1. Miller, Wendy R.

Article Content

In this issue of JNN, researchers have translated a comprehensive measure of consciousness, the Full Outline of Unresponsiveness (FOUR) score, into Swedish. The Swedish version was then evaluated for validity in comparison with the existing Glasgow Coma Scale (GCS) and also the original English version of FOUR score. This article is not only an excellent example of psychometric testing of measurement tools but also a novel method for utilizing simulation in instrument development and testing. This article shows innovation in nursing practice and research.



The purposes of this study were to translate the FOUR score into Swedish and to evaluate the reliability of the Swedish version compared with the reliability of the GCS.



Level of consciousness is a frequent and important assessment performed by nurses, especially those caring for neurologically impaired or ventilated patients. The GCS, although a reliable and valid measure of consciousness,is not comprehensive enough to ensure patient safety and to direct care. The FOUR score was developed to provide such a measure. Its original version, written in English, has been determined as a reliable instrument for measuring consciousness. The authors sought to translate thismeasure into the Swedish language for use in the Swedish healthcare system.



First, investigators translated the original English version of the FOUR score into Swedish. Translation was done by an English-speaking nurse whose native tongue was Swedish; this nurse was also familiarwith the FOURscore content. Bilingual (English and Swedish) experts reviewed the translated version to ensure important concepts were captured. The researchers then sought to confirm reliability of the translated instrument by having practicing nurses use it, not with actual patients but with simulator mannequins. Simulations were designed to represent different FOUR scores, and nurses used the instrument to rate the consciousness of the mannequins.



After four iterations, the expert panel reviewing the translated FOUR score instrument reached agreement on its contents. Satisfactory interrater ([kappa]w of 0.935-1) and internal consistency (alpha = .908-.917) reliability of the Swedish FOUR was supported.



The Swedish translation of the FOUR score is similarly reliable compared with its original English version and is thus an excellent consciousness measure for Swedishspeaking nurses. In addition, this study shows the successful use of simulation in instrument development studies.