Certified Nursing Assistants' Perspectives of Nursing Home Residents' Pain Experience: Communication Patterns,Cultural Context,and the Role of Empathy

This study explored the following issues related to pain management among nursing home (NH) residents: 1) communication patterns between NH residents and certified nursing assistants (CNAs) about pain; 2) how race and ethnicity influence NH residents' pain experiences; and 3) CNAs' personal experiences with pain that may affect their empathy toward the resident's pain experience. The study consisted of a convenience sample of four focus groups (n = 28) from a NH in central Florida. A content analysis approach was used. Data were analyzed with the use of Atlas.ti version 6.2. The content analysis identified four main themes: 1) attitudes as barriers to communication about resident pain care; 2) cultural, religious, and gender influences of resident pain care by CNAs; 3) the role of empathy in CNAs care of residents with pain; and 4) worker strategies to detect pain. Attitudes among CNAs about resident cognitive status and perceived resident burden need to be recognized as barriers to the detection and reporting of pain by CNAs and should be addressed. In addition, NHs should consider a person-centered approach to pain that is culturally competent given the cultural influences of both residents and staff. Finally, educational programs for CNAs that include empathy-inducing scenarios could potentially improve the care provided by CNAs when dealing with residents' pain.     

Culture and pain: a Mesoamerican perspective.

Culture has been identified as a factor that influences a person's reaction to and expression of pain. Research in the area of pain and culture has not established a clear link between cultural meanings and attitudes associated with pain and pain behaviors. The purpose of this ethnohistoric study was to explore the beliefs related to the experience of pain within ancient Mesoamerica. The six themes that emerged from this study represent efforts related to the discovery of the epistemics of cultural meanings of pain in contemporary Mesoamerican cultures, specifically Mexican-Americans. These findings serve as a benchmark from which to understand Mexican-American meanings, expressions, and care associated with pain.     

Voices of Mexican American caregivers for family members with cancer: on becoming stronger.

This grounded theory study report describes the experience of 34 Mexican American (MA) female caregivers who provided care to a family member with cancer. Caregivers identified a process of "Becoming Stronger" as a result of their caregiver role. The emerging theoretical model of female MA cancer caregiving offers evidence to change current cancer care approaches from patient-focused to family-focused care for this ethnic group. Findings suggest that changes most responsive to cultural values and likely to provide accessible and quality cancer care for MA families are those that involve active partnering with MA caregivers to prioritize the patient's cancer care.     

Mazes, Conflict, and Paradox: Tools for Understanding Chronic Pain

This article presents an argument for framing chronic pain within a complex adaptive systems (CAS) paradigm. The first aim of this article is to demonstrate how chronic pain can be framed as a CAS and how paradox, one of the core characteristics of a CAS, exists within the chronic pain experience. The second aim is to illustrate how paradox exists at multiple levels within the health care encounter and ongoing experience of chronic pain. Finally, the article will use the example of interactions at the patient/clinician level to illustrate how health care workers' efforts to deal with issues emergent from the range of paradoxes have for the most part been ineffective, and at times harmful, to persons experiencing chronic pain.
This article uses the example of chronic pain to explore how the manner in which health care providers and patients recognize and deal with paradoxes can either worsen the pain experience or help generate creative new ways to manage the chronic pain condition. The CAS principles discussed in this article hold application across a range of chronic conditions for which a traditional biomedical paradigm proves insufficient.     

Mexican immigrant mothers' expectations for children's health services

Women of Mexican descent living in the United States raise children who use health care services. What do immigrant Mexican mothers expect from children's health care services? And how do their expectations for children's health services compare to acculturated Mexican American mothers' expectations? This focused ethnographic study, based on repeated interviews with 28 mothers of varying acculturation levels, describes their expectations and experiences with children's health care services in the United States. Findings support a shared core of expectations for both Mexican immigrant and Mexican American mothers, and differences in health care access and financing, time spent in health care encounters, and cultural and linguistic expectations for care. Health care providers can use this information to approach Mexican-descent mothers and children with their expectations in mind, and craft a negotiated plan of care congruent with their expectations.     

Culture and musculoskeletal pain: strategies,challenges, and future directions to develop culturally sensitive physical therapy care

BackgroundPain experience has a multidimensional nature. Assessment and treatment recommendations for pain conditions suggest clinicians use biopsychosocial approaches to treat pain and disability. The current pain research is overwhelmingly skewed towards the study of biological and psychological factors including interventions, whereas, cultural factors are often ignored.ObjectiveThe aims of this Masterclass is threefold: (1) to discuss cultural influences on pain, (2) to provide strategies for delivering appropriate pain education and exercises in culturally diverse people with chronic pain, and (3) to present challenges and future directions to clinicians and researchers.DiscussionCultural factors have a relevant influence on the way individuals experience and manage health and illness. Thus, people with different cultural experience perceive, respond, communicate and manage their pain in different ways. In this aspect, the contents of pain education should be presented using different culturally appropriate examples, metaphors, images, and delivery methods that may enhance the impact of the message. Efforts should be made to produce and spread culturally adapted evidence-based materials and resources. In addition, a culturally sensitive approach may help to introduce patients to graded activities, so that they can apply these strategies in culturally acceptable and meaningful ways. Future studies should investigate the effectiveness of culturally-adapted interventions in pain-related outcomes in different pain conditions in patients with different cultural backgrounds.     

Education Changes Mexican Nurses' Knowledge and Attitudes Regarding Pediatric Pain

This study explored the effectiveness of a pain education intervention on Mexican nurses' knowledge and attitudes toward pediatric pain. A convenience sample of 106 registered nurses from three hospitals in Mexico City was recruited. A Pediatric Pain Education Program (PPEP) was developed, implemented, and evaluated by a nurse researcher, clinical nurse specialist, and a child life specialist. The 4-hour program, which was translated into Spanish, consisted of pain assessment, physiology, and management, including pharmacology and nonpharmacology. The effects of PPEP were measured in a one-group pretest-posttest design using a translated Spanish version of the Pediatric Nurses' Knowledge and Attitudes Survey (PNKAS). A total of 79 nurses completed both tests. A paired t test indicated significant differences between pre- and posttest results (p < .0001) on the PNKAS. The hospital site and years of nursing experience were significantly related to nurses' pre- and post-PNKAS scores. One test item on children's ability to reliably report their pain had a significantly lower score after the intervention (p = .016). The intervention was effective in improving Mexican pediatric nurses' knowledge and attitudes. However, it is not known how long this effect was maintained. Health care professionals can share a common vision for pain management by increasing international collaborative efforts and by advancing pediatric pain knowledge.     

Pain Expression in the Perioperative Period: Insights from a Focus Group of Somali Women

In recent years, the number of Somali persons treated in the U.S. has increased significantly. Understanding the concepts of pain and pain expression is an important aspect of nursing care. However, pain expression within this specific cultural group has not been extensively studied. This study, guided by core concepts from Margaret Newman's theory of Health as Expanding Consciousness used a focus group design to evaluate the concepts of pain expression within this population. The results of this study provide insight into how Somali women express pain, using verbal and nonverbal communication, and reveal other dynamics that are interconnected with the pain experience. The results show that pain expression for Somali women include verbal expressions that may be unique to the Somali culture. The results are helpful in developing a tool that can be used by others working with Somali women who are experiencing pain. Implications for improving transcultural nursing care, including pain assessment, management, and patient education are summarized.     

Psychometric tests of Expectations of Filial Piety Scale in a Mexican-American population

Aims and objectives. This paper reports the development of the Expectations of Filial Piety Scale for use with Mexican‐American parents regarding expectations they have of their adult children for care and support. Background. Earlier work by the authors demonstrated that filial piety is a cross‐cultural construct that can be used with Hispanic/Latino populations. More refined development of the construct required testing with more homogeneous subsets (i.e. Mexican‐Americans) within the broad designation of Hispanic/Latino adults. Design. Non‐experimental methodological design for field testing of the instrument's psychometric properties. Methods. A convenient sample of 80 Mexican‐American adults in California and Texas completed a brief biographical survey and field tested the Expectations of Filial Piety Scale. Results. Common factor analysis with orthogonal rotation was used to extract three factors, which accounted for 58% of the variance in scale scores. These factors included: I: respect for parents (24·05%); II: honouring parents (12·5%); and III: family unity (16·56%). Overall scale reliability was 0·87 with individual factor reliability coefficients ranging from 0·74 to 0·87 and test–retest correlation was 0·73. Conclusions. The results show that the Expectations of Filial Piety Scale is an internally consistent and reliable tool for use in studies of the Mexican‐American population. Mexican elders historically underuse formal services; a large portion of this population will most likely depend on support from their family members when they reach advanced ages. There is a lack of culturally sensitive instruments to measure family values in caring for older adults in Mexican‐Americans. Relevance to clinical practice This scale can enable case workers and nurses in long‐term care settings to assess the elder's expectations for family support accurately and compare these expectations with available family support, children's intentions to care for a dependent parent or other family member and the need for supplemental care in Mexican‐American families.     

Depression,anxiety and acute pain: links and management challenges

Pain is a subjective experience that is influenced by genetics, gender, social, cultural and personal parameters. Opposed to chronic pain, which by definition has to last for at least 3 months, acute pain is mostly because of trauma, acute medical conditions or treatment. The link between mood disorders and acute pain has proven to be increasingly significant since the link is bi-directional, and both act as risk factors for each other. Depression and anxiety are associated with increased perception of pain severity, whereas prolonged duration of acute pain leads to increased mood dysregulation. Although both depression and anxiety have a proven association with acute pain, the link between depression and acute pain is more thoroughly studied. Pain can be the presenting or sole complaint in depressed patients who present to primary care practices and is often overlooked by clinicians. However, reports on the perception of experimentally-induced pain in depressed patients are mixed, showing both an increased and decreased pain threshold and pain tolerance across various studies. Although less data is published about anxiety and pain, the relationship is consistent across studies as increased anxiety leads to increased severity of pain perceived and decreased pain tolerance. Anxiety as well as fear, stress, and catastrophizing are also shown to be mediators in the causal pathway between pain and disability.     

Student nurses’ experiences of communication in cross‐cultural care encounters

Scand J Caring Sci; 2010; 24; 436–444
Student nurses’ experiences of communication in cross‐cultural care encounters Background: Communication is a fundamental component of cross‐cultural care encounters. Nurses experience communication difficulties in situations where they do not speak the same language as their patients. Communication difficulties are a major obstacle for immigrant patients and can lead to insufficient information and poor quality nursing care in contrast to the majority population. Aim: To explore student nurses’ experiences of communication in cross‐cultural care encounters. Methods: Semi‐structured interviews were undertaken a purposive sample of 10 final year students from one university in Sweden: five participants were from a Swedish background and five from an immigrant background. Interviews explored participant’s experiences of communication in cross‐cultural care encounters. Interviews were tape recorded, transcribed and analysed using ‘framework’ approach. Results: Four themes were identified: conceptualizing cross‐cultural care encounters, difficulties in communication, communication strategies and factors influencing communication. ‘Culture’ was equated with country of origin. Cross‐cultural care encounters involved patients from a different immigrant background to the nurse. Student nurses experienced particular difficulties communicating with patients with whom they did not share a common language. This led to care becoming mechanistic and impersonal. They were fearful of making mistakes and lacked skills and confidence in questioning patients. Various strategies were used to overcome communication barriers including the use of relatives to interpret, nonverbal communication, gestures and artefacts. Other factors which influenced communication included the student’s attitude, cultural knowledge acquired through education and life experience. Conclusion: Although student nurses seek creative ways to communicate with patients from different cultural backgrounds they lack skills and confidence in cross‐cultural communication. Nursing programmes need to address this deficit to ensure that nurses are equipped with the knowledge and skills to provide quality care to patients from different cultural backgrounds.     

Patient-controlled oral analgesia at acute abdominal pain: A before-and-after intervention study of pain management during hospital stay

AimTo investigate the patient experience of pain management, when patient-controlled oral analgesia was compared with standard care for patients admitted to hospital with acute abdominal pain. The primary outcome measures were pain intensity and patient perception of care.BackgroundPain management of patients admitted to hospital with acute abdominal pain can be insufficient. Patient involvement in health care has been seen to have benefits for patients.MethodsA before-and-after intervention study was conducted in an emergency department observation unit and a surgical department. Data were collected from a questionnaire (APS-POQ-R-D) with the six subscales: pain severity, perception of care, interference with activity, interference with emotions, side effects and patient-related barriers.ResultsA total of 156 patients were included. During admission the median score (0–10 scale) for the pain intensity and patient perception of care subscale was 4 (p = 0.96) and 8 (p = 0.92), respectively, in both the control and intervention group. On the activity subscale, the median scores were 6 and 5 (p = 0.17); on the emotion subscale, the scores were 5 and 4 (p = 0.31); and on the side effect subscale, the scores were 3 and 4 (p = 0.18) in the control and intervention group, respectively. Overall, the score was 5–8 at one item about being allowed to participate in decisions about pain treatment as much as wanted.ConclusionPatient-controlled oral analgesia did not improve patient experience of pain management for patients admitted to hospital with acute abdominal pain.     

Prerequisites to providing culturally competent care to Mexican migrant farmworkers: a Delphi study

The purpose of this study was to identify prerequisites to providing culturally competent care to Mexican migrant farmworkers. A national sample of nurse experts who worked with Mexican migrant farmworkers (N = 93 [50.2%] in round 1; and N = 142 [54.8%] in round 2) participated during the period of August 1998 to April 1999. Using a two-round modified Delphi method, a list of 89 items was generated. The nurse experts agreed that the 89 items identified were prerequisites to cultural competence, showing consensus rates of 85.4% in round 1 and 88.8% in round 2. The prerequisites to culturally competent care identified by participants encompassed caring, cultural sensitivity, cultural knowledge (general/specific), cultural abilities/skills, and others (bi-cultural status; cultural and learning experiences).     

Ethical behaviours in clinical practice among Mexican health care workers

The objective of this study was to describe the cultural domain of ethical behaviours in clinical practice as defined by health care providers in Mexico. Structured interviews were carried out with 500 health professionals employed at the Mexican Institute of Social Security in Mexico City. The Smith Salience Index was used to evaluate the relevance of concepts gathered from the free listings of the interviewees. Cluster analysis and factor analysis facilitated construction of the conceptual categories, which the authors refer to as ;dimensions of ethical practice'. Six dimensions emerged from the analysis to define the qualities that comprise ethical clinical practice for Mexican health care providers: overall quality of clinical performance; working conditions that favour quality of care; use of ethical considerations as prerequisites for any health care intervention; values favouring teamwork in the health professional-patient relationship; patient satisfaction scores; and communication between health care providers and patients. The findings suggest that improved working conditions and management practices that promote the values identified by the study's participants would help to improve quality of care.     

Cultural attitudes and beliefs about pain.

Patients and health professionals bring their own cultural attitudes to the communication and interpretation of the patient's pain experience. In this interaction, it is the health professional's knowledge and attitudes that dominate the response to the patient's experience of pain. In Saudi Arabia, a multicultural foreign and local health care team is challenged to understand the cultural beliefs and attitudes toward pain of both patients and team members. To increase cultural understanding and knowledge, a collaborative inquiry project using a culturally diverse group was conducted to learn about cultural attitudes and beliefs on the causes, treatment, and experience of pain. This article presents the knowledge gained from the collaborative inquiry journey of action and reflection.     

Over-Rating Pain is Overrated: A Fundamental Self-Other Bias in Pain Reporting Behavior

Wide-spread cultural beliefs influence personal experiences and clinical treatment of pain, yet are often unexamined and unchallenged in the pain literature. The common cultural belief that people generally over-report or exaggerate pain is familiar, reflected in discordant patient-provider pain assessments, and compounded in the context of disparities in pain treatment. However, no studies have directly measured the prevalence of this belief among the general population, nor challenged the validity of this assumption by assessing normative pain reporting in clinical settings. Results of an initial and replication study suggest that reporting pain accurately “as-is” is the norm, yet most people still believe that others normatively over-report pain. We refer to the phenomenon by which most people report their pain as they experience it while paradoxically believing that others over-report their pain as the fundamental pain bias, and suggest this false perception may contribute to larger scale pain stigma and poor outcomes for people in pain. We also identify counter-stereotypical patterns of pain reporting among groups (ie, women, Latinx Americans) that face more disparate care. Results reinforce the need for respecting patient pain reports, and suggest that distrust surrounding others’ pain experiences is prevalent in society.PerspectiveMost people claim to report their pain as accurately as possible, while simultaneously perpetuating common cultural beliefs that others over-report their pain. This fundamental pain bias highlights a pervasive misconception that likely contributes to patient-provider mistrust and broader cultural pain stigma.