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It was agreed that in this case we would mark the item "unclear".
We present results in ascending order of the proportion of subjects rating the item unclear.
The trials were then categorised into three levels: low risk of bias (all items at low risk of bias), high risk of bias (at least one item at high risk of bias) or unclear risk of bias (at least one item unclear).
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The final section of the survey sought to elicit whether respondents found any of the items unclear, wanted to suggest any further items or add any other comments.
Uninterpretable results were reported in 18% and in 82% this item was unclear.
In addition, clinicians were asked to note if any item was unclear and to provide suggested changes.
According to the Cochrane risk of bias tool, four RCTs had more than one item with unclear risk of bias.
If an item was unclear, the interviewee was told the purpose of the item and then encouraged to suggest an alternate format or wording.
In the DSRS, "looking forward to things" (DSRS.1) required an example because at least two children identified this item as unclear.
Clearly it is best if items are clear, brief and concise, however when the meaning of items are unclear and unspecific this can leave participants floundering as they have to fill in the information not explicitly given in the item.
However, exactly how assessors are interpreting some items remains unclear, therefore it may be more valid and reliable to use the 10 items of the scale or individually to comment on the junior doctors' performance in a particular area.
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Since I tried Ludwig back in 2017, I have been constantly using it in both editing and translation. Ever since, I suggest it to my translators at ProSciEditing.

Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com