Language and cultural differences affect pain assessments

Take care not to over- or under-treat pain

Bilingual staff, cultural diversity education, and community presentations designed for specific populations are efforts that hospices throughout the country have implemented to increase access and improve care to hospice patients of all backgrounds.

Although respecting traditions and customs of a different culture are important, the most critical aspect of providing hospice care is pain management, and that is not always optimal for minority patients, says Mary Curry Narayan, MSN, RN, HHCNS-BC, a clinical education and transcultural nurse specialist and owner, Narayan Associates in Vienna, VA. "Nurses are taught that pain levels are whatever the patient says they are," she says. "This means that we under-treat pain for people who grew up in a culture that values stoicism and views admission of pain as weakness," she explains. For this reason, nurses need to understand the culture of their patient and use other cues to evaluate pain in addition to the patient's report of pain, she adds.

"If the patient says there is no pain but there is a grimace or a tight look about the face, the nurse should explore more carefully," suggests Narayan. Questions that don't ask the patient to admit pain are a good tactic to use with patients who have learned to minimize pain, she says. These questions include:

• Can you do the same activities you've always been able to do?

• Do you sleep and eat as well as you did last month?

• Are you uncomfortable?

• Did the medicine make you more comfortable?

• Are you able to sit up (or walk) more easily after taking the medicine?

Other cultures may be more expressive about pain, so a careful assessment also is needed to establish the correct level of pain medication, says Narayan. "Pain is what the patient perceives, but a nurse must be careful not to over-medicate someone just because her beliefs lead her to interpret the expressive patient's pain as extreme," she says. Asking the same questions asked of the stoic patient will help assess the patient's discomfort and the effect of pain on his or her life, she adds. "Always start with the lowest effective dose of medication and work up to higher doses," she says.

The first step to correctly assessing a patient's pain when the patient is from a different culture is to evaluate your own cultural and learned bias' regarding pain, suggests Kenneth J. Doka, PhD, professor of gerontology at the Graduate School of The College of New Rochelle in New York, and senior consultant to the Hospice Foundation of America. "If you understand your own beliefs about pain, and how your culture affected those beliefs, you'll be less likely to view someone else's reaction to pain as inappropriate or frustrating," he adds. "If you are using an interpreter to communicate with the patient, talk with the interpreter to determine his or her own biases as well," he suggests.

It is important to avoid stereotypes and biases when assessing pain, agrees Hank Willner, MD, medical consultant for Hospice Foundation of America and hospice medical director and palliative care consultant for Capital Caring in Falls Church, VA. The best advice for a pain assessment is to listen more than talk, he says. "Have empathy for the patient in pain and be curious about what the discomfort represents," he suggests. For example, does the pain prevent the patient from doing a favorite activity? If so, talk about finding a way to help the patient return to that activity, he suggests. After listening to the patient's description of the pain, explain your own perception of what you think the patient described, he recommends. "Acknowledge that everyone describes pain differently and let the patient know you want to make sure you understand his or her description."

Know limits of assessment tools

Different languages and cultures may make standard pain assessment tools ineffective, says Narayan. "The Western culture is very quantitative so we rely on numbered scales, but other cultures do not," she says. For example, some Native Americans may choose a favorite or sacred number on a pain scale as opposed to a number that actually reflects their pain, she says.

Different languages may also affect the validity of a pain assessment, points out Narayan. "Not all languages have a word for pain and interpreters may not be able to accurately describe the patient's pain," she says. When using a pain scale, be sure it has been validated for translation into other languages," she says. "I like the Brief Pain Inventory developed by M.D. Anderson," she says.

If you discover that your patient is from a different culture than you, don't be afraid to ask questions of the patient and the family to learn what is acceptable in their culture, says Jennifer Carlson, director of operations for Amedisys Hospice of Sweetwater in Sweetwater, TN. "I once had a patient who was a Buddhist monk and I not only had to rely upon a translator but I could not touch him," she says. "I did know the patient was a Buddhist monk before I arrived at the home, so I spent time with the other monks asking what was appropriate," she says. By explaining that she did not want to offend the patient or the monks who provided the actual care, she was able to ensure the monk received the proper care from the other monks. "I assessed the patient's symptoms and explained how to care for him to the other monks," she explains. "I observed as they provided the care."

Be sure to educate your staff about cultural diversity and especially about the specific cultural groups that are served by your hospice, says Carlson. Although every patient and family is different, even within the same cultural group, hospice staff members are better able to assess the patient if they understand some of the cultural differences upfront, she says.

Another facet of the person's culture that plays an important part in the care hospice provides are other people who influence the patient, suggests Willner. "Some American Indians want a shaman, medicine man, or faith healer to be present," he says. In some cases, the patient wants permission from the shaman to accept the Western health treatment, he explains. "In all cases, be sensitive to the patient's beliefs and follow the patient's wishes as to how treatment should proceed," he adds.

Remember that culture does not just refer to a different country, says Carlson. "In eastern Tennessee, we see patients whose religious beliefs are that pain is a test of their belief," she explains. Because these patients believe that a strong faith and prayer can relieve their pain, visits from a hospice chaplain can provide additional support that might help the patient accept other forms of pain management, she suggests.

Always be prepared for patients to refuse treatment for pain as part of their cultural beliefs, says Carlson. "We can listen and make sure they know we have options to control their pain, but it is ultimately the patient's decision, even if we see they are in pain," she says. "This is their journey, not ours."


For more information about cultural diversity and pain assessment, contact:

• Jennifer Carlson, Director of Operations, Amedisys Hospice of Sweetwater, 665 New Highway 68, Suite B, Sweetwater, TN 37874. Tel: (423) 351-0233; e-mail:

• Kenneth J. Doka, PhD, Professor of Gerontology at the Graduate School of The College of New Rochelle, 29 Castle Place, New Rochelle, NY 10805. E-mail:

• Mary Curry Narayan, MSN, RN, HHCNS-BC, CTN, COS-C, Clinical Education & Transcultural Nurse Specialist, Narayan Associates, 10340 Brittenford Drive, Vienna VA 22182. Tel: (703) 648-0222; e-mail:

• Hank Willner, MD, Medical Consultant for Hospice Foundation of America; Hospice Medical Director and Palliative Care Consultant for Capital Caring Capital Caring, 2900 Telestar Court, Falls Church, VA 22042. Tel: (301) 229-2855; e-mail:


• The Brief Pain Inventory can be found at, select "departments and divisions," then choose "symptom research" and "symptom assessment tools." (There is no cost for use of the tool in clinical practice.)

• The Hospice Foundation of America has developed "Addressing Cultural Diversity in Hospice Care," a free on-line webinar that looks at how and why different cultures may or may not utilize hospice. This tutorial aims to prepare and equip hospice organizations, and its providers and volunteers, with strategies and information to meet the needs of culturally diverse patients and loved ones. Go to, under "professional education" select "hospice information center CEs" and then choose "Addressing Cultural Diversity" on the right navigational bar.