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Assessing Pain
Running head: ASSESSING PAIN IN TODAY’S GLOBAL SOCIETY
Assessing Pain in Today’s Global Society
Paradai Virojphan and Tara Fedric
Texas Woman’s University
Abstract
According to the 2006 United States Census, 54,965,503 or 19.7 percent of people living in the United States speak a language other than English in their homes. Of these, 44.1 percent speak English “less than well” (U.S. Census Bureau, 2006). Among these people there exists a population of patients who are receiving inadequate healthcare due to their ethnicity or race. One area of concern is the difficulty in assessing and managing pain. Patients are not having their pain treated adequately due to cultural and language differences. Providing interpreters for all the languages spoken in communities across the country is an impossible task. Nurses need simple, useful tools to utilize with these patients. The use of written materials such as the booklet discussed in this article provide them with access to 18 different interpretations of the pain scale in one handy place in order to successfully assess and manage their patients’ pain.
Assessing Pain in Today’s Global Society
Over the years, nursing has been charged with helping all patients receive adequate pain control. Continuing education has focused on the proper assessment techniques and appropriate interventions necessary to achieve this control. Yet there exists a population of patients who are receiving substandard care due to their ethnicity and race (McNeill, Reynolds, & Ney, 2007). Green et al.(2003) and the National Healthcare Disparities Report(2004) documented significant racial and ethnic disparities across all settings and for all types of pain. Bonham, (2001), Sullivan and Eagel (2005),and Smedley, Stith, and Nelson (2003) have proposed one reason for inadequate prescribing for minority patients is the greater difficulty in assessing pain because of differences in languages and cultural background. According to the 2005 United States Census,52 million people speak a language other that English in their homes. Forty-four percent of these do not speak English well (U.S. Census Bureau, 2005)..
Even for someone such as the student author who has been living in the United States for 10 years, explaining oneself in English is difficult, if not daunting. She describes an incident that occurred during a visit to her dentist.
It didn’t take me long to realize that a language barrier does not lead to efficient healthcare delivery. As a full-time ‘non-English speaker’ myself, I had a terribly painful toothache that needed a root canal. My dentist asked me to rate the intensity and describe the quality of my pain. I was in such pain that I was surprised that I still had enough sense to understand English!
I often tell people that I am 10 years old in English and only speak it, prn. “It’s pain!” I inaccurately replied, not knowing what would be the best word to describe my pain. During the procedure, while I was numbed, I began to question how I could be a competent nurse when it was impossible for me to understand the pain my patients were experiencing. Of course, I knew enough to spell and record the pain as patients described it to me, but I would not know the differences between throbbing and gnawing or even between aching and sore. I did not understand giving my pain a number as I didn’t understand what that meant (Virojphan, 2007).
It is because of the authors’ personal and clinical experiences that a pain assessment tool was developed. It is a booklet containing several examples of pain scales interpreted into 18 languages. The students who created the booklet for a class project representedThailand, Pakistan, and El Salvador.They collected the necessary written pain descriptions from both on-line sources and from various individuals at the University and in the community. They used their local pharmacist, who was of great assistance. They compiled 12 different languages from among their classmates.The booklet includes samples of various common pain scales, including numeric, analogue, the Wong-Baker Faces Scale, and descriptive words. Aun and Lam (1986) found that, because the Chinese read vertically downwards, they understand the vertical analogue presentation more easily. The Faces Scale is useful for elderly, cognitively impaired patients as well as thosewho do not speak English. By providing various scales for each language, patients can use the one with which they are most comfortable.
As the authors worked with the community in developing the booklet, the comments from these individuals supported the need for such a tool. They were very willing to help because they believed it would fill a great need. Some even asked which hospital would be using it. They would go there for care.
After the booklet was completed, it was presented to the nursing staffs on several units at their clinical site. The responsefrom the nurses was excellent. They all wanted their own copy. While the booklet was being displayed on the units they were able to utilize it for several patients who were having problems describing and rating their pain. The only suggestionin an evaluation conducted by the students was to include more languages.
Assessment is crucial in managing the pain cycle, and it influences the total symptom experience. Adding reassessment to the overall concept can be seen as the vital component (McNeill et al., 2007). Communication is a major barrier to assessment as well as to other areas of care (Kemp, 2007). This may be due to an inability to speak English or not understanding or correctly interpreting what is being said or asked. Patients may not know how to describe their pain in terms generally used in assessment. Understanding the differences among terms such as aching, throbbing, hurting, or sore can be difficult (Limaye, & Katz, 2006).Communication is facilitated when patients and staff are all using the same pain scale. Without written tools, the nurse may have to spend precious time hunting for a staff member who can act as an interpreter or calling a service to provide one. Using interpreters is risky as the nurse can’t be sure what the patient is being told. Waiting for an interpreter to come to the hospital takes time, while the patient continues to have pain.Family members are not always available to interpret, although when available, they may be able to talk for the patient to help the nurse understand the patient’s needs.
The American Pain Society’s Position Statement (Advocacy, 2004) lists several racial and ethnic identifiers for pain research, one being to “develop and evaluate pain assessment instruments that reflect cultural, ethnic, and linguistic diversity” (p.2).The Joint Commission for Accreditation of Healthcare Organization’s (JCAHO) Standards for Assessing Compliance (2004) include providing educational materials for patients, families and staff. Fink (2000) suggests offering patients written material, pain rating scales, or figures to which the patient can point.
Managing pain appropriately has been a goal of healthcare providers for many years. Margo McCaffery’s research into pain management began in the 1960’s, and herdefinition of pain as “whatever the experiencing person says it is, existing whenever he says it does” leads nurses to the single most reliable indicator of pain (McCaffery & Pasero, 1999, p.17). Positive strides have been made in how we manage pain, yet nearly all cancer patients have some degree of poorly managed pain during the course of their illness. The problem is greatly compounded when we cannot communicate with our patients. With the variety of racial and ethnic patients in hospitals today, it would be impractical, if not impossible to have multilingual nurses available.The use of the bookletPain Management for Non-English Speaking Patients is one quick, handy tool for assessing patients’ pain and providing them with adequate pain medication.
References
Advocacy. (2004). Racial and ethnic identifiers in pain management: The importance to
research, clinical practice, and public health policy. A Position Statement from the
American Pain Society. Retrieved 12/31/2007 from
Aun, C.,& Lam, Y. (1986). Evaluation of the use of visual analogue scale in Chinese
patients. Pain, 25, 215-22.
Bonham, V. (2001). Race, ethnicity and pain treatment: Striving to understand the cause
and solutions to the disparities in pain treatment. Journal of Law, Medicine, and
Ethics, 20, 52-68.
Fink, R., (2000). Pain assessment: The cornerstone to optimal pain management.
Proceedings. BaylorUniversityMedicalCenter, 13(3), 236-239.
Green, C., Anderson, K., Baker, T., Campbell, L., Decker, S., Fillingim, R., et al. (2003).
The unequal burden of pain: Confronting racial and ethnic disparities in pain. Pain
Medicine, 4, 227-294.
Hernandez, M., Kazi, M., & Virohphan, v. (2007). Pain management in the non-English
speaking patient. Unpublished manual.
Joint Commission for Accreditation of Healthcare Organizations. (2004).
Comprehensive accrediting manual for hospitals: The official handbook (CAMH),
Oakbrook Terrace, Ill: Joint Commission for Accreditation of Healthcare
Organizations.
Kemp, C. (2007). Cambodian health beliefs and practices: A summary. Retrieved
12/31/2007 from www3.baylor.edu/~Charles_Kemp/cambodian_summary.html
Limaye, S., & Katz, P. (2006). Challenges of pain assessment and management in the
minority elderly population. Annals of Long-Term Care,14(11), 34-40.
McCaffery, M., & Pasero, C. (1999). Pain: Clinical manual. Mosby: St.Louis, MO.
McNeill, J., Reynolds, J., & Ney, M., (2007). Unequal quality of cancer pain
management: Disparity in perceived control and proposed solutions. Oncology
Nursing Forum, 34(6), 1121-1128.
National Healthcare Disparities Report: Summary, (2004). Rockville, MD: Agency for
Healthcare Research and Quality.
Smedley, B., Stith, A., & Nelson, A. (Eds.). (2003). Unequal treatment: Confronting
racial and ethnic disparities in health care. Washington, DC: National Academies
Press.
Sullivan, L., & Eagel, B., (2005). Leveling the playing field: Recognizing and rectifying
disparities in management of pain. Pain Medicine, 6, 5-10.
U.S. Census Bureau. (2006). Language spoken at home. Washington, DC: U.S. Census
Bureau. Retrieved 3/3/2008 from
Appendix A
A Case Study
Mrs. G. H., an 84 year old Egyptian patient, was admitted to the oncology unit for treatment of intractable pain. In spite of obtaining her UnitedState’s citizenship after residing in Texas for 20 years, she spoke limited English.
The nursing staff routinely assessed her for pain every four hours, and she consistently told them her pain level was 0 on a 0 to 10 pain scale. The nurses reported that she was doing well and was a very “good” patient who never asked for anything. However, as the nursing student assigned to Mrs. H. gave morning care she noticed the patient grimacing and moving very little in bed. The student’s assessment confirmed a 0 pain level, yet the patient’s actions did not.
When Mrs. H’s nephew came to visit her later that afternoon the student asked him to discuss her pain control and translate the meaning of the pain scale. The nephew spoke with the patient and found that her pain rating of 0 indicated she was getting no relief from her pain. Through the nephew, the student was able to explain the use and meaning of the pain scale and together she and Mrs. H. were able to get her pain under control.
Appendix B
Appendix C
Author Note
Paradai Virojphan, Texas Woman’s University College of Nursing, senior nursing student.
Tara Fedric, MS, RN, CNS, OCN. Texas Woman’s University College of Nursing, Adjunct Clinical Professor.
Paradai Virojphan, RN, is now employed at Methodist Medical Center-Dallas in Telemetry.
The authors wish to thank Morena Hernandez and Mansoor Kazi for their valuable assistance in developing the booklet, Pain Management for the Non-English Speaking Patient. They also thank all those who assisted in translating the material featured in the booklet.
Correspondence concerning this article should be addressed to Tara Fedric, College of Nursing, Texas Woman’s University, Dallas, Texas75235. E-mail:
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Assessing Pain