Make culture one piece of pain assessment

Biggest mistake is to generalize

Pain management for a multicultural population need not be difficult, health care professionals simply need to realize that culture and ethnicity are just one part of the pain assessment.

While there are some similarities between ethnic groups, don’t generalize, especially when writing pain management guidelines, says Gloria Juarez, RN, research specialist at the City of Hope National Medical Center’s department of nursing research and education in Duarte, CA.

The way people manage pain also depends on their experience with pain, what they have learned from their family about pain, their socioeconomic status, education, and coping styles. In addition, the amount of stress patients are in at the time, the pain education that is being provided, their motivation to learn, and their anxiety level all impact pain management, she explains.

It’s important not to stereotype people according to culture, believing that people of one culture act a certain way with pain, and people from another culture act another way. "The big thing with cultural competence is to not stereotype people according to their surname, appearance, or national origin, but to appreciate that people from different cultures may have been taught different meanings of pain. We are taught within our family or cultural framework how we behave when we have pain and also what we do when we have pain," says Pat Collins, RN, MSN, AOCN, clinical nurse specialist oncology/pain at Baptist Health System of South Florida in Miami.

It’s important for health care professionals to develop a relationship with patients so that they are comfortable enough to talk about what the meaning of pain is to them, says Collins. Ask patients how they were taught to behave when they had pain. For example, were they taught that it was OK to cry or that they should act stoic?

No matter the culture, it is important to assess each person on an individual basis with no preconceived ideas, agrees Richard Thalmann, BSRN, CCRN, instructor of nursing at New York Presbyterian Hospital in New York City. That’s why the health care facility is redesigning its admission assessment for pain. Patients will be asked for their history of pain, what increases or decreases it, what they do to control pain, either through ice packs, relaxation techniques, or medication, and how well it has worked.

"We want to ask the patients how they have been dealing with pain by the time they get to us because it’s important to know how successful they have been," says Thalmann.

Some pain education is universal

While individual assessment is important, there’s also some universal teaching that all patients need to know and understand. After working in a burn intensive care unit for 12 years at New York Presbyterian Hospital, Thalmann discovered that people of all cultures should be taught the basics of good pain management and why it is important to a good recovery. The education should include information about when patients should ask for pain medicine and why good pain management is important.

They need to understand that it isn’t just a matter of comfort, but that there’s scientific evidence that shows if pain is not managed well, a patient’s length of stay can increase and there can be complications, Thalmann says.1 If there’s a language barrier, an interpreter should be used to make sure that the patient and family members understand the basics of good pain management, he adds.

"A lot of people don’t understand that pain medicine is a modality that is part of their recovery just like antibiotics are part of their recovery when they have an infection," says Thalmann. While patients have the right to refuse treatment, it is important that the decision is an informed one.

When working with people who come from a culture that’s different from their own, health care professionals should be in a learning mode, says Collins. They should try to learn what worked for pain management in the past and what hasn’t worked in terms of their cultural background and life experience. "It is more of a teacher-learner kind of thing where we reverse the roles. I think that is how we can work best with other cultures," says Collins.

In a study on pain, which involved cancer patients of Mexican descent, Juarez found that some patients would downplay the amount of pain they were having because they did not want to worry their family. Therefore, it is often more appropriate to have patients tell about their pain by asking how they feel or if they were able to do the things they usually do each day.

"It isn’t always asking how their pain is or if they are having pain. Sometimes, the health care professional needs to ask in a different way. They need to really talk to them and get them to describe their pain and how it affects their day," says Juarez.

Reference

1. Grant M, Ferrell B, Rivera L, et al. Unscheduled readmissions for uncontrolled symptoms: A health care challenge for nurses. Nurs Clin North Am 1995; 30:673-82. 

For more information about multicultural pain management, contact:

Pat Collins, RN, MSN, AOCN, Clinical Nurse Specialist Oncology/Pain, Baptist Health System of South Florida, Miami. E-mail: pcollins@bhssf.org.

Gloria Juarez, RN, Research Specialist, City of Hope National Medical Center Department of Nursing Research and Education, 1500 E. Duarte Road, Duarte, CA 91010. Telephone: (626) 359-8111, ext. 63722. E-mail: Gjuarez@coh.org.

Richard Thalmann, BSRN, CCRN, Instructor of Nursing, New York Presbyterian Hospital, 525 E. 68th St., Box 174, New York, NY 10021. Telephone: (212) 746-1222. E-mail: rthalman@nyp.org.