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Table 2 Problems and solutions found during the cultural adaptation process

From: Cultural adaptation and harmonization of four Nordic translations of the revised Premature Infant Pain Profile (PIPP-R)

Problems found Solution Finland Iceland Norway Sweden
Problems related to the original version of the scale
 The application of the scale were not understood Title clarification X X X  
 The word oxygen used to describe both oxygen supply and oxygen saturation Wording changes to distinguish between SaO2 and FiO2 X X X X
 Scale uses both “corrected gestational age” and “gestational age” which respondents found confusing. Changed to “corrected gestational age” throughout the scale X X X X
 Unclear in step 2 which time frame that should be used for assessment Clarification which 30 s that are to be used X X X X
 The term “vital sign” is not explained in the scale Changed to “physiological indicators” X   X X
 In step 3 unclear when to include score for corrected GA and behavioral state Clarifications on when these factors should be included X X X X
Unclear time frame for when to give points for additional oxygen Clarification that it is the first 30 s that are to be assessed   X X X
Problems related to the translated versions of the scale
 Baseline not a familiar term Change of wording    X X
 Not understanding the facial indicator “Brow Bulge” Change of wording     X
 Not understanding the facial indicator “Naso-labial furrow” Change of wording X X X X
 Explanatory word for the different categories (eg minimal, maximal) not making sense Change of wording X X   
Problems that can be solved with education and training
 Unclear if you should assess baseline behavioral state once or several times Education and training X    
 Unclear if it is duration or intensity of pain that is to be assessed Education and training X X X X
 Difficult to assess several parameters at the same time Education and training X X X X
 Would like a guiding instruction for the acquired pain score/a pain algorithm Education and training X X X X
 Uses mean heart rate/oxygen saturation instead of highest/lowest Education and training   X   
 The “+” sign before each scoring category is confusing Education and training   X   
 Difficulties distinguishing between the different behavioral states categories Education and training   X X X
 Unsure about how to assess a decrease in heart rate Education and training    X X
 Difficult to understand how to score if fiO2 is increased Education and training    X  
 Scores for the time when the reaction occurs and not the duration of the reaction Education and training    X  
 Difficult to separate “Brow bulge” from “Eye squeeze” since they are highly correlated Education and training    X  
  1. The described problems were found in the language versions marked with “X”