Chapter 4: Pain Assessment

Background

Pain assessment and management are not one-size-fits-all. Pain is an individual experience and should be treated as such. It is important to have many different tools and assessment approaches in the nursing “tool kit” to assess and treat all types of patients.

The Social Determinants of Health in Relation to Pain Management

• Evans et al. (2019) studied the pain intensity experience of older Black adults living in a low-income area of Los Angeles. They determined that age, financial struggles, pain-related chronic conditions, living alone, and depression lead to an increase in pain intensity (Evans, 2019).
• Janevic et al. (2018) studied pain intensity across a diverse patient population and discovered that White adults experience less pain-related disability than Black adults. Their study showed that socioeconomic disadvantages also have a negative impact on the prevalence of chronic pain, regardless of patients’ cultural backgrounds (Janevic et al., 2018).
• Disparities in pain treatment include poor or unfairly operated social, economic, and health policies for people in low income brackets (Booker & Herr, 2021). Patients in rural or impoverished areas have limited access to the health care services they need to manage chronic pain (Booker & Herr, 2021). Therefore, their pain is left untreated and becomes unbearable.
• Bierman and Lee (2018) discovered that racialized individuals who have faced lifelong stressors are at an increased risk of clinical depression if they experience severe or chronic pain.

Barriers to Adequate Pain Management for Racialized Patients

The burden of pain is unequal across cultural groups (Meints et al., 2019). Health care providers (HCPs) may lack knowledge or have implicit biases about spiritual and cultural practices for pain management.

HCP Barriers

• HCPs may believe myths, such as the idea that Black individuals experience less pain than White individuals due to biological differences (Hoffman et al., 2016). Not only does this myth contribute to racial disparities in health care, it can also lead to inadequate assessment and treatment of pain (Hoffman et al., 2016).
• Unconscious biases, stereotyping, and false beliefs may contribute to the improper assessment and/or mistreatment of pain among racialized patients (Meints et al., 2019).
• A general misunderstanding or lack of knowledge regarding effective pain management strategies may also cause HCPs to under-assess and under-treat pain (Slatyer et al., 2022).

Cultural Factors

• Each faith and culture may have a different understanding of what pain means and how it should be treated. There are also gender differences among cultural groups, which influence pain expression as well (Can et al., 2019).
• Certain cultures believe in stoicism and not showing or reporting pain (Bautista et al., 2021).
• Certain countries do not have access to opioids. Therefore, patients may not know they are a treatment option (Bautista et al., 2021).
• Various cultures view pain as a sign of healing, penance for sins, or a manifestation of a higher power. Therefore, they do not wish to treat pain (Bautista et al., 2021).
• Many patients of different cultural backgrounds also have a fear of side effects and addiction to certain pain medications (Can et al., 2019).
• Spirituality and spiritual care in pain treatment may be very important to some patients, but they may be uncomfortable sharing this information with their HCPs (Booker, 2016).
• Cost and lack of insurance coverage for some medications, supplements, and therapies can also hinder effective pain management (Booker, & Herr, 2018).
• Patients may use metaphors to explain pain, and this could be lost in translation and shift the focus from the pain to understanding the word or phrase (Bostick et al., 2021).
• In their research, Robinson-Lane and Booker (2018) discovered that Black patients may experience a genuine mistrust of the health care system due to past experiences. This mistrust could lead to a hesitation to seek care or share information with health care providers, which could lead to undue pain and suffering (Robinson-Lane & Booker, 2018).

Pitfalls of Pain Assessment Tools

HCP should be mindful of the potential barriers that some pain assessment tools have. Pain is subjective and is difficult to assess with a standardized tool. Therefore, assumptions, implicit biases, and stereotyping may occur within the assessment process. For example, the face scale may not be useful if the image has a crying face, as patients from some cultures believe in stoicism and do not show emotion while in pain (Booker, 2016). This could deter the patients from expressing their pain fully. Furthermore, some pain scales use colours, which could impede the results, as certain colours have specific meanings for some individuals (Lor et al., 2021).

Culturally Responsive Practice Points for Health Care Providers

• HCP must be aware of the prominent ethnocultural communities within their areas of practice and familiarize themselves with how this may influence care provision and assessments, especially pain assessments (Brady et al., 2017).
• HCP can use self-reflection to revisit past encounters with racialized patients experiencing pain and examine how culture influences pain assessment and management (Bostick et al., 2021). Self-reflection is an important aspect of a HCP’s lifelong learning.
• For pain management to be effective, it is essential for the HCP to establish a trusting relationship with the patient. The HCP must ask questions about the patient’s understanding of pain and desired treatment plan (Bautista et al., 2021).
• It is beneficial for the HCP to genuinely acknowledge and appreciate the patient’s personal beliefs, values, and life patterns related to pain management (Robinson-Lane & Booker, 2018).
• There may be many cultural reasons why a patient chooses a specific pain treatment or declines pain medication. It is the HCP’s duty to provide the patient and their family with the necessary evidence-based information for decision making and to respect the patient’s wishes regardless of their decision (Can et al., 2019).
• The HCP should strive for holistic care provision, including cultural and spiritual dimensions in their daily assessments (Brady et al., 2017).
• It is important for the HCP to supplement subjective reports of pain with additional probing questions relating to the pain experiences (Slatyer et al., 2022) and objective findings of pain such as wincing, guarding, and rubbing certain areas.
• The HCP should use words like “hurt,” “aches,” “sore,” and “throbbing” to inquire about pain (Robinson-Lane & Booker, 2018).
• When they are assessing pain, it is important for the HCP to link the pain to how it affects the patient’s daily activities and functioning (Bostick et al., 2021).
• The HCP may need to accommodate and adapt aspects of care and assessment to align with the patient’s values and preferences (Robinson-Lane & Booker, 2018).
• Involving the family in pain assessments can also help. Families may pick up on nonverbal cues that the HCP may miss (Booker, 2016). Families may be able to provide guidance to HCP regarding their loved one’s preferences regarding touch and environment (Booker, 2016). Families can also be included in providing non-pharmacological pain relief such as light massage and applying warm or cool compresses (Booker, 2016)
• It is essential for the HCP to discuss and clarify common misconceptions about pain management. It is also vital for them to involve families and patients in treatment and management plans with the common goal of pain control (Booker, 2016).

Please view the following link for further information on cross-cultural pain assessments:

https://journals.lww.com/jnnonline/Fulltext/2021/06000/Cultural_Perspectives_on_Pain_Assessment_and.9.aspx

References

Bautista, C., Amatangelo, M. P., Baby, P., Cassier-Woidasky, A. K., Dycus, K., Edoh, E. I., . . . & Wessol, J. L. (2021). Cultural perspectives on pain assessment and opioid use: International neuroscience nursing research symposium conference proceedings. Journal of Neuroscience Nursing, 53(3), 149–156. DOI: 10.1097/JNN.0000000000000585

Bierman, A., & Lee, Y. (2018). Chronic pain and psychological distress among older adults: A national longitudinal study. Research on Aging, 40(5), 432–455. https://doi.org/10.1177/0164027517704970

Booker, S. Q. (2016). #Blacklivesmatter: Leveraging family collaboration in pain management. Nursing2020 Critical Care, 11(2), 1–7. DOI:10.1097/01.CCN.0000480749.23473.b6

Booker, S., & Herr, K. (2021). Voices of African American older adults on the implications of social and healthcare-related policies for osteoarthritis pain care. Pain Management Nursing, 22(1), 50–57. https://doi.org/10.1016/j.pmn.2020.09.001

Bostick, G. P., Norman, K. E., Sharma, A., Toxopeus, R., Irwin, G., & Dhillon, R. (2021). Improving cultural knowledge to facilitate cultural adaptation of pain management in a culturally and linguistically diverse community. Physiotherapy Canada, 73(1), 19–25. https://doi.org/10.3138/ptc-2019-0027

Brady, B., Veljanova, I., & Chipchase, L. (2017). An exploration of the experience of pain among culturally diverse migrant communities. Rheumatology Advances in Practice, 1(1), 1–14 https://doi.org/10.1093/rap/rkx002

Can, G., Mushani, T., Rajhi, B. H. A., & Brant, J. M. (2019). The global burden of cancer pain. Seminars in Oncology Nursing, 35(3), 315–321. https://doi.org/10.1016/j.soncn.2019.04.014

Evans, M. C., Bazargan, M., Cobb, S., & Assari, S. (2019). Pain intensity among community-dwelling African American older adults in an economically disadvantaged area of Los Angeles: social, behavioral, and health determinants. International Journal of Environmental Research and Public Health, 16(20), 1–17. https://doi.org/10.3390/ijerph16203894

Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences, 113(16), 4296–4301. https://doi.org/10.1073/pnas.1516047113

Janevic, M. R., McLaughlin, S. J., Heapy, A. A., Thacker, C., & Piette, J. D. (2017). Racial and socioeconomic disparities in disabling chronic pain: Findings from the health and retirement study. The Journal of Pain, 18(12), 1459–1467. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5682226/pdf/nihms902349.pdf

Lor, M., Kim, K. S., Brown, R. L., Rabago, D., & Backonja, M. (2021). Comparison of four pain scales among Hmong patients with limited English proficiency. Pain Management Nursing, 22(2), 205–213. https://doi.org/10.1016/j.pmn.2020.08.001

Meints, S. M., Cortes, A., Morais, C. A., & Edwards, R. R. (2019). Racial and ethnic differences in the experience and treatment of noncancer pain. Pain Management, 9(3), 317–334. DOI: 10.2217/pmt-2018-0030

Robinson-Lane, S. G., & Booker, S. Q. (2017). Culturally responsive pain management for Black older adults. Journal of Gerontological Nursing, 43(8), 33–41. DOI: 10.3928/00989134-20170224-03

Slatyer, S., Myers, H., & Kelly, M. A. (2022). Understanding nurse characteristics that influence assessment and intention to treat pain in postoperative patients: An integrative literature review. Pain Management Nursing, 23(5), 663–671. https://doi.org/10.1016/j.pmn.2022.03.003