Trnsltion nd culturl dpttion of ptient hndling ssessment tool. C. Lomi, G. Lomi b, D. Pinotsi Hellenic Institute for Occuptionl Helth nd Sfety, 143 Liosion & 6 Thirsiou Str.,104 45 Athens, Greece. b Onssis Crdic Surgery Center, 356 Syggrou Av., 176 74 Kllithe, Athens, Greece. Abstrct A direct observtion instrument for ssessment of nurses' ptient trnsfer technique (DINO) hs recently been developed in Sweden. The instrument hs stisfctory content nd criterion-relted vlidity s well s cceptble inter-observer relibility. This instrument ws trnslted from Swedish into Greek ccording to interntionl guidelines for instrument trnsltion. This mens tht two independent forwrd trnsltions were done by two bilingul physiotherpists who hve experience in teching nurses nd physiotherpists in ptient trnsfer technique nd one bck trnsltion by bilingul nurse. A first Greek version of the instrument emerged fter consensus meeting with the trnsltors. In order to further detect errors of mening nd concept nonequivlence, this version of the instrument ws finlly discussed with person with gret experience in trnsltion nd pproprite modifictions were mde. Subsequently, the two physiotherpists used the finl Greek version of the instrument to ssess 36 ptient trnsfers. The trnsfers were performed by nurses, nurse's ides, porters nd physiotherpists in n uthentic clinicl setting in the intensive cre unit nd the wrds in n cute hospitl in Athens. The evlution of the interobserver relibility ws shown to be good. Key words: helth cre ergonomics, work technique ssessment, ptient trnsfer. 1. The direct observtion instrument -DINO A direct observtion instrument for ssessment of nurses' ptient trnsfer technique (DINO) hs recently been developed in Sweden. The DINO instrument consists of 16 items divided into three phses of trnsfer: the preprtion, performnce nd result phses. In the preprtion phse, the items describe whether the ptient is encourged to cooperte in the trnsfer, if the nurse corrects the physicl environment, uses trnsferring id(s) nd obtins ssistnce from co-worker. In the performnce phse, the items describe to wht extent the nurse s performnce during the trnsfers fulfils the criteri for good blnce, coordintion, movement economy, nd low lod on the bck/shoulders. In this phse interction nd communiction with the ptient, s well s the ptient s prticiption ccording to movement bility re lso described. In the result phse the items describe if the trnsfer technique chosen by the nurse cuses ny pin, fer or uncertinty nd whether the ptient is in functionl position t the end of the trnsfer. The DINO instrument includes bckground description, s well. This bckground describes the chrcteristics of the nurse, the ptient (for exmple dignosis, weight, bility to communicte nd to perform voluntry movements) nd the environment. These dt re optionl nd cn be collected in dvnce or fter the trnsfer. In the preprtion nd result phses the items re ssessed on nominl scle nd the response lterntives in the ctegories re Yes/No. There is n 1
informtion ctegory included in the preprtion phse to indicte tht the preprtion ws impossible or unnecessry, or irrelevnt. In the performnce phse the items re ssessed on nominl scle nd they re mesured on five-point bipolr rting scle, where 0 mens tht the nurse does not t ll fulfil the criteri, nd 4 tht the nurse totlly fulfils the criteri of the item. All items, informtion ctegories nd the criteri for fulfilling or not, s well s description of how to use the instrument, re provided in the Key to direct observtion instrument. The ssessments with the DINO instrument re done without specil equipment, nd thus the instrument cn be used in both clinicl nd eductionl settings. The instrument hs been shown to hve stisfctory content nd criterion-relted vlidity s well s cceptble inter-observer relibility (1). 2. Trnsltion Permission ws obtined from the uthor of the DINO instrument for trnsltion. Reserchers in the field hve drwn ttention to the most importnt principles of instrument trnsltion, nd specific steps hve been suggested to provide dequte trnsltion (2,3). These re: Secure competent trnsltors who re fmilir with the topic Use bilingul trnsltors, for trnsltion from the originl lnguge, nd for trnsltion bck to the originl lnguge without hving seen the originl version; nd Assemble review pnel, composed of bilinguists nd experts in the field of study, who should refine the trnsltions nd ssess equivlence, congruence nd ny colloquilisms. Two independent forwrd trnsltions of the DINO instrument were done from Swedish into Greek, by two bilingul physiotherpists, who hve mny yers of experience in teching nurses nd physiotherpists in ptient trnsfer technique, both in Sweden nd Greece. Reconcilition meeting between trnsltors resulted in first Greek version of the DINO instrument. A bilingul nurse, with mny yers of experience in both Sweden nd Greece, conducted bck trnsltion of this first Greek version. There were some differences between the two Swedish versions of the DINO instrument since the trnsltions into Greek were not literl. There ws consensus meeting with ll three trnsltors to ensure tht the Greek version of the instrument ws equivlent to the source instrument both conceptully nd linguisticlly. A second Greek version of the instrument emerged. In order to further detect errors of mening nd concept nonequivlence, this second Greek version of the instrument ws finlly discussed with person with gret experience in trnsltion from English, French nd Germn into Greek. For this purpose the English version of the DINO instrument ws used. Some minor modifictions were mde in the second Greek version in order to estblish clrity in Greek. The modifictions mde in the finl Greek version were finlly discussed with the principl uthor of the DINO instrument. Some modifictions were ccepted nd some were rejected. The rejected modifictions re: ) Observtionsinstrumentet ws first modified into Greek s direct observtion nd registrtion. The uthor suggested omitthe word registrtion in the Greek version of the instrument. b) Bkgrundsinformtion ws first modified into Greek s Generl dt. The uthor clrified tht this refers to the bckground of the trnsfer, so the finl trnsltion into Greek is Generl informtion bout the trnsfer. c) Bär sin kropp in the bckground description ws modified into Greek s stnd. The uthor clrified tht ptient cn stnd using the rms tex n mputee, or use wlker. So the finl Greek trnsltion is stnd on his/her feet. d) Flytt sin fötter in the bckground description ws modified into Greek s wlk. The uthor clrified tht ptient cn tke some steps on the site, he/she doesn t need to wlk. The finl Greek trnsltion ws literl trnsltion of the Swedish expression. The modifictions ccepted by the uthor re: ) Fysisk ssistns in the bckground description ws trnslted into Greek s humn help. b) The word regim in the bckground description ws tken wy in the Greek trnsltion c) The word motivers in item 1 in the preprtion phse ws trnslted into Greek s encourged. There ws request from the uthor tht the Greek version of the instrument should mintin its nme, DINO. This ws not possible. The sme procedure ws followed for the trnsltion of the Key to direct observtion instrument, except tht in this cse the English version ws not included in the trnsltion procedure. 3. Dt collection Approprite creful trnsltion is not substitute for psychometric evlution of n instrument. Aprt from rigorous methods of trnsltion nd ssessment for culturl equivlence, the psychometric properties of the 2
Tble 1 The percentge of rtings in ech ctegory by the two observers (A nd B) in the preprtion nd the result phse of the instrument. 36 trnsfers were rted Ctegories No Yes Informtion ctegories Observer Observer Observer Α Β Α Β Α Β Preprtion phse 1. Is the ptient encourged to cooperte? b 19.4 8.3 44.4 55.6 2. Is enough spce prepred for the trnsfer? 0 0 22.2 0 77.8 100.0 3. Wheelchir nd other objects tht the ptient is trnsferred between positioned nd locked in correct wy? 8.3 5.6 25.0 11.1 66.7 83.4 4. Is the height of the bed djusted? 52.8 41.7 30.6 36.1 16.6 22.3 5. Use of trnsferring id(s)? 2.8 0 5.6 5.6 91.7 94.4 6. Correct use of the trnsferring id(s)? 5.6 8.3 0 2.8 94.4 88.9 7. Are there enough nurses? 0 5.6 100.0 94.4 0 0 Result phse 14. Does the trnsfer technique chosen by the nurse cuse ny pin to the ptient? b 44.4 47.2 19.4 16.7 15. Does the trnsfer technique chosen by the nurse cuse ny feelings of fer or 41.7 50.0 22.2 13.9 uncertinty in the ptient? b 16. Is the ptient in functionl position t the end of the trnsfer? 8.3 5.6 91.7 94.4 No such ctegories re included in this item b Non pplicble vlues for 13 intubted ptients instrument should be ressessed in ech culture/country tht the instrument is to be used in (4). In this study the inter-observer relibility of the Greek version ws tested. In the Swedish study video recordings with ptient trnsfers were used for the trining of the observers who prticipted in the relibility nd vlidity process. These recordings were used to show cler exmples from ech item of the instrument. In our study the sme physiotherpists tht were involved in the trnsltion procedure used the DINO instrument to ssess the inter-observer relibility. The uthor of the instrument suggested following the Key nd ssessing our own video films with uthentic ptient trnsfers in order to hve common understnding of the items nd ctegories. She lso recommended doing some test ssessments with the Greek version of the instrument before the finl ssessments. It ws neither possible to mke video recordings of ptient trnsfers nor ws it possible to borrow the Swedish video recordings for eductionl purposes of the Greek observers. In order to hve the sme understnding of the items nd ctegories of the instrument, the observers did four test ssessments of uthentic ptient trnsfers with the Greek version of the DINO instrument. Differences in the ssessments between the two observers were discussed in consensus meeting. Questions regrding specific items were further discussed with the uthor of the instrument (by e-mil) who clrified the mening of some items. This ws proved to be n essentil step in the eductionl process of the observers, since some incorrect ssumptions were discovered. Subsequently, the two physiotherpists used the finl Greek version of the instrument to ssess totl of 36 ptient trnsfers: 19 trnsfers in bed (from side to side, higher up in the bed, rising the upper prt of the bed to tke n X- Ry, from lying to sitting), 7 from bed to bed, 7 trnsfers from sitting to sitting, 2 trnsfers from sitting to stnding nd 1 from stnding to sitting. It hs to be pointed out tht in 13 trnsfers the ptients were intubted. The trnsfers were performed by nurses, nurse's ides, porters nd physiotherpists in n uthentic clinicl setting in the intensive cre unit nd the wrds in n cute hospitl in Athens, during period of two weeks. 4. Sttisticl nlysis The inter-rter relibility ws clculted s the percentge of greement between the two observers t time, for ech item in the instrument. The kpp coefficient (k) ws lso clculted for the two observers t time for items mesured on nominl level. Kpp, the proportion of greement corrected for the greement expected by chnce, where ll disgreements re regrded s eqully importnt, ws interpreted on three degree scle: k>0.75=excellent greement, 0.40-0.75=fir to good greement nd <0.40=poor greement (5). 3
Tble 2 The percentge of rtings by the two observers (A nd B) within ech ctegory for items ssessed in the performnce phse (items 8-13) Observer Performnce phse Α Β 8. Good blnce 0 0 0 2 2.8 2.8 3 2.8 0 4 b 94.4 97.2 9. Good coordintion 0 5.6 11.1 2 0 0 3 2.8 0 4 b 91.7 88.9 10. Good movement economy 0 88.9 77.8 1 0 2.8 2 8.3 5.6 3 0 5.6 4 b 2.8 8.3 11. How is the lod on the bck nd shoulders? 0 High lod 88.9 83.3 2 5.6 2.8 3 0 5.6 4 Low lod 5.6 8.3 12. To wht extend re the criteri in communiction nd interction with the ptient fulfilled? 0 11.1 13.9 1 0 2.8 2 11.1 11.1 3 0 2.8 4 b 41.7 33.3 ΝΑ c 36.1 36.1 13. Is the ptient llowed to prticipte ccording to her/his bility to perform voluntry movements? 0 30.6 25.0 1 0 5.6 2 13.9 13.9 3 2.8 2.8 4 b 16.7 16.7 ΝΑ c 36.1 36.1 0=not t ll fulfilled 4=totlly fulfilled c Non pplicble vlues for 13 intubted ptients The intr-clss correltion coefficient (ICC) nd 95% confidence intervl (CI) were clculted between the two observers for items 8-13. The ICC ws clculted using one-wy nlysis of vrince with repeted mesurers, nd rters rndom effects model s described by Fleiss (6). The sttisticl pckge used for the nlysis ws SPSS version. 4.1 Inter-observer relibility For ech one or the two observers the distributions between the Yes, No nd informtion ctegories for the items in the preprtion nd result phses re shown in tble 1. For items 1-7 there is no obvious greement therefore the k coefficient will be informtive. For items 14-16 the percentge of the nswers seems to be more consistent between the two observers. Nevertheless, lso in the result phse (items 14-16) the k coefficient will provide extr informtion. The distributions between the five points in the bipolr rting scles for the items in the performnce phse re shown in tble 2. For items 1-11 the mjority of the nswers re concentrted on the poles of the scle. Thus, for items 8 nd 9 both observers nswered tht good blnce ws totlly fulfilled more thn 90% of ssessments. Likewise, for item 10 the mjority of trnsfers both observers nswered tht good economy of movements ws not t ll fulfilled. In item 11 both nswered tht the lod on the bck nd shoulders ws high for more thn 80% ssessments. Regrding items 12 nd 13, 36.1% of trnsfers, both observers did not hve n pplicble nswer for the specific item s the corresponding ptients were intubted. The greement between the ssessments of the two observers for the preprtion phse (items 1-7) nd results phse (items 14-16) ws mostly fir to good, ccording to the k vlues (tble 3). Four k vlues exceeded 0.75 (i.e. excellent greement) nd none of them ws below 0.4 (i.e. poor greement). Item 4 hd the lowest k vlue (0.49) in the two observer comprison. In items 2, 5, 6, 7 it ws not possible to clculte the k vlues, since only one observer used the whole scle of nswers. Nevertheless, the percentge of greement for items 5 to 7 is higher thn 90%. The greement between the ssessments of the two observers regrding the performnce phse (items 8-13) ws good ccording to both the percentge of greements nd the ICCs (tble 4). 4
Tble 3 Inter-observer relibility of items 1-7 nd 14-16, expressed s kpp coefficient (k) nd the percentge of greement in per cent (%) between the two observers (A, B), n=36. Observers Α nd Β % k Preprtion phse 1. Is the ptient encourged to cooperte? 88.8 0.82 2. Is enough spce prepred for the trnsfer? 77.8 3. Wheelchir nd other objects tht the ptient is trnsferred between. positioned nd locked in correct wy? 75.1 0.52 4. Is the height of the bed djusted? 66.7 0.49 5. Use of trnsferring id(s)? 91.7 6. Correct use of the trnsferring id(s)? 91.7 7. Are there enough nurses? 94.4 Result phse 14. Does the trnsfer technique chosen by the nurse cuse ny pin to the ptient? 97.2 0.96 15. Does the trnsfer technique chosen by the nurse cuse ny feelings of fer or uncertinty in the ptient? 86.1 0.78 16. Is the ptient in functionl position t the end of the trnsfer? 97.3 0.79 Not possible to clculte Tble 4 Inter-observer relibility of items 8-13 expressed s ICC with 95% CI nd the percentge of greement in per cent (%) between pirs of observers. nd ll two observers (A. B). n=36. Α nd Β % CCI 95% CI Performnce phse 8. Good blnce 97 0.94 0.88-0.97 9. Good coordintion 91 0.78 0.57-0.89 10. Good movement economy 81 0.63 0.27-0.81 11. How is the lod on the bck nd shoulders? 92 0.85 0.71-0.93 12. To wht extend re the criteri in communiction nd interction with the ptient fulfilled? 13. Is the ptient llowed to prticipte ccording to her/his bility to perform voluntry movements? 86 0.89 0.73-0.95 86 0.94 0.86-0.96 5. Discussion The kpp vlue depends on n even distribution mong the ctegories in the items, which implies tht if ctegory occurs seldom or not t ll, it is difficult to obtin kpp vlue. This ws the cse in four of the items in the instrument. The kpp vlue for item 1 (ptient encourged to cooperte) ws shown to be excellent between the two observers. In items 14 (trnsfer technique chosen by the nurse cusing ny pin to the ptient) nd 16 (functionl position of the ptient t the end of the trnsfer) the greement ws excellent between the two observers nd the percentge of greement ws high (97.3 for both items). ICC ws found to be between 0.85 to 0.94 for 4 items referring to the performnce phse, which could be considered s quite good relibility nd it ws found 0.78 nd 0.63 for two items (9 nd 10), which could be considered s good relibility. This indictes tht the instrument produces similr results when used by different observers. References [1] Johnsson C, Kjellberg K, Kjellberg A, Lgerström M. A direct observtion instrument for ssessment of nurses ptient trnsfer technique (DINO). Applied ergonomics (2004) 35:591-601. [2] Medicl Outcomes Trust. Trust introduces new trnsltion criteri. Medicl Outcomes Trust Bulletin (1997) 5(4):1-4. [3] Trnsltion of n Instrument. The US-Nordic fmily Dynmics Nursing Reserch Project. M. White, G. Elnder. Scnd J Cring Sci (1992) Vol. 6, No. 3 161-4. [4] Qulity trnsltions no substitution for psychometric evlution P. R. Reese, A. Joseph. Qulity of Life Reserch, (1995) Vol 4, 573-4. [5] Fleiss JL. Sttisticl Methods for Rtes nd Proportions. Wiley, New York, 1981. [6] Fleiss JL. The Design nd Anlysis of Clinicl Experiments. Wiley, New York, 1986. 5