Translation and cultural adaptation of a patient handling

assessment tool.
C. Lomi a, G. Lomi b, D. Pinotsi a
a
Hellenic Institute for Occupational Health and Safety, 143 Liosion & 6 Thirsiou Str.,104 45 Athens, Greece.
b
Onassis Cardiac Surgery Center, 356 Syggrou Av., 176 74 Kallithea, Athens, Greece.

Abstract

A direct observation instrument for assessment of nurses' patient transfer technique (DINO) has recently
been developed in Sweden. The instrument has satisfactory content and criterion-related validity as well as
acceptable inter-observer reliability.
This instrument was translated from Swedish into Greek according to international guidelines for
instrument translation. This means that two independent forward translations were done by two bilingual
physiotherapists who have experience in teaching nurses and physiotherapists in patient transfer technique and one
back translation by a bilingual nurse. A first Greek version of the instrument emerged after a consensus meeting
with the translators. In order to further detect errors of meaning and concept nonequivalence, this version of the
instrument was finally discussed with a person with great experience in translation and appropriate modifications
were made. Subsequently, the two physiotherapists used the final Greek version of the instrument to assess 36
patient transfers. The transfers were performed by nurses, nurse's aides, porters and physiotherapists in an authentic
clinical setting in the intensive care unit and the wards in an acute hospital in Athens. The evaluation of the inter-
observer reliability was shown to be good.

Key words: health care ergonomics, work technique assessment, patient transfer.

1. The direct observation instrument -DINO
A direct observation instrument for assessment of
nurses' patient transfer technique (DINO) has recently
been developed in Sweden. The DINO instrument
consists of 16 items divided into three phases of a
transfer: the preparation, performance and result
phases.
In the preparation phase, the items describe
whether the patient is encouraged to cooperate in the
transfer, if the nurse corrects the physical
environment, uses transferring aid(s) and obtains
assistance from a co-worker. In the performance
phase, the items describe to what extent the nurse’s
performance during the transfers fulfils the criteria for
good balance, coordination, movement economy, and
low load on the back/shoulders. In this phase
interaction and communication with the patient, as
well as the patient’s participation according to
movement ability are also described. In the result
phase the items describe if the transfer technique
chosen by the nurse causes any pain, fear or
uncertainty and whether the patient is in a functional
position at the end of the transfer.
The DINO instrument includes a background
description, as well. This background describes the
characteristics of the nurse, the patient (for example
diagnosis, weight, ability to communicate and to
perform voluntary movements) and the environment.
These data are optional and can be collected in
advance or after the transfer.
In the preparation and result phases the items are
assessed on a nominal scale and the response
alternatives in the categories are Yes/No. There is an
1
information category included in the preparation phase
to indicate that the preparation was impossible or
unnecessary, or irrelevant. In the performance phase
the items are assessed on a nominal scale and they are
measured on a five-point bipolar rating scale, where 0
means that the nurse does not at all fulfil the criteria,
and 4 that the nurse totally fulfils the criteria of the
item.
All items, information categories and the
criteria for fulfilling or not, as well as a description of
how to use the instrument, are provided in the “Key to
direct observation instrument”.
The assessments with the DINO instrument are
done without special equipment, and thus the
instrument can be used in both clinical and
educational settings. The instrument has been shown
to have satisfactory content and criterion-related
validity as well as acceptable inter-observer reliability
(1).
2. Translation
Permission was obtained from the author of the
DINO instrument for translation. Researchers in the
field have drawn attention to the most important
principles of instrument translation, and specific steps
have been suggested to provide adequate translation
(2,3). These are:
Secure competent translators who are familiar
with the topic
Use bilingual translators, for translation from the
original language, and for translation back to the
original language without having seen the original
version; and
Assemble a review panel, composed of bilinguists
and experts in the field of study, who should
refine the translations and assess equivalence,
congruence and any colloquialisms.
Two independent forward translations of the
DINO instrument were done from Swedish into
Greek, by two bilingual physiotherapists, who have
many years of experience in teaching nurses and
physiotherapists in patient transfer technique, both in
Sweden and Greece. Reconciliation meeting between
translators resulted in a first Greek version of the
DINO instrument. A bilingual nurse, with many years
of experience in both Sweden and Greece, conducted a
back translation of this first Greek version. There were
some differences between the two Swedish versions of
the DINO instrument since the translations into Greek
were not literal. There was a consensus meeting with
all three translators to ensure that the Greek version of
the instrument was equivalent to the source instrument
both conceptually and linguistically. A second Greek
version of the instrument emerged. In order to further
detect errors of meaning and concept nonequivalence,
this second Greek version of the instrument was
finally discussed with a person with great experience
in translation from English, French and German into
Greek. For this purpose the English version of the
DINO instrument was used. Some minor
modifications were made in the second Greek version
in order to establish clarity in Greek.
The modifications made in the final Greek
version were finally discussed with the principal
author of the DINO instrument. Some modifications
were accepted and some were rejected.
The rejected modifications are:
a) “Observationsinstrumentet” was first modified into
Greek as “direct observation and registration”. The
author suggested omitthe word “registration” in the
Greek version of the instrument.
b) Bakgrundsinformation” was first modified into
Greek as “General data”. The author clarified that this
refers to the background of the transfer, so the final
translation into Greek is “General information about
the transfer”.
c) “Bära sin kropp” in the background description was
modified into Greek as “stand”. The author clarified
that a patient can stand using the arms tex an amputee,
or use a walker. So the final Greek translation is
“stand on his/her feet”.
d) “Flytta sina fötter” in the background description
was modified into Greek as “walk”. The author
clarified that a patient can take some steps on the site,
he/she doesn’t need to walk. The final Greek
translation was a literal translation of the Swedish
expression.
The modifications accepted by the author are:
a) “Fysisk assistans” in the background description
was translated into Greek as “human help”.
b) The word “regim” in the background description
was taken away in the Greek translation
c) The word “motiveras” in item 1 in the preparation
phase was translated into Greek as ‘encouraged”.
There was a request from the author that the Greek
version of the instrument should maintain its name,
DINO. This was not possible.
The same procedure was followed for the
translation of the “Key to direct observation
instrument”, except that in this case the English
version was not included in the translation procedure.
3. Data collection
Appropriate careful translation is not a substitute
for psychometric evaluation of an instrument. Apart
from rigorous methods of translation and assessment
for cultural equivalence, the psychometric properties
of the
2
Table 1
The percentage of ratings in each category by the two observers (A and B) in the preparation and the result phase of
the instrument. 36 transfers were rated
Categories
No Yes Information
categories
Observer Observer Observer
Α Β Α Β Α Β
Preparation phase
1. Is the patient encouraged to cooperate?b 19.4 8.3 44.4 55.6 a a

2. Is enough space prepared for the transfer? 0 0 22.2 0 77.8 100.0

3. Wheelchair and other objects that the
patient is transferred between positioned 8.3 5.6 25.0 11.1 66.7 83.4
and locked in a correct way?
4. Is the height of the bed adjusted? 52.8 41.7 30.6 36.1 16.6 22.3
5. Use of transferring aid(s)? 2.8 0 5.6 5.6 91.7 94.4
6. Correct use of the transferring aid(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 phase
14. Does the transfer technique chosen by the a a
44.4 47.2 19.4 16.7
nurse cause any pain to the patient?b
15. Does the transfer technique chosen by the
a a
nurse cause any feelings of fear or 41.7 50.0 22.2 13.9
uncertainty in the patient?b
16. Is the patient in a functional position at the a a
8.3 5.6 91.7 94.4
end of the transfer?
a
No such categories are included in this item
b
Non applicable values for 13 intubated patients

instrument should be reassessed in each
culture/country that the instrument is to be used in (4).
In this study the inter-observer reliability of the Greek
version was tested.
In the Swedish study video recordings with
patient transfers were used for the training of the
observers who participated in the reliability and
validity process. These recordings were used to show
clear examples from each item of the instrument. In
our study the same physiotherapists that were involved
in the translation procedure used the DINO instrument
to assess the inter-observer reliability. The author of
the instrument suggested following the Key and
assessing our own video films with authentic patient
transfers in order to have a common understanding of
the items and categories. She also recommended
doing some test assessments with the Greek version of
the instrument before the final assessments. It was
neither possible to make video recordings of patient
transfers nor was it possible to borrow the Swedish
video recordings for educational purposes of the
Greek observers. In order to have the same
understanding of the items and categories of the
instrument, the observers did four test assessments of
authentic patient transfers with the Greek version of
the DINO instrument. Differences in the assessments
between the two observers were discussed in a
consensus meeting. Questions regarding specific items
were further discussed with the author of the
instrument (by e-mail) who clarified the meaning of
some items. This was proved to be an essential step in
the educational process of the observers, since some
incorrect assumptions were discovered.
Subsequently, the two physiotherapists used the
final Greek version of the instrument to assess a total
of 36 patient transfers: 19 transfers in bed (from side
to side, higher up in the bed, raising the upper part of
the bed to take an X- Ray, from lying to sitting), 7
from bed to bed, 7 transfers from sitting to sitting, 2
transfers from sitting to standing and 1 from standing
to sitting. It has to be pointed out that in 13 transfers
the patients were intubated. The transfers were
performed by nurses, nurse's aides, porters and
physiotherapists in an authentic clinical setting in the
intensive care unit and the wards in an acute hospital
in Athens, during a period of two weeks.
4. Statistical analysis
The inter-rater reliability was calculated as the
percentage of agreement between the two observers at
a time, for each item in the instrument. The kappa
coefficient (k) was also calculated for the two
observers at a time for items measured on a nominal
level. Kappa, the proportion of agreement corrected
for the agreement expected by chance, where all
disagreements are regarded as equally important, was
interpreted on a three degree scale: k>0.75=excellent
agreement, 0.40-0.75=fair to good agreement and
<0.40=poor agreement (5).
3
 The intra-class correlation coefficient (ICC) and a
Table 2 95% confidence interval (CI) were calculated between
The percentage of ratings by the two observers (A and the two observers for items 8-13. The ICC was
B) within each category for items assessed in the calculated using one-way analysis of variance with
performance phase (items 8-13) repeated measurers, and a raters’ random effects
Items Observer model as described by Fleiss (6).
Performance phase Α Β The statistical package used for the analysis was
8. Good balance SPSS version.
0a 0 0
1 0 0 4.1 Inter-observer reliability
2 2.8 2.8
3 2.8 0
4b 94.4 97.2 For each one or the two observers the
distributions between the “Yes”, “No” and
9. Good coordination a “information categories” for the items in the
0a 5.6 11.1 preparation and result phases are shown in table 1.
1 0 0 For items 1-7 there is no obvious agreement
2 0 0 therefore the k coefficient will be informative. For
3 2.8 0 items 14-16 the percentage of the answers seems to be
4b 91.7 88.9 more consistent between the two observers.
Nevertheless, also in the result phase (items 14-16) the
10. Good movement economy
0a 88.9 77.8 k coefficient will provide extra information.
1 0 2.8 The distributions between the five points in the
2 8.3 5.6 bipolar rating scales for the items in the performance
3 0 5.6 phase are shown in table 2. For items 1-11 the
4b 2.8 8.3 majority of the answers are concentrated on the poles
of the scale. Thus, for items 8 and 9 both observers
11. How is the load on the back and answered that good balance was totally fulfilled more
shoulders? than 90% of assessments. Likewise, for item 10 the
0 High load 88.9 83.3
majority of transfers both observers answered that
1 0 0
2 5.6 2.8 good economy of movements was not at all fulfilled.
3 0 5.6 In item 11 both answered that the load on the back and
4 Low load 5.6 8.3 shoulders was high for more than 80% assessments.
Regarding items 12 and 13, 36.1% of transfers,
12. To what extend are the criteria in both observers did not have an applicable answer for
communication and interaction the specific item as the corresponding patients were
with the patient fulfilled? intubated.
0a 11.1 13.9 The agreement between the assessments of the
1 0 2.8
two observers for the preparation phase (items 1-7)
2 11.1 11.1
3 0 2.8 and results phase (items 14-16) was mostly fair to
4b 41.7 33.3 good, according to the k values (table 3). Four k values
ΝΑc 36.1 36.1 exceeded 0.75 (i.e. excellent agreement) and none of
them was below 0.4 (i.e. poor agreement). Item 4 had
13. Is the patient allowed to participate the lowest k value (0.49) in the two observer
according to her/his ability to comparison. In items 2, 5, 6, 7 it was not possible to
perform voluntary movements? calculate the k values, since only one observer used
0a 30.6 25.0 the whole scale of answers. Nevertheless, the
1 0 5.6
percentage of agreement for items 5 to 7 is higher than
2 13.9 13.9
3 2.8 2.8 90%.
4b 16.7 16.7 The agreement between the assessments of
ΝΑc 36.1 36.1 the two observers regarding the performance phase
a
0=not at all fulfilled (items 8-13) was good according to both the
b
4=totally fulfilled percentage of agreements and the ICCs (table 4).
c
Non applicable values for 13 intubated patients

4
Table 3
Inter-observer reliability of items 1-7 and 14-16, expressed as kappa coefficient (k) and the percentage of agreement
in per cent (%) between the two observers (A, B), n=36.
Items Observers Α and Β
% k
Preparation phase
1. Is the patient encouraged to cooperate? 88.8 0.82
a
2. Is enough space prepared for the transfer? 77.8
3. Wheelchair and other objects that the patient is transferred between.
75.1 0.52
positioned and locked in a correct way?
4. Is the height of the bed adjusted? 66.7 0.49
a
5. Use of transferring aid(s)? 91.7
a
6. Correct use of the transferring aid(s)? 91.7
a
7. Are there enough nurses? 94.4

Result phase
14. Does the transfer technique chosen by the nurse cause any pain to the
97.2 0.96
patient?
15. Does the transfer technique chosen by the nurse cause any feelings of fear
86.1 0.78
or uncertainty in the patient?
16. Is the patient in a functional position at the end of the transfer? 97.3 0.79
a
Not possible to calculate

Table 4
Inter-observer reliability of items 8-13 expressed as ICC with 95% CI and the percentage of agreement in per cent
(%) between pairs of observers. and all two observers (A. B). n=36.
Items Α and Β
% CCI 95% CI
Performance phase
8. Good balance 97 0.94 0.88-0.97
9. Good coordination a 91 0.78 0.57-0.89
10. Good movement economy 81 0.63 0.27-0.81
11. How is the load on the back and shoulders? 92 0.85 0.71-0.93
12. To what extend are the criteria in communication and interaction with 86 0.89 0.73-0.95
the patient fulfilled?
13. Is the patient allowed to participate according to her/his ability to 86 0.94 0.86-0.96
perform voluntary movements?

5. Discussion
The kappa value depends on an even distribution
among the categories in the items, which implies that
if a category occurs seldom or not at all, it is difficult
to obtain a kappa value. This was the case in four of
the items in the instrument. The kappa value for item 1
(patient encouraged to cooperate) was shown to be
excellent between the two observers. In items 14
(transfer technique chosen by the nurse causing any
pain to the patient) and 16 (functional position of the
patient at the end of the transfer) the agreement was
excellent between the two observers and the
percentage of agreement was high (97.3 for both
items).
ICC was found to be between 0.85 to 0.94 for 4
items referring to the performance phase, which could
be considered as quite good reliability and it was
found 0.78 and 0.63 for two items (9 and 10), which
could be considered as good reliability. This indicates
that the instrument produces similar results when used
by different observers.
References
[1] Johnsson C, Kjellberg K, Kjellberg A,
Lagerström M. A direct observation instrument
for assessment of nurses’ patient transfer
technique (DINO). Applied ergonomics (2004)
35:591-601.
[2] Medical Outcomes Trust. Trust introduces new
translation criteria. Medical Outcomes Trust
Bulletin (1997) 5(4):1-4.
[3] Translation of an Instrument. The US-Nordic
family Dynamics Nursing Research Project. M.
White, G. Elander. Scand J Caring Sci (1992)
Vol. 6, No. 3 161-4.
[4] Quality translations – no substitution for
psychometric evaluation P. R. Reese, A.
Joseph. Quality of Life Research, (1995) Vol 4,
573-4.
[5] Fleiss JL. Statistical Methods for Rates and
Proportions. Wiley, New York, 1981.
[6] Fleiss JL. The Design and Analysis of Clinical
Experiments. Wiley, New York, 1986.