The Intersection of Pain and Culture ____________________________________________________________
OPEN-ENDED ASSESSMENT QUESTIONS Because pain is highly subjective, some argue that a numerical score calculated from pain instruments does not capture the underlying meanings and experiences of pain. Consequently, asking open-ended questions and paying close attention to both verbal and nonverbal cues are essential to understanding a patient’s pain [71]. Experts recommend asking the following questions [116]: • What do you call your pain? What term do you use to describe your pain? • Why do you think you have this pain? • How bad is the pain? Does it last a long time? A short time? Can you be specific? • What are you most afraid about what you are experiencing? • How has the pain affected you? • What types of treatment and remedies have you received? • What types of treatment and remedies do you think would be most helpful? What would be the most important outcomes from the treatment? • Who do you talk with about your pain? What do they know? • Who helps you cope with the pain you are experienc- ing? In a qualitative study, practitioners encouraged their Hmong patients to use scenarios and images to describe their pain, as these patients had difficulty with numerical pain scores. The stories, metaphors, and imageries would often contain the elements found in quantitative pain instruments [196]. Focus- ing on physical cues, such as energy level, appetite, weight, and sleep, can be less stigmatizing [197]. The importance of rephrasing questions and breaking down questions into simpler terms were also identified [197]. Because many racial and ethnic minority patients value the role of stoicism, use of the term “pain” may not be conducive to engaging patients in conversations about their condition. The practitioner should first ask the patient which term she or he prefers to use to describe the pain [89]. Prompting with alternate terms (e.g., “nagging,” “sore”) may be helpful [16]. Asking about how a patient’s pain affects their work in and/or outside the home on a daily basis can be helpful in understanding the patient’s functioning, pain quality, pain intensity, and pain evolution [208]. Developing good rapport and trust can help overcome stoicism and allow practitioners to identify nonverbal pain indicators (e.g., tenseness, grimacing, flinching) [143; 197]. As trust between patients and providers develops, both will gradually let go of their own biases and cultural stereotypes [151]. Asking patients for their opinions and views and spend-
ing more time listening than talking will build trust. It is important to allow the patient to tell their pain story without interruption [177]. It is important to remember that patients are the experts on the pain they are experiencing. When patients tell their own narratives/stories, clinicians will have a better understanding of their meanings of pain, coping mechanisms, and impact of family and social support [151]. Patients should also be reas- sured that reporting pain is not complaining [16].
PAIN MANAGEMENT AND INTERVENTIONS
PATIENT EDUCATION AND EMPOWERMENT Education and empowerment work hand in hand. The Western biomedical culture often reduces pain to the physi- ologic symptoms and sensations, but pain is not merely about physiology, and focusing only on “curing” pain can result in patients forfeiting their sense of control and responsibility and becoming passive agents [117; 118]. If patients are educated and empowered, they can become more resourceful in manag- ing their pain and become active agents in their treatment [118; 209]. In the context of pain treatment, the main components of empowerment are [118; 127]: • Multidisciplinary pain management, with patients offered an option of resources that best suit their needs and value systems • Education • Inclusion of patients in the decision-making process • Optimistic communication and hope that positive outcomes could result • Connection with others who are going through similar experiences • Compassion (e.g., active listening) Practitioners’ conveyance of compassion is important because patients being treated for pain often fear that no one believes their pain is real. When working with racial and ethnic minorities, it is crucial for practitioners to remember that the concept of individual- ism is more embraced by Western cultures that place more emphasis on the concept of autonomy. When it comes to pain management, empowering patients assumes that they have a level of responsibility to manage their pain. However, many cultures place more value on collectivism. In these cases, prac- titioners should explore the role of the family, community, and other support networks that may be involved in the patient’s pain management [45].
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