On+a+scale+of+1+to+10+how+Culturally+‘Clued-In’+are+our+Primary+and+Emergency+Service+Providers+when+it+comes+to+Pain?

Name: Thomas Dillewaard Student No.: N8093971 Tutor: Colleen Niland

**ARTEFACT** media type="youtube" key="5rWs_tncktU http://www.youtube.com/watch?v=5rWs_tncktU ( [|blue1231], 2008)

This is a short clip taken from episode 506 of the hit television show “scrubs”. This clip shows through the eyes of doctors, a montage of short doctor patient interactions about the pain different patients may be experiencing. The patients presented all have significantly different cultural backgrounds and this leads to vastly different interactions and depiction of pain. The clip concludes by showing the pain chart a tool later discussed to help practitioners determine pain. This clip uses comedy, in order to laugh over the issue really being faced here.

**PUBLIC HEALTH ISSUE** Australia is a first world country with a top quality health care system. Yet Australia is also one of the most culturally diverse countries in the world (DFAT, 2008). This has lead to a huge amount of pressure being placed on our emergency health care professionals to be able to adapt accordingly to any particular special trait that a patient may present with or require. Yet this diversity is proving to be very difficult to adapt to, due to the high work load of our health care professionals and often subtle nature of cues about cultural diversity. This means something as simple as providing appropriate pain relief becomes a challenge. Many studies have reviewed this problem, some of these studies will now be considered to gain a broader view and achieve a better understanding of the problem.

**LITERATURE REVIEW** Pain is the most common reason for seeking medical assistance (Spencer & Burke 2011). Being a subjective sensation it is impossible for a health professional to truly observe, like a cut or burn. This makes pain difficult to measure. To make matters more difficult, every person tolerates and presents their pain differently particular when there are cultural differences from the health care provider. However after an Emergency health care professional achieves the initial steps of stabilizing life threatening injuries or illnesses, attention is then turned to controlling the patients pain. In order to control the pain the health worker needs to understand the level of pain the patient is in so they can deal with it accordingly (it’s not a case of one size fits all).

So our health workers set about questioning, poking and prodding patients to try and guess what the patient is feeling. Usually this process also incorporates the use of a pain assessment tool or pain chart (Gregory & Ward, 2010). This is a simple document (Figure 1) with illustrations of faces that is designed to minimize discrepancies and inconsistencies between patients with different demographics.

(Figure 1) (Grenara, 2009)

Yet its easy to see how pain assessment tools are very flawed as they can provide a false number for pain that does not require pharmacological pain relief like emotional pain. It may also not take into consideration the impact of a persons culture, or past experiences has on the way they present, or depict the pain they are actually experiencing.

This is an issue that is known to health care professionals and many studies have reviewed and tried to find answers to this problem. By analysing this problem researchers have found that contrary to initial belief, this could only be solved by education of health care workers about the way different cultures present their pain with charts like presented in a study by Purnel & Paulanka (2008). This shows huge quantities of information about all deferent cultures, and although useful its not practical for health professionals to be expected to be able to recognize the subtle cues of different cultures in a chaotic environment that has staff constantly being pressured by time. This is particularly so when you consider culture is not a clean-cut idea that will influence each person attaining to a particular culture, in the exact same way. Culture refers to lifestyle, the learned and shared beliefs, values, knowledge, rules, and symbols that guide the behavior of a particular group of people. Culture is passed on from one generation to another and within social groups through orientation and socialization (Racher & Annis, 2007).Additionally to this Purnel & Paulanka (2008) recognize and warn the reader of the risks associated with stereotyping or labeling a person as being from a particular culture based only on how they look as some people become quite upset and can potentially ruin the entire interaction.

Studies such as Culture, Subjectivity, and the Ethics of Patient-Centered Pain Care (Giordano, Engebretson, & Benedikter, 2009) have realized the importance that culture plays in people’s lives, but adds that in addition to considering culture a health practitioner needs to consider the ethics implicated in both their decisions as well as the desires of the family. This can be understood when considering a Hindu father speaking on behalf of his wife, deciding about pain relief during childbirth or the passing away of a person. Believing new life and the act of dying should not be clouded by drugs. This culture puts the decision of pain relief to the most senior family member or oldest son states (Thrane, 2010). During situations like these Giordano, Engebretson, & Benedikter, (2009) state that the health practitioner needs not only to consider the best treatment options for the patient but also how treatments that may cause cultural insult will be dealt with when the patient leaves hospital and return home. Additionally Bjorn-Ove (2005) study //Culture and Care in the Swedish Ambulance Service// uses interviews with Swedish paramedics asking specific questions about how paramedics deal with culture. From these interviews it was discovered that its difficult to deal with a patient's culture as they were only with the patient for such a small amount of time and don’t have the resources such as translators to help provide culturally sensitive care. Nugus & Forero (2011) extrapolate on this idea from an emergency department perspective and add that decisions made about patients in the emergency department are directly affected by the pressure created due to workload. This changing belief about the importance of culture is being concidered with more and more importance when dealing with a persons health and more recognition is being placed onto social theorys like sociocultural theory (later disscussed). This has lead to government orgsinizations such as Queensland Health making programs like the Cross Cultural learning and Development strategy (Queensland Health, 2010) for making staff more culturally aware. A self directed electronic program that provides links to services that can suport or assist practitioners and various culture profiles. It provides interpreter services and a bi annually news letter providing cultural information, events and updates to the program. This program is very much evidence based with all aspects being very well resourced. This program concludes advising the helath professional that communication is the best course of action when dealing with different cultures.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">**SOCIAL ANALYSIS** <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">Although this is a fairly new problem with appropriate pain management really only being in common medical practice in the last half century, it is surprising to see that this problem can be related to Max Webers work from //Verstehen// (understanding) theory written nearly one hundred years earlier. This theory focuses on the idea that the actions of people must be understood before situations can explained and that nothing happens //per se.// His study goes further than this arguing that different types of social action which includes both the motive and motion for the interaction) occur dependent on the relationship at the time of the interaction (Visagie, Plessis, & Wijnbeek , 2011). This is very true when considering the interaction between patients and emergency health care workers observing the time critical nature of the task. The health worker is so concerned about doing the job quickly that the relationship with the patient is diminished. Weber continues with this line of thought in his work, stating that this type of interaction is caused by loss of the individuals choice to act what would be considered appropriately in a world that is becoming more and more busy, where the focus was not customer satisfaction rather efficiency & profit (Visagie , Plessis, & Wijnbeek , 2011). This is reinforced by the growing support of economic rationalism as the model for health care systems in Australia. Economic rationalism is the belief that the market and money can always achieve far more than the governments, bureaucracies and the law (Whitwell, 1998) <span style="font-family: 'Times New Roman',Times,serif; font-size: 16px; line-height: 23px;">. Additionally it is suggested that debate is pointless as little is ever achieved, with more and more unresolvable concepts are bought to light. Therefore society should forget about history and forget about national identity, culture and ‘society’. Don’t even think about public policy, national goals or nation building. It’s all totally pointless. Simply step aside and allow prices and market forces to deliver their own economically rational solution (Blandy, R. 1993). A concept very detrimental to, promoting cultural sensitivity skills of our health professionals. <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">However, with newly emerging research supporting generalized education about cultural sensitivity and the promotion of communication to assist in this process, hopefully a new theory like the sociocultural theory be further recognized and adopted in general medicine. Sociocultural theory is a theory with its focus around the concept that society affects the development of a person and that importance needs to be placed on culture and highlights the importance of people with power such as health care professionals play in the development (Mahn, 1999).

<span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">**ANALYSIS OF THE ARTEFACT AND LEARNING REFLECTIONS** <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">This clip highlights the problem emergency doctors, nurses and paramedics face on a daily basis. The tv show “scrubs” uses comedy and laughs off the issue faced. However if someone is not receiving the best care the Australian health care system can provide, due simply to lack of understanding of different cultures depiction and expectations of pain then this issue is no laughing matter. Particularly when considering modern medicine is very capable of managing any level of pain, however to be completely culturally competent is an impossible task, there is simply too many factors that need to be taken into account. So with our health professionals holding all the keys to the doors to pain relief. and the complexity of the situation meaning pain relief often not distributed appropriately. However the professionals are not solely to blame for this however as the demographics of a patient cant be assumed. All that can be asked of our health professionals and expected of patients is that both adopt an understanding, tolerant and accepting attitude towards diversity and to communicate with each other. This is a lesson I will take with me as an aspiring emergency health care provider.

<span style="font-family: 'Times New Roman',Times,serif;">**Reference List**

<span style="font-family: 'Times New Roman',Times,serif; font-size: 11pt;">Bjorn-Ove, S. (2005). Culture and Care in the Swedish Ambulance Service. //Emergency Nurse// //, 13// (8), 30-36. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16375006

<span style="font-family: 'Times New Roman',Times,serif; font-size: 11pt;">Blandy, R., (1993). Economic rationalism and prosperity’, paper presented to the ‘Economic Rationalism?: economic policies for the 1990s’ conference, //mimeo.//, University of Melbourne,

<span style="font-family: 'Times New Roman',Times,serif;"> [|blue1231] (2008, July 13) //Scrubs Pain Scale.// Retrieved October 4, 2011, from http://www.youtube.com/watch?v=5rWs_tncktU

<span style="font-family: 'Times New Roman',Times,serif; font-size: 11pt;">DFAT. (2008). Australia: a culturally diverse society. //About Australia fact sheet//.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 11pt;">Giordano, J., Engebretson, J., & Benedikter, R. (2009). Culture, Subjectivity, and the Ethics of Patient-Centered Pain Care. //Cambridge Quarterly of Healthcare Ethics, 18// (1), 47-56. doi: 10.1017/S0963180108090087

<span style="font-family: 'Times New Roman',Times,serif; font-size: 11pt;">Gregory, P., & Ward, A. (2010). //Sanders' Paramedic Textbook.// London, United Kingdom: Mosby Elsevier.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 11pt;">Grenaram, D. (2009). //HTF Pain Chart//. Retrieved 10 2, 2011, from deviantART: []

<span style="font-family: 'Times New Roman',Times,serif;"> Mahn, H. (1999). Vygotsky's methodological contribution to sociocultural theory. //Remedial and Special Education// //, 20// (6), 341-350. doi: 10.1177/074193259902000607

<span style="font-family: 'Times New Roman',Times,serif;"> Nugus, P., & Forero, R. (2011). Understanding interdepartmental and organisational work in the emergency department. //International Emergency Nursing// //, 19// (1), 69-74. [|doi:10.1016/j.ienj.2010.03.001]

<span style="font-family: 'Times New Roman',Times,serif; font-size: 11pt;"> Purnell, L.D. & Paulanka, B.J. (2008). Transcultural health care: A culturally competent approach (3rd ed.). Philadelphia: F.A. Davis Co.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 11pt;">Queensland, Health. (2010, April 19). Cross Cultural Learning and Development Stagery. //QHEPS//. Queensland, Australia.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 11pt;">Racher, F., & Annis, R. (2007). Respecting culture and honoring diversity in community practice. Research & Theory for Nursing Practice 2007, 21(4), 255-270. Retrieved from http://www.ingentaconnect.com/content/springer/rtnp/2007/00000021/00000004/art00006

<span style="font-family: 'Times New Roman',Times,serif; font-size: 11pt;">Spencer, C., & Burke, P. (2011). The impact of culture on pain management. //AMSN// //, 20// (4), 13-15.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 11pt;">Thrane, S. (2010). Hindu End of Life, death, dying, suffering, and karma. //JOURNAL OF HOSPICE AND PALLIATIVE NURSING// //, 12// (6), 337-342. doi: 10.1097/NJH.0b013e3181f2ff11

<span style="font-family: 'Times New Roman',Times,serif; font-size: 11pt;">Visagie, J., Plessis, A., & Wijnbeek , D. (2011). MAX WEBER S THEORY RE-VISITED: MODERN ORGANISATION CULTURE STIMULATING PRODUCTIVITY. //Interdisiplanry Journal of Contemporary Reasarch in Business// //, 2// (12), 15-30.


 * Discussion**

The doctor patient relationship. http://healthculturesociety.wikispaces.com/The+Doctor+Patient+Relationship

Well done on a great and informative essay, your artefact choice reflects your study perfectly and your introduction really got my attention and kept me reading. Its disappointing to see that culture is having such a bad affect when people require medical aid. Particularly when you think that we all have the same anatomy and physiology, and it not until you undergo some research you realize just how big of a problem culture can cause. Your study focuses mainly on the doctor patient relationship, but adding nursing staff and pre hospital medical services to the equation adds another level to this problem. The study you used by Ferguson & Candib (2002, p. 353)in regards to the language barrier is partially interesting as communication is suggested in many studies, as the key culturally aware practice and this study highlights that if this fails so to does the relationship.

No pain, No Gain? http://healthculturesociety.wikispaces.com/No+pain%2C+no+gain%3F

Great work on your essay, and I completely agree that having a needle sharp nail hammered into your skin does not sounding appealing, this reinforces your artefact and makes it a great choice to display this topic.

The study by Carragee, Vittum, Truong, Burton (1999) comparing different doses of morphine required to control pain from the same injury but different cultures is particularly interesting and really reinforces your argument, the same can be said for the information you presented about the cold presser test to determine pain tolerance. Both of these ideas focus around the measurement of pain, an invisible sensation, and the expectation on our health care professionals to measure pain accurately irrespective of age, culture, ect. This makes for an really difficult situation and one that is often dealt with poorly.