Ensuring pain care equality has become a national priority given the substantial inequities and poor outcomes experienced among various populations.1,2 Black Americans are one population who clearly experience derisory pain management, and social injustices and health disparities have played a critical role in this issue.1,3
Over the past year, the hashtag “#Blacklivesmatter” has become a strong social movement advocating that the lives of all Black Americans are valuable and matter in all circumstances.4 Similarly, equitable pain management in critical care settings is an important matter for Black Americans because they are not consistently given care based on quality standards or best practices.5
Recent research using virtual case scenarios shows that healthcare providers hold implicit and explicit biases that impact pain assessment and treatment.6 Specifically, such research indicates that healthcare professionals may provide Black Americans with generic pain care rather than individualized care for maximum effectiveness. The #Blacklivesmatter movement has also made the significance of communities and families in inspiring change and advancing better social and health treatment for Black Americans apparent.
Given the importance of familial and social kinship in Black culture, intentional collaboration of family and close friends/confidants may prove worthwhile in minimizing substandard care; therefore, taking the view that pain management is a social and moral imperative and fusing this with family engagement can positively influence better pain assessment and treatment practices for Blacks in all healthcare settings, including critical care.1
Including the family in pain management is not a new idea. Outcomes for patients are often more positive when the family is included in planning and implementing pain care.7 Still, because many critical care patients require extensive, complex, and high-touch care, some may wonder how family members can actively and effectively assist in assessing and treating their loved ones. This article highlights a number of ways to leverage family involvement in pain assessment and treatment in critically ill Black patients.
Communicating with family
Family communication is essential to successful pain management. It is important to identify who is considered family to the patient and what, if any, information can be shared with these individuals. In Black culture, family and kinship networks are not always related biologically or by marriage; rather, these may be close friends the patient grew up with, “god siblings” or “play” family members (also known as fictive kin), and some extended family.
It is useful to have a family conference, preferably to determine who is considered family; the primary spokesperson or healthcare power of attorney; family expectations for pain care; and the extent to which family can be involved in pain management activities and decisions.8 Furthermore, using a family-based model can also help narrow the mistrust gap between Black Americans and healthcare providers.
During family discussions, pain management explanations should be consistent and allay any fears or misunderstandings regarding pain treatment, pain progression, and causes of pain. Pain is a difficult subject to discuss, and many Black Americans believe that worsening pain is related to disease progression, failing health, or impending death, which is not always the case.9 Nurses and providers are taught to be culturally sensitive, but it is easy to perpetuate global stereotypes (see Seven misconceptions and facts about pain in Black Americans).
This can occur in pain assessment. It is easy to dismiss and downplay (or become desensitized to) the severity of certain pain conditions prevalent in Black Americans or to undertreat pain-causing conditions that are associated with stigmas and stereotypes. These may include pain from gunshot wounds, sickle cell pain, HIV/AIDS-related pain, fibromyalgia, or other chronic pain.
The author had a conversation with a nonethnic minority nurse at a conference in which pain expression and catastrophization in Black Americans was being discussed, and the nurse equated their expressiveness of pain to being “drama queens.” This statement is not only offensive and stereotypical of Black women but also reinforces Black Americans' fears that their pain reports will not be taken seriously.10 With that said, personal views should not contaminate verbal and nonverbal communication/interactions with patients and their family nor limit the quality of care provided.
“What is known is that there is disturbing variability in how the pain complaints of ethnic minorities, older adults, women, and impoverished individuals are assessed and managed.”11 How can nurses and healthcare providers ensure that Black Americans are given quality pain care? It begins with adequate assessment that incorporates both evidence-based practices and cultural practices.
A number of models exist to improve pain management, including: AIR cycle (Assessment, Intervention, and Re-assessment), SIR (Screen, Intervene, and Reconvene), and CAPA (Clinically Aligned Pain Assessment).12-14 SIR was specifically developed with the needs and preferences for pain management of Black Americans in mind; this model can be adapted to meet the needs of patients in critical care settings.
Pain assessment in critical care settings can prove to be a difficult task, especially when communication is limited. Nevertheless, it is important to note that while verbal capacity can be limited, communication itself does not have to be. Communication can take several forms, including verbal, nonverbal/behavioral, and written. Several strategies can assist in assessing pain, including self-report, proxy report, and observation of behavioral/physiologic patterns.15 A combination of these strategies may prove more effective than any one alone, and family members can collaborate with nurses using each strategy. In fact, family and consistent caregivers should “actively participate in the pain assessment.”16
Self-report is advocated as the gold standard and first strategy for pain assessment.15,16 Still, some Black Americans feel their pain reports are not taken seriously and will not be believed by healthcare professionals.17,18 This is despairing because many critically ill patients experience acute and chronic pain simultaneously.19 However, chronic pain conditions are sometimes underrecognized in the midst of acute pain. This is problematic in ensuring effective pain control in Black Americans because they often have multiple health conditions that produce chronic pain. In fact, Black Americans with chronic pain are likely to have a diagnosed chronic pain condition.20
Appropriate self-report tools should be used when patients can self-report. Self-report tools are used to describe the severity of pain, and Black Americans have a greater tendency to report higher pain intensities when compared with other racial and ethnic populations.9 However, limited information is available on the pain self-report tools that young and middle-aged Black Americans prefer. A recent study using the Wong-Baker FACES scale with critically ill, middle-aged Black and White Americans revealed that higher pain intensity was communicated during suctioning than with the traditional numeric rating scale.21 Older Black Americans prefer the FACES Pain Scale–revised, Iowa Pain Thermometers, and Verbal Descriptor Scale.22
While the Wong-Baker FACES scale has been tested and deemed valid in adults, its use in older adults is not encouraged because the facial expressions are less realistic and display crying, which may not be acceptable to some older adults and cultures.23 In addition, those with cognitive impairment or neurologic issues affecting comprehension may choose an inappropriate face (such as a happy face) despite having pain. As a result, pain may be overlooked and misdiagnosed. Therefore, from the small body of literature evaluating pain scales, it appears that face-based scales may be a more accurate and culturally preferred method of assessing pain intensity in Black Americans across the lifespan.
Verbally communicating pain is not the only technique to obtain a pain report. Patients can be asked to nod their heads, squeeze hands/fingers, blink, or raise their fingers when asked if they are currently experiencing pain or hurting. It may be more difficult to obtain a pain intensity rating this way, but nurses can ask patients to respond to a number 1 to 10 or to descriptors (mild, moderate, or severe) using similar methods (see Practice points: Assessment).
Underreporting pain is an important issue. Specifically, Black Americans may not report pain altogether, minimize the pain report, fail to report sensations associated with pain (for example, paresthesias with neuropathy), or wait until pain is severe before reporting. Any of these situations make gaining control over pain more difficult. Several techniques can be used to ensure that pain is not present when it is denied, including rewording the pain assessment question using different descriptors (such as hurting, sore, and aching), asking patients to point to areas that are hurting or uncomfortable rather than asking if they are in pain, and/or using proxy report of pain.
In some cases, pain assessment should not be performed in the presence of family or friends because some Black Americans do not want to complain in front of or to family.11 At other times, when pain is suspected but denied, family can be helpful in conveying the importance of communicating pain to the nurse.
A proxy report is most often used when older adults with cognitive impairment or intellectual disability are unable to verbalize a pain complaint; it can also be used with critically ill patients.16 This strategy elicits family and personal caregivers' opinions of pain or potential pain in their family member or patient. Helping family and friends feel like partners in care rather than bystanders is imperative.
Participating in bedside reports/rounds is one way to facilitate family engagement. During this time, family and friends can relay information about the patient's pain communication patterns, pain cues that should alert nursing staff, reaction to pain medications, knowledge of preexisting conditions that cause pain (for example, chronic headache or chronic joint pain), and other information about the patient's pain. Particularly, family members can describe usual patterns of pain expression/communication to nurses, which can be compared to current patterns. The family may also identify subtle cues that the nurse may overlook.
While a proxy report is occasionally fraught with bias wherein proxies may under- or overestimate pain, healthcare professionals are shown to underestimate pain in Black Americans.9,24 The importance of taking patients at their word concerning pain cannot be stressed enough. Sometimes it appears that other subjective complaints, such as nausea or anxiety, are better accepted than pain. Behavioral and physiologic observation can help confirm proxy reports or suspected pain when a self-report or proxy report are unavailable.
Observing pain behaviors is becoming a reliable strategy for identifying pain, particularly in those unable to self-report.24 Using valid and reliable observational tools to identify general pain behaviors is an expected practice. In fact, families often remember nurses using pain behavior scales to assess their loved ones' pain, suggesting an opportunity to enhance family involvement in pain assessment.19 In addition to nurses and unlicensed staff, family members can be trained to use observational pain scales to assess their loved one's pain; this is a form of proxy report (as discussed above). The Care Pain Observation Tool and Behavioral Pain Scale are recommended for critical care, but other tools may be better for certain populations (such as older adults).15,25
A brief search of the literature did not generate any studies validating observational tools in Black Americans; therefore, it is unclear if the current recommended observational tools capture pain behaviors of Black Americans and which pain behaviors are common among them. A small study revealed that older Black Americans with cognitive issues use more pain facial expressions and words.26 Patient acuity levels and time limits may impact the overall comprehensiveness of a cultural pain assessment or recognition of cultural-specific pain behaviors. Nurses should describe what behaviors are being observed (see American Geriatrics Society for a list of behaviors: www.americangeriatrics.org/files/documents/2002_persistent_pain_guideline.pdf) and should ask the family if they have noticed these behaviors (or if the behaviors observed are typical or potentially related to pain).27
“Pain treatment is never about the clinician's intervention alone but about the clinician and patient (and family) working together,” and critically ill patients may be unable to voice their preferences for various pain treatment.1 In working with families to develop a plan of care, nurses and providers should:
- Determine family expectations for treatment and goals of care.
- Develop a common goal for pain control.
- Ask the family how the patient managed past pain episodes and various pain conditions at home.
- Provide pain education for family member(s); this is a Joint Commission requirement.28
- Determine knowledge and comfort level regarding various types of pain treatment methods.
- Clarify misconceptions about use of opioids or other high-risk medications.
- Determine the most effective treatment strategies; ask family members if they have noticed a difference in the patient's social interactions, function, and mood when given pain medication (see Practice points: Treatment).
Family members can be instrumental in providing pain treatment. For example, they can help administer nonpharmacologic interventions, such as light massage, guided imagery, applying warm and cool compresses, and even providing warm bed-baths. Family can share information about the patient's comfort needs, such as positioning, touch, or environmental preferences. In addition, the simple comfort of having family present can help critically ill patients cope with pain. Some Black Americans may even prefer to have a spiritual advisor visit or place spiritual items in the patient's room. However, there may a lesser role for family in terms of pharmacologic treatment. For instance, there are conflicting recommendations and expert opinion on the safety and appropriateness of family members activating patient-controlled analgesia (PCA).29
Many professional organizations do not support PCA-by-proxy but support authorized agent-controlled analgesia (AACA). Authorized agents may include healthcare professionals or nonhealthcare professionals, such as family members. AACA enables families to participate in alleviating their loved one's pain and increases their satisfaction of the loved one's overall pain control.30 However, organizations using AACA must have clear guidelines for use, and authorized agents must be deliberately selected and sufficiently educated.29
Pain treatment does not end when patients are discharged, and family can help patients understand and implement discharge pain management instructions. This is especially important when patients are not fully able to care for themselves. Meghani and colleagues show that analgesic adherence is significantly lower in Black Americans.31
A number of issues limit Black Americans' abilities to effectively manage pain after being discharged, including financial access to pain medications, physical access to pharmacies (transportation), access to pharmacies supplying opioid medications, access and referral to pain management specialists, pain management literacy, beliefs about pain and its treatment, and lack of social support.32 Families can help patients develop and adhere to a routine pain management regimen and help manage any adverse reactions (see Cultural cues: Treatment).
The complexity of critical settings does not easily facilitate direct family involvement in patient care; however, this is one avenue toward improving quality of pain care and supporting patient- and family-centered care. Critical care settings should determine ways to effectively engage Black families in pain and other symptom management because pain impacts both the patient and his or her family.
Nurses and providers are encouraged to gain the necessary skills and education to effectively care for Black Americans, and the author hopes this article is a starting place or a supplementary resource that can help nurses and providers develop confidence in providing equitable pain management in Black Americans.
Practice points: Assessment13
- Use multiple approaches to assess pain.
- Ask about pain in more than one way and at different points in care.
- Ask patients to quantify (for example, 0-10), qualify (for example, slight, mild, moderate, severe, very severe), and typify pain (for example, dull, sharp, stabbing, and so on).
- Recognize there may be multiple etiologies of pain (acute and chronic).
- Assess pain during activities (for example, turning, range of motion) and respite periods, prior to giving medications, at the peak time of action for medications, and prior to the time when pain medication levels are expected to be at their lowest.
- Black American patients may exhibit more pain facial expressions and noises when in pain or may display more stoic expressions.
- Pay close attention to the patient's and family's pain description; the nurse may need to use alternative pain words during assessment, such as hurt, ache, tender, throbbing, or sore.
Practice points: Treatment13
- Work collaboratively with patients and families to develop the best pain management plan and an acceptable level of pain.
- Provide treatment on an around-the-clock basis versus p.r.n.
- Provide treatment for both acute and chronic pain types.
Cultural cues: Treatment13
- Black Americans are conscientious about how medications will impact their body/health and often have deep concerns about short- and long-term adverse reactions. Note how often patients refuse or delay medications or use PCA.
- Spiritual care for pain management is important for Black Americans, but some patients may be apprehensive to share their spiritual beliefs regarding pain if they feel it will take the focus away from medical management of pain or that their beliefs will not be respected. Explain that preferred spiritual activities are used to complement pain treatment to enhance and improve care.
- Encourage social support systems (family, friends, church members) to assist with pain treatment during hospitalization and after the patient is discharged.
1. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research
. Washington, DC: National Academies Press; 2011.
2. Meghani SH, Polomano RC, Tait RC, Vallerand AH, Anderson KO, Gallagher RM. Advancing a national agenda to eliminate disparities in pain
care: directions for health policy, education, practice, and research. Pain Med
3. Ezenwa MO, Molokie RE, Wilkie DJ, Suarez ML, Yao Y. Perceived injustice predicts stress and pain
in adults with sickle cell disease. Pain Manag Nurs
5. Anderson KO, Green CR, Payne R. Racial and ethnic disparities in pain
: causes and consequences of unequal care. J Pain
6. Hirsh AT, Hollingshead NA, Ashburn-Nardo L, Kroenke K. The interaction of patient race, provider bias, and clinical ambiguity on pain
management decisions. J Pain
7. Nguh J. How nurses affect pain
management practices in nursing homes and shape families' perceptions of care. Ann Longterm Care
8. Booker SQ. Are nurses prepared to care for Black American patients in pain
9. Booker SQ. African Americans' perceptions of pain
management: a systematic review. J Transcult Nurs
10. Graaff K. Street literature and the mode of spectacular writing: Popular fiction between sensationalism, education, politics, and entertainment. In: King L, Moody-Turner S, eds. Contemporary African American Literature: The Living Canon
. Bloomington, IN: Indiana University Press; 2013:113–134.
11. Green CR, Prabhu M. Older African Americans. Managing pain
among the underserved and most vulnerable populations. In: Incayawar M, Knox T, eds. Culture, Brain, and Analgesia: Understanding and Managing Pain in Diverse Populations
. New York, NY: Oxford University Press; 2013:295–313.
12. Montalvo I. The National Database of Nursing Quality Indicators™ (NDNQI®
). OJIN: The Online Journal of Issues in Nursing
13. Booker SS, Herr KA. Pain
management for older African Americans in the perianesthesia setting: The “eight I's”. J Perianesth Nurs
16. Herr K, Coyne PJ, McCaffery M, Manworren R, Merkel S. Pain assessment
in the patient unable to self-report: position statement with clinical practice recommendations. Pain Manag Nurs
17. Booker SS, Pasero C, Herr KA. Practice recommendations for pain assessment
by self-report with African American older adults. Geriatr Nurs
18. Im EO, Lee SH, Liu Y, Lim HJ, Guevara E, Chee W. A national online forum on ethnic differences in cancer pain
experience. Nurs Res
19. Fink RM, Makic MB, Poteet AW, Oman KS. The ventilated patient's experience. Dimens Crit Care Nurs
20. Green CR, Ndao-Brumblay SK, Nagrant AM, Baker TA, Rothman E. Race, age, and gender influences among clusters of African American and white patients with chronic pain
. J Pain
21. Rahu MA, Grap MJ, Ferguson P, et al. Validity and sensitivity of 6 pain
scales in critically ill, intubated adults. Am J Crit Care
22. Ware LJ, Herr KA, Booker SS, et al. Psychometric evaluation of the revised iowa pain
thermometer (IPT-R) in a sample of diverse cognitively intact and impaired older adults: a pilot study. Pain Manag Nurs
23. Booker SQ, Haedtke C. Controlling pain
and discomfort, part 1: assessment
in verbal older adults. Nursing2016
. [in press].
24. Hadjistavropoulos T, Herr K, Prkachin KM, et al. Pain assessment
in elderly adults with dementia. Lancet Neurol
25. Herr K, Bursch H, Ersek M, Miller LL, Swafford K. Use of pain
tools in the nursing home: expert consensus recommendations for practice. J Gerontol Nurs
26. Ford B, Snow AL, Herr K, Tripp-Reimer T. Ethnic differences in nonverbal pain
behaviors observed in older adults with dementia. Pain Manag Nurs
27. American Geriatrics Society Panel on Persistent Pain
in Older Persons. The management of persistent pain
in older persons. J Am Geriatr Soc
. 2002;50(6 suppl):S205–S224.
29. Wuhrman E, Cooney MF, Dunwoody CJ, et al. Authorized and unauthorized (“PCA by Proxy”) dosing of analgesic infusion pumps: position statement with clinical practice recommendations. Pain Manag Nurs
30. Webb RJ, Shelton CP. The benefits of authorized agent controlled analgesia (AACA) to control pain
and other symptoms at the end of life. J Pain Symptom Manage
31. Meghani SH, Thompson AM, Chittams J, Bruner DW, Riegel B. Adherence to analgesics for cancer pain
: a comparative study of African Americans and Whites using an electronic monitoring device. J Pain
32. Mathur VA, Richeson JA, Paice JA, Muzyka M, Chiao JY. Racial bias in pain
perception and response: experimental examination of automatic and deliberate processes. J Pain
33. Becker WC, Starrels JL, Heo M, Li X, Weiner MG, Turner BJ. Racial differences in primary care opioid risk reduction strategies. Ann Fam Med
34. Becker WC, Sullivan LE, Tetrault JM, Desai RA, Fiellin DA. Non-medical use, abuse and dependence on prescription opioids among U.S. adults: psychiatric, medical and substance use correlates. Drug Alcohol Depend
35. Olsen BF, Rustøen T, Sandvik L, et al. Development of a pain
management algorithm for intensive care units. Heart Lung