The following resource was submitted with the purpose of distributing to AONE members as part of the AONE Diversity

in Health Care Organizations Toolkit Submitted by: Childrens Hospital Medical Center Contact person: Lisa Aurilio, RN, MSN, NEA-BC Director, Maternal Fetal Neonatal Services Akron, OH

Cultural Sensitivity in Nursing Care for Pain Management A Self-learning Module November 2004-2006 This module has been awarded 1.0 contact hours and should take approximately 50 minutes to complete.
Developed by: Rev Melanie Sunderland

Objectives: Describe the socio-cultural perspective of pain assessment and management. Apply the cultural beliefs of pain control to two case studies.

Memorandum
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 on Accreditation (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 216-363-2158

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. As Margo McCaffery (a pain management expert, quoted in Minority Nurse) states, Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does.

At the Cleveland Clinic Health System, we serve a diverse population of people with a variety of cultural heritages and experiences. This necessitates that we be aware of and sensitive to cultural differences and how they affect the care of the individual within the larger context of their life beyond the hospital. If we are to adequately address issues of pain with our patients, as we strive to provide excellence in patient care, addressing cultural issues is a must do part of the assessment and management of pain. This learning module is intended to give a brief overview of some sociocultural perspectives of pain assessment and management, and highlight care of Hispanic and Mid-Eastern populations, as we have a significant percentage of patients from these cultural groups within our patient population. The information provided about specific ethnic populations in this module do not represent all whom we see, but can give you a sense of what 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. The nurses own cultural background coupled with the patients expression of pain, based on their cultural background, influences the nurses assessment and management of the patients pain. It is imperative that nurses be sensitive to the differences in their own and their patients culture associated with pain management.

There are many assessment tools in the nursing care literature, and it is beyond 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 may not reflect a patients actual experience of pain. The RIDcancerPain program recommends nurses take patients through a 6-step process of assessing cancer pain, which can be adapted to other areas: 1. Representational assessmentthe patient describes beliefs about cancer 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 change by discussing the limitations of holding beliefs that are misconceptionsi.e., what one loses by maintaining those beliefs. 4. Introducing replacement information. 5. Summarizing and discussing benefits of adopting beliefs that are credible replacements [to the patient]. 6. Developing a plan and strategies.

It is important to evaluate the cultural component of pain after or during the assessment with the patient so as not to stereotype or make assumptions based 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. Important in any evaluation is not only how or to what degree the patient is experiencing pain (recognizing that some cultures do not recognize or communicate with a linear or numerical progression of pain), but what their expectations 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 experienced significant disease or injury than for someone who has had major surgery, 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 the desired 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?

 What are the barriers to pain management (fatalism, fear of addiction, fear of tolerance, concerns about side effects, need to be a good patient, fear of care providers response, interfering with care providers 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 in judging patients as noncompliant. Instead, probe for the logic behind their actions. Review of pain management literature reveals that mutually agreed upon goals 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. An attitude toward pain is learned in the social setting of family and community. Adults portray cultural meanings toward pain to children and children learn how to respond to painful stimuli. In an article entitled Social and Cultural Influences on Pain and Disability, it describes children in ethnic groups where parents show excessive concern over the children when they fall. These children tend to focus on and magnify the painful stimuli of falling. On the other hand, the children of parents in another ethnic group who minimize or distract them from the painful experiences will interpret the pain as less important. The values learned as a child are transmitted from one generation to another with other cultural norms and standards. These norms and standards are repeated over a life time and are often the fundamental mechanism of pain perception. It is important for care providers to understand what their expectations and biases are. Do you think people who cry are acting like babies? Do you believe that people should take medication regularly to stay ahead of their pain, or do you believe people should take narcotics or pain meds only if absolutely necessary? How do you define drug-seeking behavior? What are your cultural perspectives regarding pain? What do you think is normal behavior?

The information above is in part a summary of an article entitled What Color is Your Pain? by Louise Kaegi, found in Minority Nurse pages 28-35, in the Summer 2004 issue. For more information visit their web site: www.MinorityNurse.com. Culture influences the way nurses respond to and manage pain of their patients. Nurses as a work group value self-control and ability to work well under stress. They often expect patients to hold the same values when dealing with pain. In general nurses tend to under-evaluate patients pain accrediting pain behaviors to psychological or mental distress rather than actual physical pain. In an article entitled, Culture and Nurses Inferences of Suffering, a study of 4,000 nurses from 13 countries believed that Jewish and Hispanic patients were suffering more than Anglo-Saxon or German patients. Nurses of European and American background inferred the least patient suffering. These Ethnic groups often believe that a constrained behavior is best when dealing with pain. Nurses from Africa, where cultures are more emotional and expressive, related that the patient had the highest level of suffering. If the nurse does not understand the way a patient expresses pain, the resulting attitude can affect how the patients pain will be managed. If the patient senses a feeling of an uncaring attitude from the nurse, the patient may have a more difficult time controlling pain. The patients expression of pain should not influence the nurses treatment of pain. The expression of pain does not necessarily indicate an inability to tolerate it. In Hispanic, Jewish and Iranian cultures, the expression of pain is allowed and even rewarded with attention. Anglo-Saxons, Asian and German cultures displays of pain is shameful and should never be made public. It is evident that the expression or non-expression of pain does not mean that the patient is not experiencing pain. Each culture has expectations of the expression of pain. The best way to break down cultural barriers is to allow the patients to self-report pain.

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 medications b. Fear of tolerance of medication c. Fear of caregivers response to their pain d. All of the above 3. A mutually-acceptable goal for pain relief is the single best predicator of quality of pain management. True False 4. 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 in a. Pain threshold b. Cultural norms and beliefs about pain expression c. Pain tolerance d. Intensity of pain Answers are on page 21

The information presented below is copied with permission from Culture and Nursing Care: A Pocket Guide edited by J.G. Lipson, S.L. Dibble, and P.A Minarik, and published by the School of Nursing at University of California, San Francisco. The complete guides should be available at each nursing unit and can be referred to for more information. Only relevant sections are included here and you may want to view each cultural perspective within a broader context and with more complete information. To begin, it is important to understand how to make a Cultural Assessment (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 be included in cultural assessment of any patient (Lipson & Meleis, 1985). The chapters that follow provide information on many other topics relevant to nursing 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 practices? 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 cultural assessment. Family members pressed into service as interpreters may be unable to assist health care providers because of role conflicts or lack of medical vocabulary. They often base their messages to both patient and provider on their own perception of the situation and may withhold vital information because it may embarrass their family member. Even a bilingual friend, or agency employee may be ineffective when untrained, or when not used appropriately by the health provider. The Cleveland Clinic Western Region Hospitals have access to trained interpreters through AT&T. Ask your nursing manager or supervisor for assistance with this.

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ARAB AMERICANS This 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 Arab Americans, Middle Eastern Americans-or by country of origin, such as Egyptian Americans or Palestinian Americans. Ask about country of origin; some may identify city (e.g. Ramallah). Communication Major language(s) and dialects. Arabic. Literacy assessment. Arab professionals speak English fluently as do those in small or large businesses. Although they communicate well in everyday language, their language skills may still be limited. Some may assess themselves as speaking English moderately or fluently but still find it difficult to understand language of health professionals and may have difficulty following directions. Also they may be too proud to admit they do not understand. Arabs tend to repeat the same information several times if they think others do not understand them. Saying that you understand and repeating will help affirm your understanding. Nonverbal communication. Expressive, warm, other-oriented, shy and modest. May have flat affect to protect others from accessing their inner feelings. Arabs respect elders and professionals and are reluctant to take up their time. Are comfortable in touching within gender but not between genders. Traditional women may avoid eye contact with non-acquaintances and men. Very polite. Therefore, may not disagree outwardly and may respond in ways that they think others want them to respond.

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Use of interpreters. After assessing language skills, inform them of availability of interpreters and give them option of interpretation. Use same sex interpreters whenever possible. Tone of voice. Loud voice means message is important. Tend to repeat messages for emphasis and for increasing understanding. Consents. Written consent forms may be problematic because verbal consent based on trust is a more acceptable mode of contracting. Dislike listening to all possible complications before procedure. Explain need for written consent, emphasize positive consequences and humanize the process (e.g. when asked for your advice, indicate what you would do for member of your own family). Privacy. Value modesty and privacy, particularly with strangers. Respect for professionals allows disclosure and loss of privacy. Segregate genders when procedure calls for undressing. Disclosure enhanced by gender matching. Serious or terminal illness. Family members buffer sick person from knowing whole truth about situation. Confide first in spokesperson of family and consult on best way to approach patient with news. Family prefers to disclose information but may request presence of health professional. If information given in Arabic by family member, no guarantee that seriousness of situation is conveyed. Accommodate family needs for gradual and prolonged disclosure of information. Activities of Daily Living Modesty. They are very modest. Most need long gown and robe. Drape patient appropriately and carefully, particularly in presence of opposite gender health professionals. Toileting. Toilet paper is not purifying enough. Most prefer to wash after every urination and bowel movement. May insist on using a bidet to wash up after urination and bowel movement. Respect privacy.

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Special clothing/amulets. Depends on country of origin. For many women, scarves are important and essential. They like their Koran or Bible handy and may have blue beads or other amulets to ward off evil eye and may keep special amulets during illness. Self-care. Maintain belief in complete rest and abdication of all responsibilities during illness. Expect family and hospital personnel to take care of them. Energy should be reserved for healing, not expended on self-care. Ask family members to assist. Explain rationale for self-care and its role in patients recovery and progress. Pain. (Wagaa or Allam) Very expressive about pain, particularly in presence of family members with whom they feel comfortable. Focus is on present 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 not care about protecting them and pain that is inevitable due to procedure or to course of recovery. Express pain metaphorically, using symbols such as fire, iron, knives and rocks. Important for health professional to find out symbols and their meaning. Some patients can respond to numerical pain scale, others cannot. Their response may not reflect reality of pain. Believe injections more effective than pills. Some may perceive intravenous fluids as indication of severity of situation. Explain meaning. Some may be able to manage self medicating. Provide detailed information about differences and advantages and disadvantages. Be prepared to offer advice. Dyspnea. (Deeket Mfas) Panic attached to being unable to breathe. Tend to 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 of fatigue. Encourage afternoon nap, ask family members to allow patient to rest. 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. Not unusual to have within same household uncles, aunts, nephews, nieces, and grandparents. Family-oriented structure. Decision making. Families make collective decisions. Extended families also participate in decision making. Father, eldest son, or elderly uncle usually family spokesperson. Spokesperson. If there is a grandmother, many families defer to her counsel. 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. Among children, deprivations considered cause of illness. Sick role. Physically sick individuals treated well. Mentally ill individuals believed to be able to control their illness; therefore may not be treated well by family. Patients expected to assume passive roles in any decisions related to them or others. Patients expect to be pampered. Acceptance of procedures. Explain procedures clearly and slowly. Deemphasize potential pain and complications. Seek family member to provide support. Donation of blood may be reserved for loved ones. High acceptance of treatments and procedures expected to cure; low acceptance of complications, viewed as due to negligence or lack of expertise.

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. Lets review this case study to apply the principles of care: #1: A 54 year Arab man was admitted to the hospital with chest pain. He works as a professor at the local college and does speak fluent English. When doing your assessment, you find the following factors. Review the 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 is moaning 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 and wants pain pills He wants to do all of his care himself. He insists on doing a sponge bath after ambulating to the bathroom for a bowel movement.

Answers on page 21

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

Written by Teresa Juarbe Cultural/Ethnic Identity Preferred term. Hispanic was used in 1980 U.S. Census to collectively describe all individuals of Mexican, Cuban, Central American, Spanish, and Puerto Rican heritage. Communication Major language(s) and dialects. Spanish and English have been official languages for many years. Hispanics will ask nurses to speak slowly to enhance understanding. Literacy assessment. Education highly regarded and respected. Many migrate to United States in search of educational opportunities. High incidence of school dropout, with small percentage striving for professional education. Nonverbal communication. Puerto Ricans are very loving and affectionate. Known for hospitality and desire to be likeable, warm, smooth interpersonal relationships. With respect, they express gratitude by providing goods, such as homemade tradition cookies, to health care providers. Consents. In conversation, many will nod affirmatively but not necessarily mean agreement or understanding of dialogue. Using a friendly and respectful approach, it is acceptable to ask for clarification/repetition of information provided. Some would like time to obtain verbal approval from another family or community member who is respected in health matters.

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Privacy. Most Puerto Ricans open to expressing their physical ailments and discomforts to health care professionals. Private environment preferred for disclosure of health care matters. Serious or terminal illness. Terminal Illness often kept secret from patient. This protective mechanism, seldom discussed with family allows the family to provide an optimistic atmosphere and provide the best quality of 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 perform hygiene by themselves or with minimal assistance from family members of same gender. Symptom Management Pain. Very loud and outspoken in expressing pain. Nurses should not censure pain expression as an exaggeration. Accept as socially learned mechanism to express and cope with pain. Prefer PO or IV medications for pain rather than IM or rectal. Dyspnea. Fanning or blowing into patient believed to provide oxygen or relieve dyspnea. Family Relationships Composition/structure. Nuclear and extended family structure. All activities, decisions, social and cultural standards conceived around the family. Decision making. Many Puerto Ricans still consult adults and elderly in decision-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 assume passive role but are to provide financially for care. Because sick person is to assume passive role, this may hinder recovery and could contradict the healing process. Illness Beliefs Causes of physical illness. Illness might be seen as hereditary or as outcome of punishment, sin or lack of personal attention for health. Illness also may be result of evil or negative environmental forces in the individual. Sick role. Patients usually assume a passive role. Family members must do all care for sick, including preparing food. Home and folk remedies. Many times home and folk related remedies used before or in combination with Western medicine. Acceptance of procedures Many fears exist about blood transfusions but most families will accept if needed and if options are explained clearly and questions asked appropriately. Care seeking. In health matters, most consult friends and family before they consult a physician or nurse.

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Lets review this case study to apply the principles of care: #2: A 54-year old Hispanic/Puerto Rican was admitted to the hospital with chest pain. He owns a Restaurant and speaks English and Spanish. When doing your assessment, you find the following factors. Review the items and place a check mark next to the ones that are common in the Hispanic/Puerto Rican Population. _____ _____ _____ 1. He states he has a level 8 on the pain scale although he is 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 he asked for clarification of his pain medications several times. 4. He will not sign the consent on his catheterization until his family comes to visit 5. He denies he has had chest pain and continued to work in his restaurant for hours after the chest pain started.

_____ _____

Answers on page 21

An important paragraph in the book Culture and Nursing Care: A Pocket Guide states that nurses can not indiscriminately apply the cultural facts to a patient of a particular ethnic group. Cultural information can lead to stereotyping patients. Stereotyping makes assumptions about a person based on the membership to a group. Thus it is important to learn whether people consider themselves typical or different from others in the cultural group.

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Answers to check-ups and Case studies: Check-up: 1. 2. 3. 4. 5. 6. False D True Your own answer True B

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

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

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