Table 2.

Problems and solutions found during the cultural adaptation process

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

The described problems were found in the language versions marked with “X”