Since time immemorial, the nature of science fears the idea of subjective data due to its capricious and unpredictable characteristics. Wherein science is ultimately based on empirical evidence of cause and effect relationships, the nature of pain is highly dependent on physical, psychological and environmental factors. A pioneer in pain management once said, “pain is whatever the person experiencing it says it is and exists whenever he says it does” (1999, p. 98). Margo McCaffery meant to say that pain experience will always be subjective by nature and can only be disclosed by the patient in question. This creates an important emphasis on in-depth nursing assessments and individualized nursing interventions.
Referring to the International Association for the Study of Pain, mentioned in Linton’s “Introduction to Medical-Surgical Nursing”, pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage.” This means that pain signals danger and prevents humans from harming themselves while alerting the body to damages done unto one’s system. In some cases, too much pain can be crippling and can make living a form of endless agony. Essentially, even ‘good pain’ can turn bad, when the pain of a past injury persists after the damage has healed.
As a nurse, it is imperative that they should be “nonjudgmental and avoid comparing one individual in pain with another individual in pain” (Linton, 2016, pg. 213). It is acknowledged that there is no such thing as two exact patients even though they are matched on numerous aspects such as medical conditions or biological identities. For most patients, pain is temporary, lasting as long as the causal stimuli followed by a sudden disappearance. For other patients, pain evolves into a chronic problem that usurps one’s identity. Ultimately, both patients want liberation; an end to their ordeal.
Relationship between Culture and Pain
Based on 2018 Immigration Statistics of the Government of Canada, the country gained an influx of between “290,000 and 330,000 permanent residents, which is the highest level in recent history,” with numbers increasing by ten percent each year. This means that nurses will engage in constant ever-changing relationships with a multitude of cultures. Different cultures tend to have different values, beliefs, and experiences meaning different ways of handling pain. “Some cultures are expressive about their pain while others are introverted” (Potter, P. et. al, 2014). This creates a greater emphasis on cultural competence and cultural sensitivity to better help each individual with pain management.
Cultural Differences in Pain Perception
Cultural Sensitivity refers to a nurse’s awareness of how culture shapes the patient’s values, beliefs and world views. In doing so, nurses will strive to understand potential differences and ensure respect for these varying cultures. Following this attitude and respect, cultural competence is the knowledge and skills required to obtain positive outcomes in cross-cultural encounters. In knowing about a culture’s customs, nurses can achieve better pain relief and competency-based practice. For example, “[Caucasians] were two and a half times more likely than African Americans and nearly one and a half times more likely than Hispanics to use “self-care” for pain relief” (Hastie and Riley, 2005, Ethnic Differences and Responses to Pain in Healthy Young Adults). One reason for this likelihood is given that Caucasians had the highest proportion of insured participants thus they were more likely to pursue health care options for pain relief. Another possible conjecture is that people with higher incomes tend to fear pain and loss more than those of lower incomes. This is due to the fear of losing what one has. For cultures with more to lose, they have greater fear. Death and pain are unfathomable and more likely to instill fear in cultures with more to lose such as families, wealth, lifestyle etc. With this in mind, the Asian culture can be considered as the opposite of Hispanic, Caucasian and African culture in a sense where they value stoicism more than expression.
Interpretation of Patients’ Pain Experience
In a sense, an important aspect of the client-focussed provision of care is to recognize one’s own prejudices and biases and to care for one’s patients in a manner that does not affect the nurse’s own perception of a patient’s pain complaints. Imposing the nurse’s own way of handling pain creates a disconnect to the bridge that helps understand the patient’s pain. The moment this seed of mistrust begins, any form of pain management will be inadequate. Pain is a “highly personal experience, which can be accurately described only by the individual experiencing it and report of pain should be accepted as valid” (Potter, P., 2014) Thus, nurses are bound by their license to provide an accurate pain assessment while acknowledging the patient’s perception and culture into account, without this accuracy, pain management will be mediocre. Connecting this to the Chinese Culture, they prefer not to express pain for a variety of reasons such as being perceived as weak. If the nurse lacks cultural competence or continues to exhibit bias and generalization, pain management will become of poor quality thus increasing the level of anxiety and slowing down the healing process altogether.
Communication issues such as linguistic and nonverbal differences can hinder the nurse’s understanding of the patient’s complaints and be considered as life-threatening. People from different cultures “describe pain and distress quite differently” (Meuter, R., 2015, Overcoming Language Barriers). It is problematic when health care practitioners lack the linguistic and cultural skills needed and translators are unavailable. As a result, patients may have to rely on their family members who are medically inexperienced which may worsen health outcomes due to the risk of miscommunication and lack of understanding.
According to Rethinking the Concept of Acculturation, acculturation is defined as “changes that take place as a result of contact with culturally dissimilar people, groups, and social influences” (Gibson, 2001). Realistically speaking, these changes can happen with any kind of crosscultural contact but the focus is on its effects on pain. The social norms of some Caucasian cultures are to report their pain as soon as possible. Adding to this scenario, a chinese immigrant were to move to Canada, they are disinclined to report their pain because they do not want to worry their family; they would rather endure the pain rather than explore relief options. Acculturation can be positive or negative in a sense where, a predominantly Caucasian community will influence the minority group to accustom to their tendencies of reporting their pain as much as possible. Similarly, a predominantly Chinese community may influence the minority group, which were originally more vocal about their pain, to become more stoic and reserved. Nurses need to be aware to not impose and to be very open to their patients so that they can diagnose the most accurate form of pain management.
For Chinese patients, their outlook on pain and treatment is deeply rooted in philosophical and religious beliefs that affect all aspects of pain assessment and management. To properly assess the patient’s pain complaint, it is “important to evaluate the meaning that pain has in the person’s life and the causal attributions that the individual gives to his or her pain. In addition, the philosophical approach that a patient has toward whether pain should be treated will need to be discussed before a pain education program and a pain management plan can be implemented” (Chen, L. 2008, The Cancer Pain Experience). Since they see their pain differently, nurses need to avoid generalization to better understand their patient’s views.
Chinese patients may believe that pain is caused by a Yin and Yang imbalance in the body. If so, they will prefer to refer to Traditional Chinese Medicine or the use of acupuncture by “blocking their meridians” (Chen, L. 2008). If nurses do not understand this belief, they will assume that the patient is not adhering to their analgesic regimen. Yin energy represents negative energy while Yang energy represents positive energy. If an imbalance occurs, this just means that there is a nonharmonic situation that is causing this disease or symptom to occur. Taoism believed that to treat this disease, Chinese patients must enhance the “feng shui” meaning harmony of their environment such as “move some furnishings, ask clinicians to perform procedures at a specific time, and refuse visitors who are foes to them” (Chen, L. 2008)
Nurses need to understand that Chinese patients may believe that pain should be endured. Based on a variety of beliefs (eg, sin from last life, the Inn and Ko [cause and effect], a trial or sacrifice, a born-to-be fate, and afraid to bother either family or clinicians), “Chinese patients tend to bear and accept their pain. They report pain only when it becomes unbearable.” (Chen, L. 2008) Some patients may choose to endure intractable pain to accomplish their life trials. This form of persistence is in accordance with their belief. Any form of surrender is a sign of weakness and the lack of faith in Buddhism. Nurses need to discuss this belief with patients. They need to inform patients about the detrimental effects of unrelieved pain on their mood and functional status. In some cases, nurses may need to support the patient’s belief system and assure them that they will be available to assist with pain management. (Chen, L. 2008) By creating an open-door policy, Chinese patients will have a sense of comfort in times of distress.
Some Chinese patients may blame themselves for their illness, whereas others “may negotiate with God(s) to change their fate by praying in the temple or at home, intonating gospel, giving alms to the poor, becoming a vegetarian, or wearing a Fu (amulet)” (Chen, L. 2008). Confucianism is a form of bargaining with a higher power. This is exhibited by other cultures as well such as Hispanic and Filipino cultures. Filial piety and humaneness are essential values of Confucianism because in honouring one’s parents or by helping those of poorer opportunities, they are increasing the likelihood of good karma. Again, Nurses need to ask patients to describe the various approaches that they use to manage their pain and their illness. By involving the patient in their care, this can increase the relationship between patient and nurse while creating a sense of trust and improving the healing process due to increased pain tolerance.
Another deciding factor in the Chinese culture’s adherence to analgesic is opioid-phobia. Back in the 18th century till this day, there has been an increase in opioid addiction. The Chinese culture fears that they will be consumed by opioid dependence if they allow the medical team to use morphine for pain relief. Thus they would rather refer to other options of care.
Pain Assessment Tools
The Critical-Care Pain Observation Tool includes four behavioural categories: facial expression, body movements, muscle tension, and compliance with the ventilator for intubated patients or vocalization for extubated patients. (Yaowei, L. 2015) Items in each category are scored from 0 to 2 with the total score of the CPOT ranging from 0 to 8. In a sense, it is very similar to the pain scale commonly used in Canada where you rate your pain from 0 to 10 with 0 being no pain and 10 being unbearable pain. The Chinese version of the “CPOT used in this study was translated by Li et al. with evidence of reliability and validity demonstrated as an instrument for pain assessment in Chinese critically ill ventilated adults” (Yaowei, L. 2015)
In conclusion, it is necessary to consider the role of culture in patients’ pain experienced. In knowing the nature of pain, nurses can create better customized care. “Know thy enemy, know thy self” (Sun Tzu) In knowing about pain and how cultures perceive it, nurses can better battle this enemy and release the patients from this pain. Chinese perception of pain is certainly influenced by stoicism, philosophy and opioid history. Their culture has a great impact on assessment and pain management so it is best to be culturally competent. In order to provide ultimate care for these culturally influenced individuals; nurses should develop awareness and understanding of Chinese patient perception and behaviour. They often suppress pain and choose not to verbalize their concerns about pain. Their culture also influences how they seek treatment that is acceptable and favourable to them. Traditional treatment will be relevant for this group of people such as acupuncture, tai chi, and some herbal medicines.
- Potter, P (2014) Canadian Fundamental of Nursing
- Linton, M. (2016) Introduction to Medical Surgical Nursing
- Tung, W (2015). Pain and Beliefs and Behvaiours Among Chinese