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                  Assessing Pain in Today‟s Global Society

                     Paradai Virojphan and Tara Fedric

                        Texas Woman‟s University
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       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.
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                         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
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       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

represented Thailand, 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 those who 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.
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After the booklet was completed, it was presented to the nursing staffs on several units at

their clinical site. The response from 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

suggestion in 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 co ncept 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
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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 her

definition 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 wo uld be

impractical, if not impossible to have multilingual nurses available. The use of the

booklet Pain Management for Non-English Speaking Patients is one quick, handy tool

for assessing patients‟ pain and providing them with adequate pain medication.
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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. Baylor University Medical Center, 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 mana gement 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


Kemp, C. (2007). Cambodian health beliefs and practices: A summary. Retrieved

   12/31/2007 from
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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


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

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                                         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 United State‟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.
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                   Appendix B


     English: Do you have any pain?

      Spanish: ¿usted tiene dolor?

O      English: no pain
       Spanish: ningún dolor

2      English: mild pain
       Spanish: dolor suave

4      English: moderate pain
       Spanish: dolor moderado
       English: severe pain
       Spanish: dolor severo
       English: very severe pain
10     Spanish: dolor muy severo

       English: worst possible pain
       Spanish: el peor dolor posible
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                   Appendix C


       English: Do you have any pain?
    Vietnamese: co dau cho nao khong?

O       English: no pain
        Vietnamese: khong dau

2       English: mild pain
        Vietnamese: dau mot chut

4       English: moderate pain
        Vietnamese: dau nhieu
        English: severe pain
        Vietnamese: dau that nhieu
        English: very severe pain
10      Vietnamese: dau that nhieu

        English: worst possible pain
        Vietnamese: dau lam chiu khong noi
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                                        Author Note

      Paradai Virojphan, Texas Woman‟s University College of Nursing, senior nursing


      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


      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


      Correspondence concerning this article should be addressed to Tara Fedric, College

of Nursing, Texas Woman‟s University, Dallas, Texas 75235. E- mail:
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