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Assessment:

Are Cultural Disconnects Tanking Your Pain Outcomes?

Published on Mon Mar 05, 2012

A stoic patient may be masking pain.

Your answers to the OASIS pain items are being shared with the public on Home Health Compare. Could a cultural misunderstanding be skewing your results?

OASIS items M1240 -- Has this patient had a formal pain assessment?, M1242 -- Frequency of pain interfering with patient's activity or movement, and

M2400d -- Interventions to monitor and mitigate pain provide data for both OASIS outcomes and Home Health Compare. But many agencies aren't looking at the effect culture has on their patient's pain experience.

Consider Why Ethnicity is Related to Poor Pain Management

Studies have shown that minorities are more likely to get inadequate pain assessment and treatment across the spectrum of health care providers, Mary Curry Narayan, MSN, RN, HHCNS-BC, CTN, COS-C, home health clinical nurse specialist from Vienna, Va. said during her presentation at the National Association for Home Care & Hospice's 2011 Annual meeting.

Ethnicity could be having a negative impact on pain outcomes for a variety of reasons, Narayan tells Eli. First, there's the potential language barrier. If the patient and the clinician assessing his pain speak two different languages and there's no interpreter, it's bound to affect the pain assessment. If you're not speaking the same language, it's difficult to determine the quality of the pain and when it gets better or worse, she says. Inadequate interpreters can also lead to a skewed understanding of a patient's pain.

A patient's culture, or learned patterns of thinking and acting, can also impede an accurate pain assessment, Narayan says. For example, some cultures are stoic and believe you shouldn't verbalize expressions of pain. These patients may try to mask their facial expressions when experiencing pain and believe that they must bear the pain. They are more likely to choose to be alone. Other cultures may be more expressive and be ready to verbalize their pain. These patients will allow facial grimacing and believe they should seek relief from pain. They are more likely to seek support or sympathy.

Culture can affect the patient's view of pain in a variety of ways, Narayan said. Should you avoid pain? Or is there gain in experiencing pain? Is pain thought to be a punishment? Or if you suffer now, might you be better off in the long run?

Problem: Some pain assessment tools that screen only for pain intensity may not be appropriate for use with minority patients, Narayn points out. For example, in some cultures, there is no association between pain and the 1 to 10 pain scale. These patients would be more likely to say "my pain is as dark as a storm" than "my pain is an 8."

And while the Wong-Baker faces scale has been proven effective with pediatric patients, it may not be the right tool for a fully-functioning adult patient who doesn't speak English. One problem with this scale is the tearful face at the high end of the scale. Tears are considered bad in some cultures, Narayan points out. And patients from a stoic culture aren't likely to identify with the faces that show such intense emotion.

Minority patients may also be afraid to admit how much pain they are experiencing because they believe the doctor will stop treating them if they are honest, Narayan says.

Try These Culturally Sensitive Assessment Techniques

The first step to conducting better pain assessments is to know your own reaction to pain, Narayan says. Do you value stoicism and find more expressive patients troubling? Are there other behaviors around pain that make you crazy? How did your parents deal with pain? If you don't recognize your own biases, they can rule you, she says. Understanding your own ideas about pain will help you to prevent them from clouding the data you gather.

Advocating for your patients will also help improve your pain outcomes, Narayan says. Do something when you see that things aren't being done properly. For example, don't be satisfied with poor interpretation. Obtain good language services.

Learn about cultural differences. There are many resources in books and online that you can use to get a better understanding of the way different cultures view and express pain. Become aware of the different approaches to pain in the populations you serve, but don't try to fit each patient into a particular cultural mindset. Using a patient-centered care approach where you adapt your care to meet each patient's needs is always best. Consider using a culture-sensitive pain assessment tool like the one described below.

 

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