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Transcultural Pain Management

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Adrienne Huston

on 18 November 2013

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Transcript of Transcultural Pain Management

Culture's Effect on Pain
Transcultural Pain Management
Katrina Petsinis, Adrienne Huston, Yuri Choi, Karen Columbres Guleng, and Jennifer Adada
Culturally Competent
Pain Assessment
Culturally Competent Pain Management
The purpose of this presentation is to illustrate the depths to which
culture is integrated into our lives, even when we are in pain.
Narayan, M. C. (2010). Culture’s effects on pain assessment and management. American Journal of Nursing, 110(4), 38–47.

Povolny, B. (2008). Acupuncture and traditional chinese medicine: an overview. Techniques in regional anesthesia and pain management, 12, 109-110.

Li, D., Puntillo, K., & Miaskowski, C. (2008). A review of objective pain measures for use with critical care adult patients unable to self-report. The journal of pain : official journal of the American Pain Society, 9(1), 2–10. doi:10.1016/j.jpain.2007.08.009

Rose, L., Haslam, L., Dale, C., Knechtel, L., Fraser, M., Pinto, R., … Watt-Watson, J. (2011). Survey of assessment and management of pain for critically ill adults. Intensive & critical care nursing : the official journal of the British Association of Critical Care Nurses, 27(3), 121–8. doi:10.1016/j.iccn.2011.02.001

Shan, Y. (2007). Using acupuncture to manage pain. Primary Health Care, 17(7), 25-29.

Srivastava, Rani H. The healthcare professional's guide to clinical cultural competence. Toronto, Ontario: Elsevier Canada, 2007. 89-98.

University of Washington Medical Centre. (2011). Culture clues. Retrieved from http://depts.washington.edu/pfes/CultureClues.htm
Pick a Pain Scale
for YOUR Patient
General Tips
1. The Usual - Pain Numeric Rating Scale & OPQRSTU

2. For Kids - Wong-Baker FACES Scale

3. It's not that Brief - Brief Pain Inventory

4. Get their perspective - Explanatory Method of Pain

5. Pourquoi? - Behavioural & Observational tools
Are you ethnocentric? No, really?
Generalizations or Acculturation?
Don’t assume. EDUCATE.
Translate. Translate. Translate.
Consider religion/spiritual influences and folk remedies.
Keep the goal of culturally competent care.
COMMUNICATE the goal of culturally competent care.
Biological Differences
Between Cultures
An Italian client, Mr. Russo, had a knee replacement surgery two days ago and does not report any pain whenever his nurse, Katie, assesses his pain.

Katie remembered reading an article stating that Italians are expressive about pain. Since Mr. Russo is Italian, Katie assumed that he would tell her if he has any pain.

However, she noticed that although he denies he having pain, Mr. Russo's facial expression indicates otherwise.
1. Teach you how culture & pain interact
2. Discuss options for pain assessment
3. Identify choices for pain management
What is Pain?
According to The International Association for the Study of Pain (1994),

Pain = an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage

Experienced by all people from all cultures, regardless of age, sex, and socio-economic status.
What could nurse Katie have done better?

How would you assess pain on
a stoic client like Mr. Russo?

Pain Assessment of Stoic Clients
It is possible to preserve stoicism
while addressing pain.

1. Acute Pain
2. Chronic Pain
3. Nociceptive Pain
4. Neuropathic Pain
5. Idiopathic Pain
Types of Pain
Pain Threshold
Pain Tolerance
Do you know the difference?
= Avoid showing pain
= Expressive about Pain
e.g. moaning, crying, etc

In general,
which cultures are which?

Stoicism &
Western Medicine
Pharmacological interventions
non steroidal anti-inflammatory drug  (NSAID)
Morphine is the gold standard to which all narcotics

Treatment = For various mild, moderate, and severe pain

Cultures commonly use = American/Canadians/Christian/ Jewish/European

Cultures not accepting of Western medicine = Asian/ African/Aboriginal/Some Caribbean

Illegal drug in most countries & the Drug Enforcement Agency

 THC (delta-9-tetrahydrocannabinol) as a form of medicine

Treatment = for various chronic pain associated with CANCER & AIDS

Cultures commonly use = Subsets in urban communities/Caribbean/ Westernized African/Subset of youth in Western culture

Cultures not accepting = South Asian/Hindu/Christian/Chinese/ Jewish
How Culture Affects Pain
Different definitions of words
Language barrier
Belief about meaning of pain

Describing pain and making decisions on pain management
Other Cultural Approaches to Pain
Case Scenario:
Stoicism or Culture?
Expressing Pain
in American Sign Language (ASL)
Vocabulary = pain, sick, medicine
Using facial expression to describe location and severity
Physical Approach
Historical Concepts of Pain Management
Philosophical, religious, and political meanings of pain prevailed before the medical profession began to study pain.

The history of the meaning of pain shapes our current understanding of pain.

Pain Stats
- The cost of treating pain in Canada is estimated to be approximately $60 Billion dollars.

- The economic cost to people waiting for pain treatment at multidisciplinary pain treatment facilities in Canada is $17,544 per year.

- Women are more likely to report chronic pain than men, older people more than younger people.

- More than 60% of people with moderate to severe chronic pain had lost their job as a result of their pain
Korean, Russian, Hispanic,
African American Heritages
Stoic or Expressive?
Iranian, Italian, Arabic,
and Cuban Heritages
Stoic or Expressive?
1. Language and interpretation problems
• Interpreters
• Language barrier

2. Non verbal communication problems
• Facial expression
• Body language

3. Culturally or linguistically inappropriate assessment tools
• Numeric scale
• Translation issues
• Direction of reading

4. Under-reporting
• Good patients don’t complain

5. Reluctance to use pain medications
• Cultural taboos/fears of use
• Home remedies
• Biological

6. Access to pain medications
• Minority group

7. Providers’ fears of drug abuse
• Associate certain groups of people with drug seeking and drug abusing behaviours

8. Prejudice and discrimination
• Stereotypes or negative judgments based on race or ethnicity.

Barriers complicating
Indirect Pain Assessment involves...
Factual Questions
Non-verbal cues
... with the GOAL of Culturally Competent Pain Management.
As future nurses, we hope you can put all of this together with...
Your own experiences...
Your patient's needs...
Available Resources
Allie Brosh's Unique Pain Scale
... and Creativity!
Partners Against Pain <--- Resource Heaven!
Numerical Pain Scale in 17 languages - slightly longer pain scale than our Visual Analog one
thank you so much
Our Handouts for you
- Summary
- the Article "Culture's Effects"
- the Brief Pain Inventory
- Multilingual Numeric Pain Scale
- Wong-Baker Faces
Traditional Chinese Medicine (TCM)
TCM contains several types of remedies that aid in healing such as herbal remedies, acupuncture, exercise, & meditation.

The main concept of this alternative therapy
is the yin and yang

The yin and yang signify how it must be in a state of equilibrium. When there is an imbalance in either of the two, this is when disease occurs.
Qi is known as the body’s vital energy force

Acupuncture and Pain management

There are channels of patterned energy that run through and on the surface of the body

The channels are called Meridians

The Meridians have 14 primary channels which correspond with 12 organ systems in the body
Acupuncture = Method of stimulating certain points on the body by inserting unique needles which can alter client’s perception of pain or treat/prevent illness.

By inserting the needles, acupuncture assists in regulating the flow of Qi in whichever specific points inserted.

The needles are inserted along the meridian channels called acupoints.

The needles unblock where there is obstructed energy in the body allowing the flow of energy to not be interrupted.
Case Scenario:
Ayurvedic Understanding
Rathika - a Tamil refugee living in Norway - sought out a doctor for aphagia and pain in his throat/chest. The doctor did a physical assessment, short history, ordered an X-ray, gave him a sick note, and encouraged him to eat soft foods in the interim.

Yet Rathika left the office and complained: "The doctors don't care about me. I'm happy for the x-ray, but... they only look at the organs. I am a person, but he doesn't know me."
Ayurvedic Medicine
Focuses on the person as a complete social being

The patient may have up to an hour or more conversation with the doctor
During which ALL patterns of behaviour are discussed: diet, sleep, physical and social activities, work, emotions
CLOSE association of the body and the psyche as well as the body and the psyche
Illness = a symptom of patient & family's vulnerability
patient and doctor are COLLABORATIVE
Was the care given sufficient?
In learning these aspects of Ayurveda, how do you think Rathika felt about the care he received from the Norwegian doctor?
Codeine = Morphine? Not always
5-10% Caucasians
20% African Americans
1% Asians
Codeine is found in:

Tylenol #1, #2, and #3
Atasol 8, 15, 20
RNAO BPG: Assessment and Management of Pain

American Journal of Critical care. (May 2013). Behavioral pain assessment tool for critically ill adults unable to self-report pain. Retrieved from: http://www.aacn.org/wd/Cetests/media/A132232.pdf

Arcy, B. Y. D. (2009). The effect of culture on pain. Nursing made Incredibly Easy, (May/June), 5–7.

Grønseth, A. S. (2006). Experiences of tensions in re-orienting selves: Tamil Refugees in northern Norway seeking medical advice. Anthropology & Medicine, 13(1), 77–98. doi: 10.1080/13648470500516303

Hao, Y. Y., Liu, H. H., Yue, S. S., & Liu, X. X. (2011). Introducing traditional Chinese nursing: a review of concepts, theories and practices. International Nursing Review, 58(3), 319-327. doi: 10.1111/j.1466-7657.2011.00918.x

Li-Mei, L., Shu-Fang, W., Ru-Ping, L., Bang-Gee, H., Nu-Man, T., & Tai-Chu, P. (2013). Changes in skin surface temperature at an acupuncture point with moxibustion. Acupuncture In Medicine, 31(2), 195-201. doi: 10.1136/acupmed-2012-010268
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