ABSTRACT
Background
Systematic assessment of family satisfaction is essential for improving the quality of care in intensive care units (ICUs). The Family Satisfaction with Care in the Intensive Care Unit questionnaire (FS‐ICU‐24R) is internationally used but has not previously been available in Danish. This study aimed to translate and culturally adapt the FS‐ICU‐24R into Danish and to evaluate its face and content validity.
Methods
The translation followed a standardized multistep procedure involving forward translation by six bilingual ICU nurses and researchers, reconciliation through consensus, and blinded back‐translation by another bilingual ICU nurse. The Danish version was compared with the original to resolve discrepancies and ensure conceptual equivalence. Face and content validity was assessed through cognitive interviews with six relatives, who completed the questionnaire while verbalizing their understanding of each item. Comments were reviewed by the translator team, and problematic items were revised.
Results
The translation process identified linguistic and cultural issues requiring adaptation. Key challenges concerned the Danish legal framework for decision‐making, necessitating adjustments to Items #21, #22, and #24 to avoid implying that relatives act as surrogate decision‐makers. Item #23 was modified by replacing “control” with “overview/oversight” to reflect the intended meaning without suggesting authority over patient care. Additional adjustments improved clarity and relevance to the Danish context. Cognitive interviews confirmed that the revised items were understandable and acceptable to relatives.
Conclusion
The FS‐ICU‐24R was successfully translated and culturally adapted into Danish using a systematic approach. The Danish version is culturally appropriate and demonstrated good face and content validity. Psychometric evaluation is now warranted to establish its reliability and construct validity in Danish ICU settings.
1. Introduction
Family‐centred care is a cornerstone of high‐quality intensive care for critically ill patients [1]. Family members hold unique knowledge about the patient's health and medical history, serve as advocates for the patient's preferences [2]. Their presence has been linked to improved patient motivation, enhanced recovery, and a strengthened connection to life outside the hospital [3].
Close relatives often wish to be present in the ICU to provide support for the patient and to gain reassurance regarding the care delivered is of the highest quality [4]. Accordingly, unmet core family needs—such as comfort, information, proximity, and reassurance—are associated with increased levels of depression and anxiety among family members [5].
Evidence from an umbrella review highlights that optimal family support requires attention to families' existential concerns, opportunities for reciprocal communication, and a consistently humanized approach to care [2]. In line with this, the Society of Critical Care Medicine's 2024 consensus statement recommends liberal visitation policies, structured communication, active family participation, and staff education to strengthen family support [1].
Systematic assessment of family satisfaction with patient care and support offers an important foundation for improving ICU quality of care [6]. The Family Satisfaction with Care in the Intensive Care Unit (FS‐ICU‐24R) [7], originally developed in Canada and now available in 24 languages (fsicu.org), is one of the most widely used instruments for this purpose. The questionnaire comprises 32 items divided into four sections covering satisfaction with care (16 items), information (six items), decision making (four items), experiences of bereaved relatives (three items), and three open‐ended questions for comments and suggestions. However, no validated Danish version exists. Therefore, the aim of this study was to translate and culturally adapt the FS‐ICU‐24R into Danish and to explore face and content validity of the Danish version.
2. Method
2.1. Design
Translation and back‐translation following a standardized multistep approach described by Cha, Kim and Erlen [8] followed by qualitative exploration of face and content validity.
2.2. Translation and Cultural Adaptation
Permission to translate the FS‐ICU‐24R was obtained from one of the original authors of the questionnaire, Dr. Daren K. Heyland, Queen's University, Kingston, Ontario, Canada.
The translation team consisted of:
Three experienced Danish ICU nurses (KLH, CF, TH), all fluent in English and certified as postgraduate ICU nurses.
A Danish ICU nurse manager (ATJ) with a master's degree, fluent in English, who lived in the United States for five years and is certified as a postgraduate ICU nurse.
Two Danish ICU nurses and researchers (ASÅ, AHN), both PhD‐trained and certified as postgraduate ICU nurses.
An experienced bilingual ICU nurse (KD), a native English speaker who has lived in Denmark for 23 years and is certified as a postgraduate ICU nurse.
The translators were recruited from three ICUs at (A) the Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark, and (B) the Department of Anaesthesiology, Gødstrup Hospital, Herning, Denmark, where the researchers are employed. The researchers contacted the head nurses of these ICUs to request assistance in recruiting ICU nurses interested in participating in the translation process and willing to volunteer for this work and co‐authorship of the present paper. The head nurses received information about the task and an estimate of the expected time commitment. Based on this, they approached members of their nursing staff to ask whether they wished to participate, and all invited nurses accepted. One of the head nurses also volunteered to take part herself. The time the ICU nurses devoted to the translation work was covered by their respective units.
To ensure meaningful cross‐cultural application, questionnaires like the FS‐ICU‐24R must be carefully translated and culturally adapted. Such adaptation seeks to preserve the conceptual equivalence while ensuring linguistic clarity and cultural relevance for respondents in the target settings [8].
The first step of the translation process (committee approach) involved independent forward translation of the instrument by three of the ICU nurses (THN, KLH, CF), the ICU head nurse (ATJ), and the two researchers (ASÅ, AHN). Next, the translators compared the six Danish versions in detail with the original Canadian version. Each item was discussed until consensus was reached on the most accurate and culturally appropriate wording, resulting in a reconciled version. The aim was to achieve conceptual and cultural accuracy rather than literal equivalence [8], while ensuring content validity through the professional expertise and reflections of the translators and researchers. During the process of comparing the different translations and agreeing on the best wording, a secretary assisted to facilitate the work. In the third step, the bilingual ICU nurse who was blinded to the original questionnaire back‐translated the reconciled Danish version. The back‐translation was compared with the original, and discrepancies were discussed and resolved before agreeing on a version ready for face validity testing.
2.3. Face Validity
Face validity was assessed through cognitive interviewing [9] during questionnaire completion (think‐aloud with item‐by‐item probing); the facilitator recorded de‐identified hand‐written notes only. Six family members of hospitalized ICU patients, none of whom were healthcare professionals, were recruited through convenience sampling and invited to complete the Danish questionnaire in the presence of one of the translators or researchers. For each item, participants explained their understanding and rationale for their chosen responses. Non‐identifying comments from the family members were noted by hand and later discussed by the entire translator team, and items identified as difficult or ambiguous were revised based on their suggestions. Eventually, the final Danish version was approved by Dr. Heyland.
2.4. Ethics Statement
To recruit family members for face validity testing of the Danish version of the questionnaire, six family members with whom the ICU nurse already had an established relationship were approached in person in the ICU by one of the nurses who had participated in the forward translation. Approaches were only made when the patient was in a clinically stable phase. Before approaching the family members, the ICU nurses carefully considered the ethical appropriateness and timing of the contact, acknowledging the family members' vulnerable situation and the potential for a perceived power imbalance in relation to the nurse translator and/or the care team, which could create a sense of pressure to participate. Initially, each family member received a brief verbal explanation of the study's purpose and procedures, and they all agreed to participate. They were explicitly informed that participation was entirely voluntary and that declining to participate would have no impact on the patient's treatment, the care provided, or their relationship with staff, and that the testing could take place in a location chosen by the family member. Verbal informed consent was obtained from all participating family members prior to participation. With the aim of ensuring that family members were able to participate without undue burden, the ICU nurse maintained continuous dialogue with the family member throughout the 15–30 min cognitive interviewing process and the item‐by‐item review of the questionnaire and, based on this interaction, assessed whether it was necessary to pause or terminate the session. No personal or identifying information about the family members was recorded. All cognitive interviews were conducted in a quiet room in the ICU.
The study was registered with the Central Denmark Region (D 1–16–02‐51‐24) and on Clinical Trials (NCT07087132) [10]. Permission from the regional Research Ethics Committee was not required following Danish legislation.
3. Results
The translator group (excluding the back‐translator) met via videoconference on three occasions for 1.5–2 h each and additionally corresponded by email between meetings. Correspondence with the back‐translator regarding the back‐translated version in comparison with the original version, as well as clarification of linguistic and cultural details relevant to the translation, took place through several rounds of back‐and‐forth email exchanges. The following section illustrates key linguistic and cultural issues encountered during the translation and adaptation process.
3.1. Overall Wording
Care: In Danish, “care” is synonymous with “nursing care.” To capture the full spectrum of professional activities associated with care in English, we used “treatment and care” [pleje og behandling].
Family member: In Danish, “familiemedlem” denotes a blood relative. To include both family and other close persons, we used “pårørende” (relative). However, as this term could also refer to a relative's relative, i.e., the patient, in the questionnaire's introduction section we clarified that “patient” referred to the hospitalized individual and “pårørende” to family members and other close persons.
Decision making: Items #21, #22, and #24 address decision‐making. In Denmark, family members are considered important partners contributing unique information about the ICU patient's life and preferences. However, according to Danish legislation, family members do not act as surrogate decision‐makers, except in specific legal contexts, e.g., care of a child, patients with a legal guardian, or organ donation. Thus, literal translation could cause misunderstanding. After careful consideration we agreed on a translation that reflects the type of shared decision making practiced in Danish ICUs. We therefore adapted Item #21 (”How included or excluded did you feel in the decision‐making process?”) to “Hvor udelukket eller inddraget følte du dig i de beslutninger, der blev taget?” (“How included or excluded did you feel in the decisions that were made?”) to reflect the collaborative but non‐decisional role of families. Also, by using the plural form of the word “decision” we implied a broader view on decisions about patient care. Furthermore, by using the more passive phrase “that were made” we suggested that the question was not about decisions made by the family members themselves. A similar wording was used in Items #22 and #24.
To improve readability, we consistently preferred shorter and more familiar Danish expressions when possible.
3.2. Item‐Specific Adjustments
Item #9: Skill and competence of ICU doctors (all doctors including residents)—The explanatory note in parenthesis was omitted as it was unnecessary in the Danish context.
Item #23: Did you feel you had control over the care of your family member? One of the test participants commented on our initial literal translation [Følte du, at du havde kontrol over behandlingen af dit familiemedlem?]. She said “I did not feel a need to have any control with the care of my family member. I have full confidence that my husband receives the care he needs”, and she found that none of the response categories reflected her view. This prompted reconsideration of the term “control” [kontrol], which in Danish implies authority rather than oversight. To capture the intended meaning of “control”, we explored other possible meanings and nuances of the word. After thorough discussions and consultation with Dr. Heyland, we replaced “kontrol” (control) with “overblik” (overview, oversight), which is the kind of control one may have from a control tower, thus capturing the intended sense of awareness without implying authority.
3.3. Demographics
Question 7 (education level) was adapted to reflect the Danish educational system.
4. Discussion
During the translation and cultural adaptation of the FS‐ICU‐24R into Danish, one key issue emerged. The concept of decision‐making for families in the ICU required clarification to accurately reflect practice in Danish intensive care settings. According to Danish legislation, when a critically ill or dying patient is unable to speak for themselves, family members should be consulted to provide their perspective on what would be in the patient's best interests. However, they are not asked to make final decisions about treatment or changes in treatment level that may lead to the patient's death. Danish law assigns such final decisions to physicians [11] a measure intended to relieve families of responsibilities that would require a level of medical expertise they cannot be expected to possess [12].
In other countries, when families are asked to make decisions about care, they may experience emotional distress even when their decisions align with the patient's preferences [13]. Internationally, legal and ethical questions regarding patient and family involvement in decision‐making have been widely discussed [14, 15]. Rather than reflecting a paternalistic approach, we believe the Danish model of family involvement in ICU decision‐making aligns with the definition of shared decision‐making used by the American College of Critical Care Medicine and the American Thoracic Society: “Shared decision‐making is a collaborative process that allows patients, or their surrogates, and clinicians to make health care decisions together, taking into account the best scientific evidence available, as well as the patient's values, goals, and preferences.” A study from 2018 showed that a vast majority of Danish family members seem to prefer this type of decision‐making [16].
Consistent with the issues related to decision‐making, we also adjusted the translation of Item #23 “Did you feel you had control over the care of your family member?” We replaced “control” (“control”) with “overblik” (“overview/oversight”) to better reflect that Danish family members are not expected to have control over the care of a loved one in the ICU. The Danish, Swedish, and Norwegian cultures and languages share many similarities; however, in both the Swedish and Norwegian versions of the FS‐ICU‐24R, the translators retained the original wording of Item #23 without modifying the term “control” [17]. It is, however, very likely that the different choices of wording between the Scandinavian versions may reflect subtle but real differences between cultures including differences in legislative systems and languages underscoring that any translation needs to be aligned with the language and culture in which it will be utilised.
The Danish version of the FS‐ICU‐24R provides an important foundation for health professionals to conduct large‐scale assessments of family satisfaction and to identify areas in Danish ICU care that require improvement [6]. In addition, it offers a tool for systematically measuring the effects of patient‐ or family‐focused interventions on family satisfaction in Danish ICUs. To explore the underlying experiences that shape family satisfaction, qualitative methods should instead be applied [18].
A strength of the study is that we applied a widely used methodological framework [8] to guide the translation and cultural adaptation of the questionnaire. Our translator team of well‐educated and experienced ICU nurses worked closely together, and any uncertainty raised by one of the six translators could be readily identified and discussed by the others, resulting in a clear and consistent Danish version of the questionnaire. However, including other ICU professionals, e.g., a physician, in a multiprofessional translation team might have contributed to further strengthening the work of adapting the questionnaire to the Danish context. Further, although proficient in English, neither the translators nor the back‐translator were professional translators. At the same time, all translators and the back‐translator were certified post‐graduate ICU nurses with extensive experience in critical care, enabling them to evaluate the content validity of the translated questionnaire effectively.
5. Conclusion
The aim of this study was to translate and culturally adapt the FS‐ICU‐24R into Danish and to examine the face and content validity of the Danish version. Using a widely applied approach to guide translation and back‐translation, the translation team produced a culturally adapted questionnaire. Items #21, #22, and #24 required clarification, as Danish legislation on decision‐making differs from Canadian law. In addition, Item #23 concerning family members' “control” over the care of their loved one needed adjustment to align with Danish language use and ICU care culture. Face and content validity were assessed by ICU family members and by the translation team, all of whom were well‐educated ICU nurses with extensive critical care experience. The final Danish version was approved by Dr. Daren Heyland, one of the developers of the original questionnaire. We conclude that the Danish version of the FS‐ICU 24R is culturally appropriate and has face and content validity. The next step is to conduct a psychometric validation of the Danish FS‐ICU‐24R.
Author Contributions
Conceptualization and methodology: A.S.Å., A.H.N. Translation and cultural adaptation: A.S.Å., A.H.N., A.T.J., C.K.F., K.D., T.H.N., D.K.H. Original draft, review and editing: A.S.Å. Writing, review and editing: A.H.N. Review: A.T.J., C.K.F., K.D., T.H.N., D.K.H. All authors accepted the final version of the manuscript.
Funding
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgements
We thank critical care nurse Karina Lynge Hehlert, Gødstrup, Denmark (K.L.H.) for her contribution to the translation and cultural adaptation of the Danish version. We also thank the six family members of I.C.U. patients for generously completing the questionnaire and participating in cognitive interviewing as part of the process.
During the preparation of this manuscript, we used ChatGPT to improve language clarity.
Ågård A. S., Jepsen A. T., Frydendal C. K., et al., “Translation and Cultural Adaption of the Revised ICU Family Satisfaction Questionnaire (FS‐ICU‐24R) Into Danish,” Acta Anaesthesiologica Scandinavica 70, no. 4 (2026): e70210, 10.1111/aas.70210.
The work was carried out at (A) Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark, and (B) Department of Anaesthesiology and Intensive Care, Gødstrup Hospital, Herning, Denmark.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.