 (25.2) 120 (37.7) 95 (29.9) 2.58 6 0.975 40 (12.6) 124 (39.0) 82 (25.8) 72 (22.6) 2.74 6 0.943 32 (10.1) 98 (30.8) 110 (34.6) 78 (24.5) 1.80 6 0.849 139 (43.7) 116 (36.5) 50 (15.7) 13 (4.1) 1.70 6 0.785 150 (47.3) 121 (38.2) 37 (11.7) 9 (2.8) Some percentages are rounded. One participant did not respond to this statement (N 317). limited knowledge or skills or as a laborer. Strategies to help foster this understanding include preceptors discussing with all constituents the role of the ATS in advance of the clinical assignment each semester. This discussion will help solidify the ATS's place within the power structure. In addition, preceptors need to allow ATSs to have structured autonomy by making legitimate decisions (ie, more than how to set up a eld for practice) and communicating regularly with individuals within the power structure. This structured autonomy can help ATSs to be viewed as competent health care providers. The ATSs also reported higher levels of frustration when preceptors did not allow them to perform skills associated with their educations. This nding addresses the type of clinical supervision that occurs during a clinical experience. It varies across settings because of preceptor personalities and previous experiences. However, the Approved Preceptor Workshop rst proposed in 1996 was created to improve the teaching and evaluation skills of preceptors.1 Weidner and Henning28 pointed out that in the eld of athletic training, most preceptors are chosen out of convenience and expertise as clinicians and not because of their expertise as Journal of Athletic Training 71 Table 4. Student Frustrations in the Clinical Setting by Sex Sex Construct Skill Statement of Frustration I I I I Supervision I Interaction Respect Demand a b Male (n 106), Female (n 208), Mean 6 SD Mean 6 SD am not confident in performing skills. cannot recall previously learned information. do not recognize injuries that occur. perform a previously learned skill incorrectly. feel my clinical experience lacks opportunities to apply my education and skills. My preceptor does not allow me to perform skills associated with my education. My preceptor does not provide me verbal feedback on my knowledge and skills during my first year as an athletic training student. My preceptor does not provide me verbal feedback on my knowledge and skills as an experienced athletic training student. My preceptor does not respond to athletes' needs seriously. My preceptor does not want to know what I already know. My preceptor provides no explanation for the type of care that he or she wants me to perform. I do not speak with my preceptor on a daily basis. My fellow students compete with me for learning opportunities during the clinical experience. Student-athletes complain of being injured when they do not appear to be. Student-athletes do not report their injuries to the athletic training staff and/or athletic training students. I am asked to perform tasks that are not associated with my direct responsibilities as an athletic training student. Athletes express a negative attitude toward me in my role as an athletic training student. Student-athletes do not respect my role as an athletic training student. The preceptors do not respect my role as an athletic training student. The coaching staff does not respect my role as an athletic training student. I cannot balance my clinical obligations with my personal life. I cannot balance my clinical obligations with my schoolwork. I have too much athletic training responsibility during my clinical experience. There is a high volume of athletes to provide care for on a given day. 2.23 2.60 2.38 2.48 2.39 6 6 6 6 6 0.681 0.763 0.773 0.744 0.949 2.58 2.80 2.54 2.75 2.49 6 6 6 6 6 0.719a 0.736b 0.773 0.791b 0.998 P Mann-Whitney U ,.001 .03 .12 .005 .34 8600.000 9561.500 10034.000 9126.000 10431.000 2.59 6 0.951 2.61 6 0.883 .85 10991.000 2.36 6 0.798 2.60 6 0.947 .06 9772.000 2.36 6 0.862 2.61 6 0.947b .02 9482.00 2.16 6 0.923 2.07 6 0.887 2.39 6 0.866 2.47 6 1.01b 2.26 6 0.853 2.63 6 0.917b .01 .05 .03 9289.000 9729.500 9569.500 1.53 6 0.744 1.75 6 0.881 1.59 6 0.769 2.19 6 0.998a .52 ,.001 10696.500 8312.500 2.36 6 0.914 2.33 6 0.856 .92 11054.500 2.02 6 0.812 2.32 6 0.783a .002 8907.000 2.23 6 0.947 2.44 6 0.961 .08 9848.000 2.43 6 0.902 2.66 6 0.928b .03 9574.000 2.02 6 0.812 2.32 6 0.783b .01 9278.500 2.69 6 0.975 2.92 6 0.935b .04 9650.500 2.69 6 0.975 3.01 6 0.862a .007 9148.500 2.53 6 0.974 2.51 6 0.955 1.69 6 0.782 2.61 6 0.967 2.84 6 0.916a 1.85 6 0.875 .54 .003 .15 10682.000 8956.500 10092.000 1.64 6 0.780 1.73 6 0.789 .34 10362.000 Significant difference at P , .01. Significant difference according to Mann-Whitney U test (P , .05). educators. This lack of formal training in the area of teaching may contribute to the higher level of frustration reported by ATSs with regard to skill performance.29 Preceptors must consistently be reminded of their roles as clinical educators and nd ways for ATSs to regularly apply their knowledge and skills. Allowing ATSs to make quality decisions will empower and prepare them for their futures. Athletic training programs should continue to use preceptor training to help give feedback to preceptors on their ability to provide meaningful opportunities for ATSs. Regular use of formal assessments completed by ATSs and program administrators can provide valuable feedback for programs and preceptors to ensure that students are being instructed to apply the skills needed for their futures. Frustrating clinical situations related to ATSs' abilities to recall and apply skills and information correctly were also reported to cause higher levels of frustration. This nding can be explained by the type of learning that occurs during 72 Volume 49 \u000f Number 1 \u000f February 2014 the clinical setting. Learning that takes place during the clinical setting is often complex and requires students to use higher-order skills to properly perform their duties.13 After completion of and concurrent with their didactic coursework, ATSs are instructed to use and perform many skills regularly in the clinical setting. Furthermore, the variability of exposures during a clinical experience may or may not require students to apply what they learned until months or years after it was taught. In nursing, researchers3-6 have recognized that the application of skills is a common cause of negative emotional response among students. Investigators3,5,6 have found that being uncertain about one's ability and clinical skills and having a fear of making mistakes were the most anxiety-producing situations. Preceptors can alleviate this frustration by creating a structured learning environment through scaffolding.17 Scaffolding occurs when a preceptor controls parts of a situation through guided autonomy.17 Strategies to achieve scaffolding initially are to prepare students for their clinical interactions by discussing previous clinical experiences. This allows preceptors to gain a sense of students' skill levels. Preceptors can build on these interactions by performing mock practicals or questioning students through scenariobased examples, further enabling students to apply their skills and recall information in smaller elements. These techniques help build condence and rene students' skill sets before working with individual athletes. The demand of the clinical experience, specically the ability of ATSs to balance clinical obligations with schoolwork, was perceived to cause a high level of frustration. As ATSs progress into the clinical experience, the preclinical structure (ie, solely attending class) is supplemented with clinical experiences. In addition to balancing their classes and clinical responsibilities, ATSs are expected to maintain their social identities as college students. Unlike other allied health care elds, the athletic training clinical setting can be less organized because of last-minute scheduling conicts or weather-related cancellations or adjustments. All of these changes in ATSs' daily routines may contribute to their increased levels of frustration because of the multiple roles they maintain (students, ATSs, social beings). The ATPs need to recognize this frustration because researchers30 have found that managing multiple roles can lead to burnout. The ATSs should understand the demands of the profession and have time outside of required clinical responsibilities. To do this effectively, ATPs should communicate with ATSs early about coping strategies, such as having appropriate social support outside of their ATPs and ensuring that ATSs take personal time by being involved in activities unrelated to athletic training.30 One possible strategy is to have ATSs complete surveys on how they like to spend their free time, which may help them recognize activities to pursue outside the clinical and schoolwork responsibilities. Sex and Frustration As shown in Table 4, female ATSs reported higher levels of frustration than male ATSs in 13 of the 24 items. In 10 of the other 11 items, women reported higher levels of frustration than men but the differences were not signicant. Although determining the reason for gender differences is beyond the scope of this study, authors of previous research in this area have provided some ideas. Gender socialization research, specically gender schema theory,31 indicates that all behavioral and emotional differences between the sexes are due to learning inuenced by differing socialization patterns. As children develop, they are introduced to stereotypical messages that may or may not be overt.31 Given that some perceptions may be attributed to genetics, many are caused by the socialization of gender into their respective environments.32 The cultural environment of athletic training is rooted in organized sport. The language of sport continues to emphasize men's interests, and given this emphasis, researchers33 have found that some women in athletic training have been stereotyped as being too demanding if they make decisions. Whereas the percentage of women has recently surpassed that of men in the National Athletic Trainers' Association certied membership,34 athletic training has traditionally been a male-dominated profession, and men are still more often found in supervisory positions.35 As indicated, students learn not only through interactions within themselves but also from others in their respective environments.16 For this reason, preceptors should be more cognizant of the societal stereotypes about the cultural environment of sport and strive to make the clinical experience as unbiased as possible to professionally socialize ATSs during the clinical experience.35,36 Investigators36 have demonstrated that differences exist between female and male students regarding the clinical experience and authority. Nicholson encouraged British medical school instructors to reect on their attitudes toward sex ''especially for female students who are frequently lacking appropriate role models.''36(p1057) Wimer et al37 highlighted the sex differences in learning activities of ATSs. They noted that women more often choose to be less assertive in mixed groups. Brady and Sherrod38 lent support to the concept of professional socialization when they discussed the importance of opposite sexes being given tasks similar to those they will be expected to perform in the profession. Throughout their lives, male and female ATSs have been placed in categories, given different tasks, or addressed in different ways based on their sex. Regardless of whether this is deliberate, these interactions have contributed to or reinforced gender stereotypes. Our results allow preceptors to become aware of clinical situations that lead to higher levels of frustration among the sexes. This knowledge can help ATSs be socialized appropriately into the profession and create a more conducive environment for learning in the clinical setting. Limitations We used a nonrandom, purposeful sample of ATSs in Pennsylvania. We chose them because of their proximity to the researchers. Despite this, the sex breakdown of the participants in our study reected the breakdown of sexes from the 2005 to 2006 CAATE-accredited programs.25 Generalizability of the results to other states or groups of students is limited. Our participants were instructed to submit self-report data. We assumed that participants were forthcoming and honest. A limitation is the extent to which these assumptions are true. The ATSFI was a valid and reliable instrument, but it intentionally measured frustration using a Likert scale that did not allow for neutral responses or responses aligning with not being frustrated; this is also a limitation of the study. CONCLUSIONS A student-perceived level of negative emotion during the clinical experience has been demonstrated in medicine and a variety of allied health professions but had not been evaluated in athletic training. Whereas certain levels of emotion are normal, educators need to know which situations cause higher levels of frustration because they can affect student learning. This study helped to establish a foundation for perceived levels of frustration during the clinical experience in ATSs. The ndings indicated that ATSs have higher levels of frustration about how they are respected by various constituents, their performance and ability to remember skills and information, the opportunity Journal of Athletic Training 73 to apply skills daily, and the demand of the clinical obligation. The ATPs and preceptors should recognize these frustrations and discuss strategies to help mitigate their occurrence. Strategies such as building on students' previous experiences, progressively allowing guided autonomy during clinical educational opportunities, and designing professional socialization into the clinical setting could be implemented. Frustration cannot be eliminated, but by recognizing and discussing this emotion, ATPs and preceptors can help create a more conducive environment for learning and student success. REFERENCES 1. Laurent T, Weidner TG. Clinical instructors' and student athletic trainers' perceptions of helpful clinical instructor characteristics. J Athl Train. 2001;36(1):58-61. 2. Peer KS, McClendon RC. Sociocultural learning theory in practice: implications for athletic training educators. J Athl Train. 2002;37(4 suppl):S136-S140. 3. Kim KH. Baccalaureate nursing students' experiences of anxiety producing situations in the clinical setting. Contemp Nurse. 2003; 14(2):145-155. 4. Sarikaya O, Civaner M, Kalaca S. 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Address correspondence to Scott Heinerichs, EdD, ATC, Department of Sports Medicine, West Chester University, Sturzebecker Health Science Center, West Chester, PA 19383. Address e-mail to sheinerichs@wcupa.edu. 74 Volume 49 \u000f Number 1 \u000f February 2014 Copyright of Journal of Athletic Training is the property of Allen Press Publishing Services Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. Copyright of Journal of Athletic Training (Allen Press) is the property of Allen Press Publishing Services Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. JSLHR Research Article Development of a Self-Report Tool to Evaluate Hearing Aid Outcomes Among Chinese Speakers Lena L. N. Wonga and Na Hanga Purpose: This article reports on the development of a self-report toolthe Chinese Hearing Aid Outcomes Questionnaire (CHAOQ)to evaluate hearing aid outcomes among Chinese speakers. Method: There were 4 phases to construct the CHAOQ and evaluate its psychometric properties. First, items were selected to evaluate a range of culturally relevant outcomes. These procedures provided evidence for face and content validity. Second, items with inappropriate psychometric properties were eliminated. Items related to listening performance were subjected to exploratory factor analysis to identify the factor structure, which was later confirmed via a confirmatory factor analysis in Phase III. These procedures also ensured content and discriminant validity. Internal consistency reliability was evaluated, and normative data were obtained. Finally, test-retest reliability was evaluated, and construct validity was established by comparing results with corresponding items from the International Outcome Inventory for Hearing Aids. Results: The final 26-item CHAOQ contains (a) 3 scales evaluating speech understanding in situations in which communication is relatively more difficult or easy or includes reduced listening cues; (b) a scale evaluating listening comfort; (c) a scale measuring negative responses; and (d) an item measuring overall satisfaction. Conclusion: The CHAOQ possesses good reliability and validity. T an important role in English. Thus, it is uncertain whether hearing aid (HA) fitting algorithms that were designed to optimize speech understanding in English speakers would produce similar benefits for Mandarin speakers. However, because of a lack of standardized measures, there is limited research on HA fitting and outcomes among Mandarin-Chinese; a review of the literature revealed that almost all studies used functional gain as an outcome measure (see, e.g., Geng, Xia, Sun, & Jin, 2005). Although functional gain could be used to verify amplification to very soft sounds, it does not reflect the ability to hear in daily situations in which the acoustic environment varies. A few studies utilized self-report measures that were designed for the purpose of research (see, e.g., Duan, Zhang, & Peng, 2004) without proper evaluation of the psychometric properties (i.e., reliability and validity). Others used translated versions of measures that were developed in Western societies, and thus some items (e.g., church attendance) were not culturally appropriate to maintain content validity (Beaton, Bombardier, Guillemin, & Ferraz, 2000; Purdy & Jerram, 1998). However, changing some unsuitable items is not recommended he National Bureau of Statistics of China (2006) reported at least 27.8 million people with hearing impairment (HI) in mainland China, 73.58% of whom were people ages 60 years and older. Those ages 60 years and older make up 13.31% of the total population in mainland China (National Bureau of Statistics of China, 2010), and this number will increase by 3%-4% every year (Jia & Liu, 2004). Together with a recent per capita increase in income in mainland China (Shi & Tao, 2005), a dramatic increase in hearing aid sales is expected. Mandarin is the national language in mainland China. It is a tonal language, in which tones are lexically meaningful. Xu and Pfingst (2003) found that temporal fine structure (i.e., short-term spectral changes) is relatively more important for Mandarin tonal perception than temporal envelope information (overall amplitude fluctuations), which plays a University of Hong Kong, China Correspondence to Lena L. N. Wong: llnwong@hku.hk Editor: Craig Champlin Associate Editor: Chang Liu Received January 30, 2013 Revision received June 18, 2013 Accepted January 1, 2014 DOI: 10.1044/2014_JSLHR-H-13-0024 1548 Key Words: emotional response, hearing aid, listening comfort, listening performance, reduced cues, satisfaction, use Disclosure: The authors have declared that no competing interests existed at the time of publication. Journal of Speech, Language, and Hearing Research Vol. 57 1548-1563 August 2014 A American Speech-Language-Hearing Association because the original properties of items or subscales will not be maintained (Hyde, 2000). A Chinese version of the International Outcome Inventory for Hearing Aids (IOI-HA; Cox, Stephens, & Kramer, 2002) is available to evaluate outcomes in seven domains: usage, benefit, residual activity limitation, satisfaction, residual participation restriction, effects of the hearing impairment on significant others, and quality of life. Specific situations were not mentioned in the IOI-HA. For example, the item on Benefit states, \"Think about the situation where you most wanted to hear better, before you got your present hearing aid(s). Over the past two weeks, how much has the hearing aid helped in that situation?\" This type of item allows HA users to define which listening situation they most want to hear, and variations across individuals are expected. This single-item evaluation of benefit is easy to administer and is not limited by differences in the HA users' cultures and geographic regions. However, it also limits the application of the IOI-HA to a subjective judgment by the user and may not allow troubleshooting and comparison of outcomes in specific situations across listeners. The clinician may not be able to learn about benefits in other listening situations and therefore cannot gain a full understanding of hearing aid outcomes. Domains of Hearing Aid Outcomes Hearing aid outcomes may be measured in terms of performance, listening comfort, benefit, satisfaction with hearing aids, usage, and reduction in negative emotional responses and participation restrictions. Aided performance in various situations is probably one of the most frequently measured outcomes of hearing aids. Aid users differ in what they regard as important listening situations (Cox & Alexander, 1999; Cox & Gilmore, 1990; Demorest & Erdman, 1987; Dillon, James, & Ginis, 1997; Gatehouse, 1999; Kramer, Kapteyn, Festen, & Tobi, 1995; Ringdahl, Eriksson-Mangold, & Andersson, 1998; Ventry & Weinstein, 1982). Effective communication in noisy situations is often regarded the most important benefit of HA use (Ruscetta, Palmer, Durrant, Grayhack, & Ryan, 2005), and Dillon, Birtles, and Lovegrove (1999) reported that device users were concerned about hearing performance in a wide range of situations. This may include conversation in quiet and noise, TV viewing and radio listening at normal volume, phone conversations, a telephone ring from another room, the sound of the doorbell or knocking, traffic noise, and speech in church or at meetings. Brooks (1990) found person-to-person conversation and TV listening were more important than family conversation or conversation during other social activities such as luncheon clubs, social clubs or church, telephone use, and outdoor use of the aids in a group of older people. Overall, previous research indicates that there may be five general types of listening situations (Cox & Gilmore, 1990; Walden, Demorest, & Hepler, 1984): (a) favorable situations in which conversation occurs at normal conversational level in a quiet place and the speaker is close to the listener; (b) difficult situations in which communication occurs in background noise, in group situations, or with reverberation; (c) situations in which reduced cues are present, there is distance between communication partners, speech is at a low intensity, or visual cues are absent; (d) detection of environmental sounds; and (e) comfort with loud sounds. Performance is often measured pre- and postfitting to derive benefit ratings in a variety of listening situations. Satisfaction is defined as a pleasurable feeling as an outcome of product performance evaluation in relation to expectations (Wong, Hickson, & McPherson, 2003). It has been regarded as the \"gold standard\" to determine outcomes in the HA industry in recent years (Kochkin, 2000; Uriarte, Denzin, Dunstan, Sellars, & Hickson, 2005; Wong et al., 2003). Studies show that about 70% of users are satisfied with their HAs (Parving, 2003; Purdy & Jerram, 1998; Wong et al., 2003). Satisfaction can be measured as a single global measure (Brooks, 1985) or a profile consisting of many items (Cox & Alexander, 1999; Kochkin, 1998, 2002). Global satisfaction could be assessed with the question, \"Are you satisfied with your hearing aids?\" Profile measurements evaluate satisfaction in specific facets, such as listening performance, residual negative emotional responses, participation restrictions, listening comfort, device use problems, service, and cost (Cox & Alexander, 1999; Dillon et al., 1999; Kochkin, 2005). Among these areas, listening performance probably contributes most to the rating of satisfaction (Wong et al., 2003). Satisfaction could be profiled with tools such as the Satisfaction with Amplification in Daily Life (SADL; Cox & Alexander, 1999) and MarkeTrak survey (Kochkin, 2005). Negative emotional response is often reduced in HA users, compared with those who do not use aids. These emotional responses include feeling embarrassed, frustrated, stupid or dumb, handicapped, upset, depressed, uncomfortable, irritable, and left out. Hearing impairment is also associated with participation restrictions, particularly in activities such as going to church, shopping, and visiting friends (Ventry & Weinstein, 1982). These issues may improve with HA use (Humes, Garner, Wilson, & Barlow, 2001; Humes, Halling, & Coughlin, 1996; Malinoff & Weinstein, 1989; Moore, Stainsby, Alcantara, & Kuhnel, 2004; Taylor, 1993). On the other hand, HA stigma is often reported (Cox & Alexander, 1999). Although there are widely accepted means to evaluate performance, benefit, satisfaction, negative responses, and participation restrictions in English speakers, measurement of aid usage is not as straightforward. Aid usage can be measured in terms of average daily hour usage and frequency of use (e.g., always, often). Accuracy of reported usage is affected by how well the person remembers and how the data are collected; overestimation of use time is common and can be by as much as an average of 4 hr per day (Humes et al., 1996). Because of uncertainties regarding measurement of usage, we did not attempt to evaluate it in the current study. Wong & Hang: Amplification Outcomes in Chinese Speakers 1549 Aims of the Study Because of a lack of standardized self-report tools, we developed the Chinese Hearing Aid Outcomes Questionnaire (CHAOQ) to assess outcomes in four domains: (a) performance as the ability to understand speech in various situations and the ability to detect important environmental sounds (Cox & Alexander, 1999; Dillon et al., 1997; Gatehouse, 1999); (b) listening comfort; (c) negative responses (e.g., frustration, participation restrictions); and (d) overall satisfaction. This article reports on the development of the CHAOQ and our subsequent testing of its reliability and validity. Method There were three phases of data collection. First, we generated the initial items and a rating scale with equal intervals. These procedures ensured face and content validity. Second, we used exploratory factor analysis (EFA) to categorize listening performance (LP) items into scales, and, based on results from an internal consistency reliability analysis, inappropriate items were eliminated. Third, the factor structure of the final CHAOQ, as found in Phase II of the research, was confirmed via a confirmatory factor analysis (CFA). That is, CFA was used to confirm whether the items that were found to be associated with specific factors in the EPA were valid in another sample. Normative data and internal consistency reliability were examined. These procedures also provided evidence for construct validity. In Part 2 of this Phase II, test-retest reliability and construct validity were evaluated. Statistical analyses were conducted using SPSS 12.0., except that confirmatory factor analysis was conducted using AMOS 4.0 (Arbuckle, 1997) software. This research was approved by the Human Research Ethics Committee for Non-Clinical Faculties, at the University of Hong Kong. Informed consent was obtained from all subjects. Phase I: Selecting Items and Generating Rating Scales for the Initial Questionnaire Subjects and equipment. To generate initial items through a focus group, convenience sampling was used to recruit 13 current HA users attending a private hearing clinic in Beijing. They had worn HAs for at least 3 months prior to the study. There were nine men and four women, ages 20-77 years (M = 54.5, SD = 19.2). The interviews were recorded using a JNC USB-11 digital audio recorder for verbatim transcription. Three experienced audiologists were interviewed to generate additional items, and another two examined the content validity of items. Another 25 subjects with self-reported normal hearing helped to determine the rating scales. All subjects were able to communicate fluently in Mandarin Chinese, although they may have also been able to speak another native dialect. Procedure. As there were no standardized self-report outcome measures in mainland China, only those in English were reviewed and translated. The items were generated to address the four HA outcomes commonly considered in previous research, as discussed previously. The items covered three general types of communication situations, as defined in previous research (Cox & Gilmore, 1990; Walden et al., 1984): (a) favorable situations, in which conversation occurs at normal conversational level in a quiet place, and the speaker is close to the listener; (b) difficult situations (e.g., noise); and (c) situations in which reduced cues are present, there is distance between communication partners, speech is at a low intensity, or visual cues are absent. Items that were culturally inappropriate were excluded (e.g., attendance of church, parties, or picnics); additional items were written to cover a range of culturally relevant situations. Subjects were invited to respond to four open-ended questions and to elaborate on specific situations in their daily lives: (a) What do you expect from your HAs? (b) In which situations do you still have trouble hearing with HAs? (c) In which situations do you find hearing with HAs easier? and (d) What are the types of amplified sounds that would cause discomfort? Although the second and third questions seemed to be inquiring similar information, they differed in that the second question focused on difficulties and the third one addressed more positive experiences. These questions were addressed to the subjects, and clarification was sought when needed. Items were extracted from the recorded transcriptions. Three audiologists also were interviewed about how their clients would respond to the same four open-ended questions. Items assessing negative responses were translated from the Hearing Handicap Inventory for the ElderlyScreening Version (HHIE-S; Ventry & Weinstein, 1983). The item on religious service was eliminated because of cultural irrelevance. To avoid repetition of the items from the focus group interview, three items related to listening performance were excluded. Six items remained, including three on emotional responses (feeling embarrassed, frustrated, or handicapped) and three on social responses (problems when visiting friends or others, arguments with family members, and HI hampering personal or social life). Because the use of hearing devices would ideally reduce negative effects on significant others as well (Cox et al., 2002; Stark & Hickson, 2004), an item was added to assess frustration among family members. To ensure content validity, two other experienced audiologists independently evaluated these items. An item was deleted if any of the two audiologists felt that most HA users would not experience the situation or if the item tapped more than one domain. An item was reworded if it was not well written or was unclear. A pre-study was used to determine Chinese descriptors of frequency of occurrence that were equal intervals apart (Edwards, 1957). The rating descriptors that were commonly used in English self-report measures were used as a reference, and a total of 15 translations describing frequency of occurrence of problems were obtained from the English-Chinese Dictionary (Lu, 2002) and the Rating Scale for Mental Health (Wang, Wang, & Ma, 1999). Another 25 words describing degrees of satisfaction were adopted from the Rating Scale 1550 Journal of Speech, Language, and Hearing Research Vol. 57 1548-1563 August 2014 for Mental Health (Wang et al., 1999). Descriptors were rated, with 0 indicating no problem at all and 100 indicating problems happening all the time. A rating of 0 would indicate that the individual was not at all satisfied, and 100 suggest a feeling of complete satisfaction. Results and discussion. In the focus group interview, responses to the first question\"What do you expect from your HAs?\"showed that all subjects expected cheaper aids and to hear speech clearly. Hearing telephone conversations, undistorted sounds, and some environmental sounds such as doorbells were important to 38.5%, 30.8%, and 15.4% of subjects, respectively. Five subjects reported embarrassment with HAs. Four subjects (30.8%) requested sweatproof aids. Eight subjects (61.5%) reported frequent repairs and preferred better quality aids. These issues, use problems like battery insertion, and cost concerns did not belong to domains predefined at the outset of the study; therefore, they were not included in the initial item pool. Responses to the second question\"In which situations do you still have trouble hearing with HAs?\"revealed that conversing with more than one partner and in noisy environments were the main complaints, reported by 92.3% and 100% of subjects, respectively, followed by listening to the TV without captions (76.9% of subjects). Four other situations that appeared less frequently in the English literature were added: listening on a bus, at a bus station, at a hospital, and in a wet market (a busy market with stalls selling fresh produce and meat). For the third question\"In which situations do you find hearing with HAs easier?\"all subjects reported that HAs eased listening in quiet surroundings and in one-to-one communication. Conversations with family members and listening to the TV improved for some users (23.1% and 30.8%, respectively). Telephone conversations became easier for 15.4% of subjects. To the final question\"What are the types of amplified sounds that would cause discomfort?\"about 30.8% of subjects reported no discomfort from sounds. Discomfort from wind noise and toilet flushing was reported by 23.1% of subjects. Dishes clattering, high-frequency sounds, and construction noise caused discomfort to one to two persons. Other loud sounds that caused discomfort included door slamming, car horns, bicycle bell ringing, telephone/mobile phone ringing, heavy objects falling on the floor, pre-recorded announcements on a bus, thunder, traffic noise, children crying/screaming, bus braking, women's voices, and keys jangling. Based on responses from the focus groups, 77 items covering the four domains defined in the introduction were generated: (a) LP in terms of speech understanding in 39 situations and detection of nine environmental sounds; (b) 20 types of sounds that could cause discomfort; (c) eight items related to emotional and social response; and (d) an overall satisfaction item. All items were nominated by more than 30% of subjects; some subjects reported discomfort with sounds, and these items were added to profile possible problems and provide information for troubleshooting. Based on the content and relevance of these items, they were assigned by the second author into the four domains. Comments from three audiologists did not generate new items but resulted in 18 items being eliminated or combined with other items, either because the situations did not occur frequently or because two situations were similar. Eight items were reworded to make their meaning clearer. All items were considered to tap corresponding domains. Finally, 59 items remained, with 36 items assessing LP, 14 items evaluating listening comfort, eight items examining negative responses, and one item assessing overall satisfaction. These procedures ensued content validity. The items, except the one evaluating overall satisfaction, were worded negatively to avoid acquiescence, affirmation, or agreement bias (DeVellis, 2003). The seven descriptors with mean ratings closest to equal intervals apart were selected. These were as follows: (always, M = 93.9%, SD = 5.5), (almost always, M = 78.0%, SD = 11.2), (most of the time, M = 70.2%, SD = 9.1), (half of the time, M = 52.4%, SD = 8.5), (sometimes, M = 35.7%, SD = 13.0), (seldom, M = 18.5%, SD = 10.0), and (never, M = 1.9%, SD = 6.8). They were coded from 1 ( always) to 7 ( never). The following were selected for rating overall satisfaction: (totally dissatisfied, M = 7.0%, SD = 9.8), (dissatisfied, M = 20.2%, SD = 15.8), (somewhat dissatisfied, M = 38.7%, SD = 9.2), (neutral, M = 56.7%, SD = 12.3), (somewhat satisfied, M = 68.9%, SD = 8.5), (satisfied, M = 74.0%, SD = 7.6), and (totally satisfied, M = 95.7%, SD = 5.3). They were also coded from 1 to 7, respectively. As Chinese culture is heavily influenced by the Confucian teaching of moderation, it is not unexpected for some Chinese speakers to avoid rating the descriptors \"always,\" \"never,\" and \"total,\" which rested at the extreme ends of the scale (i.e., 0 and 100) (Wong et al., 2009). Phase II: Determining Factor Structure and Selecting Items With Good Internal Consistency Reliability Subjects and procedure. Adults with at least 3 months' HA experience were recruited to ensure that their outcomes had become stabilized (Stephens, 2002). More specific recruitment criteria were not used because the CHAOQ is aimed at assessing outcomes among general users. Subjects were recruited from different socioeconomic and geographical regions: a hospital in Shanghai and four private HA centers in Beijing, Kunming, Foshan, and Shenzhen as well as a random sample of 200 HA users in the GN ReSound customer database. All of the HAs were self-purchased and of various brands and prices. Subjects received the questionnaire by mail or filled it out when they visited the hearing clinic. To ensure that the data collection procedures were equivalent, whether the questionnaires were distributed via mail or in the clinics, staff members at the hearing clinics were instructed not to provide comments or further explanation of the questionnaire items. An item was eliminated if it met at least one of three criteria: (a) the item had more than 5% \"not applicable\" responses or missing data, suggesting that the item may not Wong & Hang: Amplification Outcomes in Chinese Speakers 1551 be relevant to most HA users; (b) the item yielded mean ratings less than 2.0 or greater than 6.0, indicating that particular situations occurred seldom or frequently, respectively, such that ceiling or floor effects might reduce the usefulness of the item as an indicator of outcome; and (c) the item had a standard deviation less than 1.0, suggesting similar degrees of difficulty in the situation. Removing items that met at least one of the criteria above would help ensure discriminant validity. Remaining items that evaluated LP were subjected to EFA with oblique rotation to identify items with jointly varying ratings in response to a common latent variable (or a scale). To evaluate the internal consistency reliability of the CHAOQ, Cronbach's alpha was calculated. Although a value exceeding .90 would indicate excellent reliability and thus suggest that the items in a scale are highly intercorrelated, a Cronbach's alpha of .80 indicates good reliability. EFA was not conducted on items of other domains because they are well accepted as specific domains of outcomes. Results. The 59-item questionnaire was returned by 223 subjects. Those who returned the questionnaire were ages 18-87 (M = 53.3, s = 21.3), and 56.2% of them were male. HA usage ranged from 3 months to 40 years. Of these 223 questionnaires, 85 had missing data and were excluded from the study. EFA was conducted on the remaining 138 questionnaires, which were from 70 men (50.2%) and 68 women (49.8%), ages 18-86 (M = 51