When you're caring for a patient from a different culture, do you think they experience pain differently than patients who are culturally similar to you? Have you found there are similarities and differences in the pain experience that make some patients more difficult to treat and others less problematic? In the past, Hispanic patients and patients from Mediterranean regions were felt to be emotional and expressive about their pain. Other groups, such as patients from Asian or Scandinavian cultures, were felt to be more reserved and stoic. These generalized stereotypes don't allow for the individual response to pain that each patient feels, and you may find that you're focusing more on pain behaviors than on the pain itself. Let's look at a patient who may illustrate this problem.
Mrs. Osaka is a 62-year-old Japanese patient who has been admitted for a recurrence of breast cancer. She has two sons, two daughters, and six grandchildren and has been widowed for 10 years. She lives alone, but her children are supportive and live in neighboring communities.
The healthcare provider speaks to Mrs. Osaka and tells her that her disease has progressed to the point where little treatment is available. She has large open areas on her chest where the surgical incisions have failed to heal and wound care needs to be performed. When you come in to assess her on the same morning, she's quiet and reserved. She answers your questions and when you ask about her pain she tells you she's fine. The wound and ostomy nurse comes to perform wound care and tells you she can't change the dressing because the procedure will be too painful for the patient. She wonders why you haven't medicated her for pain and tells you, “All Asian patients are stoic. You have to just give them the medication. They won't ask.” You ask Mrs. Osaka to rate her pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable, and she tells you it's a 6. You wonder why she hasn't asked for pain medication and told you she was fine.
Although the patient's unwillingness to express her pain in public may be a reflection of her cultural beliefs about appropriate behavior when experiencing pain or unpleasantness, there may be many other reasons that she won't take pain medication. She may not like the medication being offered, it may cause her to be nauseated, or she may want to be more alert when her family visits to discuss the news from the healthcare provider. To say that the patient won't take pain medication because she's Asian may lead to a misunderstanding of the individual nature of the pain experience.
The pain experience
Pain is a universal condition. At some time, each person will experience pain from illness or injury. Pain isn't only a physical experience; it also has an emotional component that may trigger behaviors that play an important role in how a patient's pain is perceived by others. As nurses, we all come to the patient's bedside carrying the effect of our family values and beliefs about pain and illness. Overarching this is the effect that religion, culture, and personal bias may have on how we interpret the meaning of pain for any individual patient. It's an important aspect of nursing care to recognize our own prejudices and biases and to care for our patients in a manner that doesn't let these affect our perception of a patient's beliefs and pain complaints.
For example, on a general oncology unit, a dying patient from a foreign country was receiving very aggressive care despite his obvious decline. The nurses were upset that the patient was receiving so many interventions that wouldn't change the terminal outcome of his disease. Some nurses suggested the family was in denial about their loved one's terminal condition. After discussing the situation with medical staff from the patient's home country, the nursing staff discovered it was the custom in that country to buy medical treatment for a member of the family until he died. To do less would have shown disrespect to the patient and his memory, and it would have disgraced the family in the eyes of their fellow citizens. When the nurses learned about the patient's culture, they realized they had been too quick to impose their own cultural beliefs on a patient who had different values than the majority of the staff caring for him.
Culturally diverse nursing interventions
Satisfaction with pain management is a nursing-sensitive outcome, yet many of the patients for whom we care are from different cultures and may not be interested in satisfaction with pain management. When dealing with populations of diverse patients who have different concepts and feelings related to pain and pain relief, it's difficult to provide the needed individualized care. Remember that pain beliefs can go beyond individual cultures, gender differences, and intercultural beliefs; for example, the “no pain, no gain” attitude can also affect nursing care related to pain relief. Attempt to treat each patient as an individual and provide the type of pain relief that's the best fit for his pain complaint.
Culturally focused nursing interventions include:
* Listen and explore the patient's meaning of pain.
* Determine whether he's representative of his culture or if he has become acclimated to American culture. Don't assume each member of a culture is the same. For a generalization of various cultural beliefs about pain management, see Understanding cultural effects on pain.
* Be sensitive to the fact that he may come from a culture in which pain management is limited. For example, he may not be familiar with the concept of patient-controlled analgesia.
* Don't focus on pain behaviors, rather educate the patient about pain assessment and the importance of reporting pain.
* Patients from some countries can't read English and will need special assessment tools and techniques. When assessing the patient, either use a scale that's translated into his language or use a translator to help explain the meaning of the pain assessment.
* Be sensitive to the fact that many cultures have religious or spiritual feelings about pain. You may not agree with the patient, but it's important to recognize his right to these feelings.
* Consider that many cultures have local folk remedies for treating pain. Folk healers are common in some cultures and may play an important part in pain relief from the patient's perspective. Ask him about the use of herbs, teas, and folk medicines to ensure that there are no contraindications to continued use.
* Assure the patient that your main interest is in providing culturally sensitive care to relieve his pain. Encourage him to tell you his ideas and wishes related to pain management. Adjust the care plan to incorporate the patient's cultural needs.
Make a difference by recognizing difference
Patients appreciate having their care reflect their cultural needs. With the changing population of the Unites States, nurses will need to adjust their ideas about care when dealing with the needs of patients who are from a culture with different values and perspectives on pain, pain management techniques, and pain relief than their own.
Understanding cultural effects on pain
Culture consists of many different concepts, such as religion, gender differences, language, and the view of older members' role in society, which can all create a barrier to adequate pain management. To get a generalized idea of cultural beliefs related to pain management, let's look at some instances of the cultural effect on pain.
In the Chinese culture, pain is a result of blocked Qi. To resolve the pain, the blockage must be removed and the patient must return to a state of harmony with the universe. Nurses who care for Chinese patients should be aware of the effect of Buddhism, Taoism, or Confucianism on the patient's view of his condition and reaction to pain. The Chinese patient may not feel that complaining of pain will help set his world right, rather he may see the pain as a trial or sacrifice needed to recreate the balance and harmony in his life. Pain is perceived as a powerful sensation that comes from a barrier in the last life or other people, animals, and material. If the patient is a Buddhist, remaining calm when in pain is viewed as bringing himself to a higher state of being. For the Chinese patient, the experience of pain may play a positive role in his cultural identity.
African American culture
In an open online forum study of cancer pain in African Americans, participating patients tended to report more severe levels pain and see pain as a sign of cancer. The cultural effect of the strong woman's role in African American culture tended to cause the female cancer patients to be less interested in complaining of pain and finding pain relief. Some participants in the study felt that cancer was a stigma and complaining of cancer pain wasn't something they would discuss openly. Although the respondent group was primarily female, the idea of being strong and enduring pain should also be considered for male patients because African American culture has a matriarchal structure that influences men as well as women.
Hispanic and Latino cultures are Spanish-speaking cultures that can be found in South America, Central America, and island nations such as Cuba and Puerto Rico. Their cultures are diverse and include many different nationalities. The effect of religion on the experience of pain is very pronounced in these cultures. Hispanic patients tend to experience pain in a stoic manner because pain is viewed as something to be accepted and endured. Pain can also be seen as a punishment for bad or immoral behavior. In Hispanic culture, a person is predetermined to have pain and should endure it to prove that he has personal strength and fortitude and so he isn't seen as being weak. This focus on stoicism can lead to underreported and undertreated pain.
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