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Pain Module

Apr 14, 2018



Blake Kammin
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    The following resource was submitted with the purpose of distributing to AONE members as part of theAONE Diversity in Health Care Organizations Toolkit

    Submitted by: Childrens Hospital Medical CenterContact person: Lisa Aurilio, RN, MSN, NEA-BC

    Director, Maternal Fetal Neonatal ServicesAkron, OH

    Cultural Sensitivity in Nursing Carefor Pain Management

    A Self-learning Module

    November 2004-2006

    This module has been awarded 1.0 contacthours and should take approximately 50

    minutes to complete.

    Developed by: Rev Melanie Sunderland

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    Describe the socio-cultural perspectiveof pain assessment and management.

    Apply the cultural beliefs of pain

    control to two case studies.


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    To: Fairview and Lutheran Nursing Staff

    From: Cindy Willis, RN, BSN, MBA

    Date: October 11, 2004

    Re: Self-learning Module for Cultural Sensitivity in Nursing Care

    This educational module entitled Cultural Sensitivity in Nursing Care has met the criteria established by

    the Ohio Board of Nursing for educational contact hours. After completing the module, you will receive

    1.0 Continuing Nurse Education (CNE) credit.

    *Fairview Hospital (OH 093) is an approved provider of continuing education by the Ohio Nurses

    Association, an accredited approver by the American Nurses Credentialing Centers Commission onAccreditation (OBN-001-91). Provider status is valid through 4/1/07.

    In order to obtain your CNE certificate the following actions must be taken:

    Read the educational material According to the CNEs, this should take you approximately 50

    minutes to complete the entire module, case studies and quiz.

    Complete the check-up and case studies. Check your answers for accuracy.

    Complete the evaluation sheet.

    Sign the attendance sheet found at the end of module.

    You are responsible for submitting evaluation and the sign-in sheet to Cindy Willis in the Moll

    Center Basement (Organization and Staff Development) in order to obtain your CNE credit.

    A certificate of CNEs will be sent to you.

    File the CNE certificate with your other contact hour information.

    If you have questions related to the materials or post-tests, contact the following content

    specialists/Feedback Personnel: Cindy Willis at 216-476-7322 and Melanie Sunderland at



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    Cultural Sensitivity in Nursing Care for Pain Management

    Pain Management is not just about giving appropriate pain medications.How one perceives and copes with pain is rooted in their unique physical,psychological, economic class, socio-cultural, and spiritual makeup. AsMargo McCaffery (a pain management expert, quoted in Minority Nurse)states, Pain is whatever the experiencing person says it is, existingwhenever the experiencing person says it does.

    At the Cleveland Clinic Health System, we serve a diverse population ofpeople with a variety of cultural heritages and experiences. Thisnecessitates that we be aware of and sensitive to cultural differences andhow they affect the care of the individual within the larger context of theirlife beyond the hospital. If we are to adequately address issues of painwith our patients, as we strive to provide excellence in patient care,addressing cultural issues is a must do part of the assessment andmanagement of pain.

    This learning module is intended to give a brief overview of some socio-cultural perspectives of pain assessment and management, and highlightcare of Hispanic and Mid-Eastern populations, as we have a significantpercentage of patients from these cultural groups within our patientpopulation. The information provided about specific ethnic populations inthis module do not represent all whom we see, but can give you a sense ofwhat you need to be aware of.

    Each individual differs in how pain is tolerated and expressed. Cultural

    differences play an important part in an individuals expression of pain. Thenurses own cultural background coupled with the patients expression ofpain, based on their cultural background, influences the nursesassessment and management of the patients pain. It is imperative thatnurses be sensitive to the differences in their own and their patients cultureassociated with pain management.


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    There are many assessment tools in the nursing care literature, and it isbeyond the scope of this module to present the benefits of any given tool.However, it is important to consider with any given tool, how it may or maynot reflect a patients actual experience of pain. The RIDcancerPainprogram recommends nurses take patients through a 6-step process ofassessing cancer pain, which can be adapted to other areas:

    1. Representational assessmentthe patient describes beliefs aboutcancer pain along five dimensions (identity, cause, timeline,consequences and cure/control).

    2. Exploring misconceptions, with emphasis on their origins [experience,

    family belief, religious/spiritual understanding, folk-medicine, myth,etc].

    3. Creating conditions for conceptual changeby discussing the limitations of holdingbeliefs that are misconceptionsi.e., whatone loses by maintaining those beliefs.

    4. Introducing replacement information.

    5. Summarizing and discussing benefits ofadopting beliefs that are crediblereplacements [to the patient].

    6. Developing a plan and strategies.


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    It is important to evaluate the cultural component of pain after or during theassessment with the patient so as not to stereotype or make assumptionsbased on race or ethnicity. It is also important to be sensitive to what role

    community plays in the patients life; a persons view of collectivism vs.individualism is critical to effectiveness and compliance issues. Importantin any evaluation is not only how or to what degree the patient isexperiencing pain (recognizing that some cultures do not recognize orcommunicate with a linear or numerical progression of pain), but what theirexpectations regarding pain management are, including:

    In what context is a personal assessment made (the meaning of level

    8 pain may be very different for a person who has never experiencedsignificant disease or injury than for someone who has had majorsurgery, or a significant accident or infection).

    At what level does the patient expect to be controlled?

    How the patient wants or anticipates achieving their expected level of

    pain control.

    What specific assistance does the patient need to achieve thedesired level of pain control?

    What education does the patient and/or their family require regarding

    expectations and pain management techniques.

    What are the spiritual/religious interpretations of pain?


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    What are the barriers to pain management (fatalism, fear of addiction,

    fear of tolerance, concerns about side effects, need to be a goodpatient, fear of care providers response, interfering with careproviders assessments and judgments, fear of masking symptoms

    that may signal problems, and fear of harm to the body).

    Why is a given patient refusing, overusing, or otherwise being

    noncompliant with any specific treatment? Always be careful injudging patients as noncompliant. Instead, probe for the logicbehind their actions.

    Review of pain management literature reveals that mutually agreed upongoals for pain relief were the single best predictor of the quality of pain

    management (p. 31).

    How individuals deal with pain has a component of learned behavior. Anattitude toward pain is learned in the social setting of family andcommunity. Adults portray cultural meanings toward pain to children andchildren learn how to respond to painful stimuli. In an article entitled Socialand Cultural Influences on Pain and Disability, it describes children inethnic groups where parents show excessive concern over the childrenwhen they fall. These children tend to focus on and magnify the painful

    stimuli of falling. On the other hand, the children of parents in anotherethnic group who minimize or distract them from the painful experienceswill interpret the pain as less important. The values learned as a child aretransmitted from one generation to another with other cultural norms andstandards. These norms and standards are repeated over a life time andare often the fundamental mechanism of pain perception.

    It is important for care providers to understandwhat their expectations and biases are. Do youthink people who cry are acting like babies? Do

    you believe that people should take medicationregularly to stay ahead of their pain, or do youbelieve people should take narcotics or pain medsonly if absolutely necessary? How do you define

    drug-seeking behavior? What are your cultural perspectives regardingpain? What do you think is normal behavior?


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    The information above is in part a summary of an article entitled WhatColor is Your Pain? by Louise Kaegi, found in Minority Nurse pages 28-35,in the Summer 2004 issue. For more information visit their web

    Culture influences the way nurses respond to and manage pain of theirpatients. Nurses as a work group value self-control and ability to work wellunder stress. They often expect patients to hold the same values whendealing with pain. In general nurses tend to under-evaluate patients painaccrediting pain behaviors to psychological or mental distress rather thanactual physical pain. In an article entitled, Culture and Nurses Inferencesof Suffering, a study of 4,000 nurses from 13 countries believed thatJewish and Hispanic patients were suffering more than Anglo-Saxon or

    German patients. Nurses of European and American background inferredthe least patient suffering. These Ethnic groups often believe that aconstrained behavior is best when dealing with pain. Nurses from Africa,where cultures are more emotional and expressive, related that the patienthad the highest level of suffering. If the nurse does not understand the waya patient expresses pain, the resulting attitude can affect how the patients

    pain will be managed. If the patient senses a feeling ofan uncaring attitude from the nurse, the patient mayhave a more difficult time controlling pain. The patientsexpression of pain should not influence the nursestreatment of pain.

    The expression of pain does not necessarily indicate aninability to tolerate it. In Hispanic, Jewish and Iraniancultures, the expression of pain is allowed and even

    rewarded with attention. Anglo-Saxons, Asian and German culturesdisplays of pain is shameful and should never be made public. It is evidentthat the expression or non-expression of pain does not mean that thepatient is not experiencing pain. Each culture has expectations of the

    expression of pain. The best way to break down cultural barriers is to allowthe patients to self-report pain.

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    Check Up

    1. The degree of pain (i.e level 8 is equal in all cultural groups?)True False

    2. Barriers of pain management may include:a. Fear of addiction of pain medicationsb. Fear of tolerance of medicationc. Fear of caregivers response to their paind. All of the above

    3. A mutually-acceptable goal for pain relief is the single best predicatorof quality of pain management.

    True False4. Describe your cultural perspective on pain?

    5. Overall, nurses tend to underestimate pain?True False

    6. The differences in expression of pain is due to differences ina. Pain thresholdb. Cultural norms and beliefs about pain expressionc. Pain tolerance

    d. Intensity of pain

    Answers are on page 21


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    The information presented below is copied with permission from Cultureand Nursing Care: A Pocket Guideedited by J.G. Lipson, S.L. Dibble,and P.A Minarik, and published by the School of Nursing at University ofCalifornia, San Francisco. The complete guides should be available ateach nursing unit and can be referred to for more information. Onlyrelevant sections are included here and you may want to view each culturalperspective within a broader context and with more complete information.

    To begin, it is important to understand how to make a CulturalAssessment (from page 3):

    A thorough cultural assessment can take many hours, but nurses rarely

    have that luxury. We believe that, at a minimum, the following list must beincluded in cultural assessment of any patient (Lipson & Meleis, 1985). Thechapters that follow provide information on many other topics relevant tonursing care, which could be asked about or observed.

    Where was the patient born? If an immigrant, how long has the

    patient lived in this country?

    What is the patient's ethnic affiliation and how strong is the patient's

    ethnic identity?

    Who are the patient's major support people: family members, friends?Does the patient live in an ethnic community?

    What are the primary and secondary languages, speaking and

    reading ability?

    How would you characterize the nonverbal communication style?

    What is the patient's religion, its importance in daily life, and current


    What are the patient's food preferences and prohibitions?

    What is the patient's economic situation, and is the income adequate

    to meet the needs of the patient and family? What are the health and illness beliefs and practices?

    What are customs and beliefs around such transitions as birth,

    illness, and death?


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    Communication and Interpreters

    Language differences pose a barrier to even the most basic culturalassessment. Family members pressed into service as interpreters may beunable to assist health care providers because of role conflicts or lack ofmedical vocabulary. They often base their messages to both patient andprovider on their own perception of the situation and may withhold vitalinformation because it may embarrass their family member. Even abilingual friend, or agency employee may be ineffective when untrained, orwhen not used appropriately by the health provider.

    The Cleveland Clinic Western Region Hospitals have access to trainedinterpreters through AT&T. Ask your nursing manager or supervisor forassistance with this.


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    ARAB AMERICANSThis a brief summary of the chapter in the pocket guide. Refer to the

    pocket guide for further reference. This pocket guide is available on

    each nursing division.

    Written by Afaf Ibrahim Meleis

    Cultural/Ethnic Identity

    Preferred terms. Identified by region, such as ArabAmericans, Middle Eastern Americans-or by country of origin,such as Egyptian Americans or Palestinian Americans. Ask about countryof origin; some may identify city (e.g. Ramallah).


    Major language(s) and dialects.Arabic.

    Literacy assessment. Arab professionals speak English fluently as dothose in small or large businesses. Although they communicate well ineveryday language, their language skills may still be limited. Some mayassess themselves as speaking English moderately or fluently but still findit difficult to understand language of health professionals and may havedifficulty following directions. Also they may be too proud to admit they donot understand.

    Arabs tend to repeat the same information several times if they think othersdo not understand them. Saying that you understand and repeating willhelp affirm your understanding.

    Nonverbal communication. Expressive, warm, other-oriented, shy andmodest. May have flat affect to protect others from accessing their innerfeelings. Arabs respect elders and professionals and are reluctant to take

    up their time. Are comfortable in touching within gender but not betweengenders. Traditional women may avoid eye contact with non-acquaintancesand men.

    Very polite. Therefore, may not disagree outwardly and may respond inways that they think others want them to respond.


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    Use of interpreters. After assessing language skills, inform them ofavailability of interpreters and give them option of interpretation. Use samesex interpreters whenever possible.

    Tone of voice. Loud voice means message is important. Tend to repeatmessages for emphasis and for increasing understanding.

    Consents. Written consent forms may be problematic because verbalconsent based on trust is a more acceptable mode of contracting. Dislikelistening to all possible complications before procedure. Explain need forwritten consent, emphasize positive consequences and humanize theprocess (e.g. when asked for your advice, indicate what you would do formember of your own family).

    Privacy. Value modesty and privacy, particularly with strangers. Respectfor professionals allows disclosure and loss of privacy. Segregate genderswhen procedure calls for undressing. Disclosure enhanced by gendermatching.

    Serious or terminal illness. Family members buffer sick person fromknowing whole truth about situation. Confide first in spokesperson of familyand consult on best way to approach patient with news. Family prefers todisclose information but may request presence of health professional. Ifinformation given in Arabic by family member, no guarantee thatseriousness of situation is conveyed. Accommodate family needs forgradual and prolonged disclosure of information.

    Activities of Daily Living

    Modesty. They arevery modest. Most need long gown and robe. Drapepatient appropriately and carefully, particularly in presence of oppositegender health professionals.

    Toileting. Toilet paper is not purifying enough. Most prefer to wash afterevery urination and bowel movement. May insist on using a bidet to washup after urination and bowel movement. Respect privacy.


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    Special clothing/amulets. Depends on country of origin. For manywomen, scarves are important and essential. They like their Koran or Biblehandy and may have blue beads or other amulets to ward off evil eye andmay keep special amulets during illness.

    Self-care. Maintain belief in complete rest and abdication of allresponsibilities during illness. Expect family and hospital personnel to takecare of them. Energy should be reserved for healing, not expended onself-care. Ask family members to assist. Explain rationale for self-care andits role in patients recovery and progress.

    Pain. (Wagaa orAllam) Very expressive about pain, particularly inpresence of family members with whom they feel comfortable. Focus is onpresent pain experience. Pain feared and causes panic when it occurs.

    Pain to be avoided at all expense. Some may have low pain threshold.Better able to cope with pain if source and prognosis of pain is understood.Tolerance for pain of procedures also high when benefits understood.Differentiate between pain they believe inflicted because staff does notcare about protecting them and pain that is inevitable due to procedure orto course of recovery. Express pain metaphorically, using symbols such asfire, iron, knives and rocks. Important for health professional to find outsymbols and their meaning. Some patients can respond to numerical painscale, others cannot. Their response may not reflect reality of pain. Believeinjections more effective than pills. Some may perceive intravenous fluidsas indication of severity of situation. Explain meaning. Some may be ableto manage self medicating. Provide detailed information about differencesand advantages and disadvantages. Be prepared to offer advice.

    Dyspnea. (Deeket Mfas) Panic attached to being unable to breathe. Tendto hyperventilate. Need careful coaching about meaning of oxygenation,associated with severity and urgency of situation. May panic more.

    Fatigue. (Taab, taaban, andy doukha, habtaan) "Tired, fatigued, dizzy,

    cannot open my eyes, my blood pressure is low" are all expressions offatigue. Encourage afternoon nap, ask family members to allow patient torest. Give them permission to be away from patient so everyone can rest.


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    Family Relationships

    Composition/structure. Family includes nuclear and extended family. Notunusual to have within same household uncles, aunts, nephews, nieces,and grandparents. Family-oriented structure.

    Decision making. Families make collective decisions. Extended familiesalso participate in decision making. Father, eldest son, or elderly uncleusually family spokesperson.

    Spokesperson. If there is a grandmother, many families defer to hercounsel. Physicians expected to make decisions related to care of patient.

    Illness Beliefs

    Causes of physical illness. Physical illness caused by evil eye, bad luck,stress in family, loss of person or objects, germs, winds and drafts,imbalance in hot and dry; cold and moist, and sudden fears. Amongchildren, deprivations considered cause of illness.

    Sick role. Physically sick individuals treated well. Mentally ill individualsbelieved to be able to control their illness; therefore may not be treated wellby family. Patients expected to assume passive roles in any decisionsrelated to them or others. Patients expect to be pampered.

    Acceptance of procedures. Explain procedures clearly and slowly. De-emphasize potential pain and complications. Seek family member toprovide support. Donation of blood may be reserved for loved ones. Highacceptance of treatments and procedures expected to cure; lowacceptance of complications, viewed as due to negligence or lack ofexpertise.


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    Lets review this case study to apply the principlesof care:

    #1: A 54 year Arab man was admitted to the hospitalwith chest pain. He works as a professor at the localcollege and does speak fluent English.

    When doing your assessment, you find the following factors. Reviewthe items and place a check mark next to the ones that are common

    in the Arab-American Culture.

    ______ He states he has a level 4 on the pain scale although he ismoaning and thrashing in front of his family members.

    ______ He describe the pain as a knife in the chest.

    ______ He does not want to be medicated with an injection andwants pain pills

    ______ He wants to do all of his care himself.

    ______ He insists on doing a sponge bath after ambulating to thebathroom for a bowel movement.

    Answers on page 21


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    Hispanics/Puerto RicansThis is a brief summary of the Chapter in the pocket guide. Refer to the Pocket guide for further


    Written by Teresa Juarbe

    Cultural/Ethnic Identity

    Preferred term. Hispanic was used in 1980 U.S. Census to collectivelydescribe all individuals of Mexican, Cuban, Central American, Spanish, andPuerto Rican heritage.


    Major language(s) and dialects. Spanish and English have been officiallanguages for many years. Hispanics will ask nurses to speak slowly toenhance understanding.

    Literacy assessment. Education highly regarded and respected. Manymigrate to United States in search of educational opportunities. Highincidence of school dropout, with small percentage striving for professional


    Nonverbal communication. Puerto Ricans are very loving andaffectionate. Known for hospitality and desire to be likeable, warm, smoothinterpersonal relationships. With respect, they express gratitude byproviding goods, such as homemade tradition cookies, to health careproviders.

    Consents. In conversation, many will nod affirmatively but not necessarily

    mean agreement or understanding of dialogue. Using a friendly andrespectful approach, it is acceptable to ask for clarification/repetition ofinformation provided. Some would like time to obtain verbal approval fromanother family or community member who is respected in health matters.


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    Privacy. Most Puerto Ricans open to expressing their physical ailmentsand discomforts to health care professionals. Private environmentpreferred for disclosure of health care matters.

    Serious or terminal illness. Terminal Illness often kept secret frompatient. This protective mechanism, seldom discussed with family allowsthe family to provide an optimistic atmosphere and provide the best qualityof life for the patient.

    Activities of Daily Living

    Modesty. Modesty highly valued among most men and women.

    Self-care. When in the sick role, most Puerto Ricans like to performhygiene by themselves or with minimal assistance from family members ofsame gender.

    Symptom Management

    Pain. Very loud and outspoken in expressing pain. Nurses should notcensure pain expression as an exaggeration. Accept as socially learnedmechanism to express and cope with pain. Prefer PO or IV medications forpain rather than IM or rectal.

    Dyspnea. Fanning or blowing into patient believed to provide oxygen orrelieve dyspnea.

    Family Relationships

    Composition/structure. Nuclear and extended family structure. Allactivities, decisions, social and cultural standards conceived around the


    Decision making. Many Puerto Ricans still consult adults and elderly indecision-making issues as a sign of respect and search for wisdom.Several family members might be involved in decision making.

    Spokesperson. Oldest daughter/son, older women in family.


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    Caring role. Women assume active role in caring for ill. Men assumepassive role but are to provide financially for care. Because sick person isto assume passive role, this may hinder recovery and could contradict thehealing process.

    Illness Beliefs

    Causes of physical illness. Illness might be seen as hereditary or asoutcome of punishment, sin or lack of personal attention for health. Illnessalso may be result of evil or negative environmental forces in the individual.

    Sick role. Patients usually assume a passive role. Family members mustdo all care for sick, including preparing food.

    Home and folk remedies. Many times home and folk related remediesused before or in combination with Western medicine.

    Acceptance of procedures Many fears exist about blood transfusionsbut most families will accept if needed and if options are explained clearlyand questions asked appropriately.

    Care seeking. In health matters, most consult friends and family beforethey consult a physician or nurse.


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    Lets review this case study to apply the principles ofcare:

    #2: A 54-year old Hispanic/Puerto Rican was admitted tothe hospital with chest pain. He owns a Restaurant andspeaks English and Spanish.

    When doing your assessment, you find the following factors. Reviewthe items and place a check mark next to the ones that are commonin the Hispanic/Puerto Rican Population.

    _____ 1. He states he has a level 8 on the pain scale although heis calm and stoic.

    _____ 2. He is very quite and allows his wife to care for him.

    _____ 3. Was labeled confused by the night nurse because heasked for clarification of his pain medications severaltimes.

    _____ 4. He will not sign the consent on his catheterization untilhis family comes to visit

    _____ 5. He denies he has had chest pain and continued to workin his restaurant for hours after the chest pain started.

    Answers on page 21

    An important paragraph in the book Culture and Nursing Care: A PocketGuide states that nurses can not indiscriminately apply the cultural facts toa patient of a particular ethnic group. Cultural information can lead to

    stereotyping patients. Stereotyping makes assumptions about a personbased on the membership to a group. Thus it is important to learn whetherpeople consider themselves typical or different from others in the culturalgroup.


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    Answers to check-ups and Case studies:


    1. False2. D3. True4. Your own answer5. True6. B

    Case study 1

    __X___ 1.__X___ 2.__ ___ 3.__ ___ 4.__ x __ 5.

    Case study 2__ ___ 1.__ ___ 2.__X_ __ 3.__X_ __ 4.__ __ _ 5.