Table 7 Example of a HCA answer not matching with the intended item meaning

Wording of the original English item

My organization effectively balances best practice and productivity.

German wording approved for the cognitive debriefing

Meine Einrichtung schafft erfolgreich den Ausgleich zwischen optimaler Pflege- und Betreuungsqualität und Wirtschaftlichkeit.

English back translation of the German wording

My organization successfully manages the balance between optimal care quality and cost effectiveness.

Researcher question (paraphrasing)

“Can you repeat the question in your own words?”.

Participant answer

“If we are able to be there for the residents and to give them the best possible care—the care they want and need”.

Researcher question (comprehension/interpretation probe)

“What does ‘Ausgleich’ [‘balance’] mean to you?”.

Participant answer

“To take into account resident‘s habits and to do things as he used to do them”.

Researcher question (comprehension/interpretation probe)

“OK, and how did you understand ‘Wirtschaftlichkeit’ [‘productivity’]?”.

Participant answer

“Well, I can‘t do anything with it. No idea”.