1. Introduction
Pain, which is one of the oldest and most complex health problems, is an unpleasant sensory and personal experience with physical, emotional, social, and cultural characteristics that adversely affect the patient’s functioning and quality of life [
1,
2]. Despite technological advances in pharmacology, surgical techniques, and peri-operative care, pain is a significant symptom experienced by surgical patients [
3], with 86% reporting the pain as severe [
4]. Post-operative pain is experienced at the highest level within the first 36 hours following surgery and gradually decreases by the third postoperative day [
3,
5,
6].
As pain management is a fundamental right of the patient [
7], patients expect that health professionals, especially nurses, will actively monitor and relieve pain with pharmacologic, non-pharmacologic, and complementary therapies. Nurses’ attitudes regarding pain, the assessment of pain, and decisions regarding pain management are important, given the realization that inadequate pain assessment results in inadequate pain management [
8,
9]. When post-operative pain is not well controlled, it may cause various physiological and psychological effects, as well as increase the risk of acute pain turning into chronic pain [
10]. Inadequate post-operative pain control also increases the cost of care by delaying hospital discharge and prolonging the healing process [
4].
Since pain is a subjective experience, if a person says that he or she has pain, it should be accepted as true [
11]. Yet, it is known that nurses’ and patients’ attitudes toward pain and pain management are affected by the person’s past pain experience, age, and familial and cultural reactions to pain [
8,
12]. One of the challenges in providing healthcare in the US is caring for patients of diverse cultural backgrounds and ethnic groups, who may have similar or different attitudes and perceptions related to pain [
13,
14,
15]. Although patients may have the same surgical procedure and the same pain stimulus, they also may have very different pain tolerance levels and, given their cultural backgrounds, may express pain differently [
8,
15]. While nurses and patients of the same cultural background may have similar attitudes, differences in cultural background may increase the likelihood of patients’ pain not being properly evaluated and treated [
8,
15]. There are no studies in the literature that focus on the similarities and differences of attitudes, social norms, and behaviors of nurses and patients of the same or different cultural or ethnic backgrounds. The purpose of this study was therefore to explore the similarities and differences of nurse and post-operative patient dyads of the same or differing cultural and ethnic backgrounds regarding attitudes, social norms, and behaviors related to pain and pain management. This article focuses on the results of interviews of the cohort of nurses in the post-operative observation unit.
1.1. Research Question
In qualitative research, a research question states the phenomenon of interest and the population of interest. In this study, the research question was posed not as a declarative statement but as an interrogative question, specifically “What are the attitudes, social norms, and behaviors of culturally diverse nurses related to pain and pain management who are caring for patients during the post-operative period?”.
1.2. Conceptual Framework
This study was guided by the Theory of Planned Behaviors [
16], which is a socio-psychological approach purporting that an individual’s intention toward behavior can be estimated by his or her attitudes and social norms, which may include cultural expectations regarding a behavior [
17]. The Theory of Transcultural Nursing by Leininger (1999) further emphasizes the importance of cultural values, beliefs, practices, and attitudes in the care of patients and the effect of nurses’ awareness of their own cultural influences on pain assessment and management [
18,
19].
4. Discussion
All the nurses in this study agreed that pain is a subjective experience, and a patient’s report of pain should be believed, as purported by Özveren et al. (2018) [
22]. The nurses also reported that patients’ reactions to pain and pain tolerance are different, which supports the perceptions of Wray (2014) [
23]. Consistent with Yolcu, Akin, and Durna (2016), the nurses further recognized that pain restricts movement, affecting the activities of daily living, and can lead to serious post-operative complications [
24]. In addition, our findings are consistent with Murray-Nobles’s (2017) [
25] study, who stated that although patients may exaggerate their pain levels to receive pain medication, the nurses should not judge the level of pain reported, but there is an ethical responsibility to treat pain.
The nurses believed that establishing a personal relationship with the patient was also important and wished there was more time to get to know the patient. They realized that the way a patient reacts is also different depending on the family involvement. The nurses did express distress when patients reacted to pain by screaming or being demanding or aggressive. Yet, the nurses often felt that the patients were not understanding of their workload. The nurses wished for potentially lower nurse-to-patient ratios to decrease their own work burden and respond more quickly to patients. Patients with substance abuse histories were also of concern, as they realized that the patient may have a different level of pain tolerance and require a higher dose of medication. Yet, addiction was of serious concern, with worry about negative work outcomes if the patient was overmedicated. The nurses in the post-operative setting did wish they had a greater understanding of the disease process and patients’ pain histories to guide their assessments and treatment of pain. They understood that a patient’s level of pain was also related to the extensiveness of the surgery. However, the nurses reported that their assessments focused on visually assessing a patient, and they depended on a patient’s rating of pain on the assessment scale. The nurses did not speak about conducting a comprehensive pain assessment, which includes documentation of the location of pain, quality of pain, duration, relieving and exacerbating factors, associated factors, or the meaning of the pain as per the patient [
8]. They did not report conducting a physical exam, including inspection and palpation of the pain site.
The nurses did ask the patients about their preference for pain medications. However, they expressed significant concern if a patient had a strong preference, given the possibility of addiction. The nurses realized that in the first post-operative day, most patients experience moderate-to-severe pain and need IV pain medication. However, on post-op day 2, the nurses preferred to administer weaker medications by mouth, such as NSAIDS, to prepare patients for discharge home. The nurses expressed a preference for relieving pain using non-pharmacologic methods, such as positioning, walking to relieve gas, and creating an environment with minimal stimulation. However, they had limited knowledge of other non-pharmacologic pain treatments and the use of complementary therapies, such as music or distraction. Although these complementary therapies may be used in their personal or family context, this knowledge did not transfer to informing complementary therapies they could offer to their surgical patients. Midilli et al. (2019) [
26] stated that non-pharmacological treatments, such as heat, ice, and repositioning, should be used in combination with medications for pain relief, as they are independent nursing practices without side effects which can be taught to patients following surgery.
Consistent with the nurses’ concerns, Şenyüz and Kocaşlı (2017) discussed the side effects of opioids used for moderate and severe pain, specifically the effects on respiration and bowel function [
27]. The nurses’ behaviors indicated that they acted quickly in administering pain medications when the patients were in severe pain and were distressed if an emerging post-operative crisis with another patient delayed their response time.
With regard to social norms, such as culture, the nurses expressed greater comfort in caring for patients of their same cultural or ethnic backgrounds, as they were more “familiar” with their expectations and behaviors. These results suggest that culture does play a role in nurses’ experiences when caring for patients of the same and different cultural backgrounds, which will be addressed more fully in another manuscript. Narayan (2010) [
28] believed that nurses have a cultural perspective of pain going back to their childhood and try to provide culturally acceptable pain management.
The nurses expressed concern regarding overprescribing opioids, which could “get us into trouble” if the patient experienced negative outcomes related to opioid use. In contrast, the nurses indicated that physicians and nurse practitioners needed more education on prescribing appropriate doses of pain medication. An additional challenge expressed was the medical coverage of the unit, as there was often difficulty reaching practitioners post-operatively. The nurses were upset themselves when the pain medications ordered did not sufficiently relieve pain, and the provider did not come to see the patient but questioned the nurses’ judgement. Similar to Costello (2015) [
29], who emphasized that upon post-op hospital discharge, nurses have a responsibility to educate patients about the use of opioids to prevent misuse, the nurses in the study spoke about the need to educate patients about types of pain medication, when to expect relief, and side effects, as well as recommending non-pharmacological treatments.
The nurses spoke of the importance of individualized care, recognizing differences in patients’ pain experiences and levels of pain tolerance, the extent of the surgical procedure, and differences in pain perceptions and preferences based on a patient’s cultural background. Yet, juxtaposed to this perspective, each of the nurses mentioned that they were taught to “treat all patients the same”. This potentially reflects a cognitive dissonance between patient-centered individualized care verses diversity and equity. “Treating all patients the same” may lead to a “one size fits all approach”. Access to adequate pain medications is important for all ethnic and cultural groups, but in the process of “standardizing” care, there may be a risk of jeopardizing patient-centered, individualized care. In addition, given that the nurses expressed greater comfort in caring for a patient of the same cultural background, it is unclear how this may negatively impact care offered to patients of differing cultural backgrounds from the nurse. For example, if vocalization of pain is culturally accepted, a nurse from a culture that has a stoic approach to pain may interpret “screaming” as an inappropriate pain response. Therefore, further understanding of cultural differences related to pain and pain responses needs to be discussed in educational offerings related to pain assessment and management.
In reviewing the information shared by this cohort of nurses in a post-operative observational unit, several important issues have been raised: (1) the need for nurses to conduct a comprehensive pain assessment, (2) identifying the personal attitudes and preferences of nurses related to pain and pain management in comparison to patients, (3) exploring the impact of patients’ and nurses’ cultural backgrounds on pain management, (4) offering appropriate pain management in accordance with the level of pain severity, (5) using pharmacologic treatments, including opioids, non-opioids, and adjuvant therapies, and reassessment of pain following the administration of pain medications and other treatments, (6) increasing nurses’ and patients’ knowledge regarding the use of non-pharmacologic and complementary pain therapies, and (7) lastly, in consultation with pain management experts and unit management, determining the availability of non-pharmacologic and complementary therapies available during the post-operative hospitalization period.
Limitations
This study was approved by the institutional review boards during the first 3 months of the COVID-19 pandemic, a time when all hospitals were closed to visitors and on-site research could not be conducted. Data collection was therefore delayed until a COVID Mitigation Plan could be submitted, indicating measures to limit transmission of the virus. The time frame for data collection was also shortened, as only emergency surgeries were being performed in the first few months of the pandemic. As a further limitation, the researcher was working within a specified time frame to complete her research as stipulated by the Republic of Turkey Ministry of National Education, which funded the study. The nurses were also working under the stress of the pandemic, and the recruitment of nurses was challenging as they had time constraints related to time availability for interviews. Although the sample for this study included a cohort of six nurses of varying cultural backgrounds (Caucasian, African American, and Hispanic), no Asian nurses were working on the unit at the time of data collection, which was an identified limitation. Furthermore, the study consisted of nurse–patient dyads, with 6 nurses and 12 patients, 1 of the latter representing the same cultural background as the nurse and 1 patient being of a different cultural background from the nurse. Although a sample size of 18 participants was satisfactory for a qualitative study, the sample size of nurses was limited. Given the usual small sample sizes of 10–30 participants in qualitative studies, the results are not generalizable. However, the results provide a contextualized understanding of the human experience through intensive study of a few cases. Rather than the term generalizability often associated with quantitative studies, qualitative research speaks of transferability, which is known as case-to-case translation [
30]. Let it be known that the data regarding patients will be presented in a separate manuscript, as will the data comparing the attitudes, social norms, and behaviors of the nurse–patient post-operative dyads of similar and different ethnic and cultural backgrounds.
5. Relevance to Clinical Practice and Conclusions
Based on the results of this study, it is suggested that nurses on the post-operative unit have a greater understanding of the medical history and prior pain history of patients. In addition, nurses should receive education regarding conducting a comprehensive pain assessment, including visualization of the pain site. In continuing education seminars, perhaps in “unit huddles”, a nursing staff could discuss the challenges to pain assessment and management and discuss “case studies” representing patients who had significant pain management issues.
Further consideration should be given to the nurses’ concerns about the use of opioids and opioid addiction. Nurses should be instructed regarding the use of the World Health Organization pain model, which indicates the importance of using non-steroidal medications, as well as adjuvant medications for mild pain (0–3 intensity), then adding opioids to this regimen in the face of moderate-to-severe pain [
8]. Given the opioid crisis in America, the attitudes, social norms, and behaviors of the nurses in this study indicated heightened concerns about administration of opioids and the nurses’ preference to discontinue opioid use as soon as possible. Nurses therefore need education about the appropriate and often necessary use of opioids, particularly during the post-operative period, while educating patients about misuse. Nurses must be knowledgeable about all medications that may relieve pain to provide a balanced perspective regarding pain management, while recognizing the varying needs of patients dependent on their past pain histories, surgical experiences, substance abuse histories, and cultural influences. In addition to pain medications, education should also emphasize the use of non-pharmacologic and complementary therapies. Nurses should advocate for the availability of these treatments in the post-op unit, such as the availability of headsets so that music can be used for distraction and the creation of a calming environment during the post-op period.
Given the nurse-to-patient ratios and consideration of emergencies other than pain management, the nurses expressed distress about workloads and feeling pressured when patients were extremely demanding, which may lead to an increased risk of medication error. This suggests the need for consideration of the nurse-to-patient ratios during a 12-h shift, given the types of surgeries scheduled. Written pain protocols may also be important in treating patients during the post-operative period, particularly if the prescription providers are not immediately available to write pain orders. NP coverage of the unit may ensure the availability of providers to write pain orders.
Based on the results of this study, there remains concern that differences in the cultural backgrounds of the nurse and patient may influence the quality of care offered, specifically pain management. “Treating all patients the same” may result in stereotyping, in which the attitudes, norms, and behaviors of a person are contextualized primarily by culture. Nurses should be educated about assessing a person’s degree of assimilation in American culture and their individual perspectives regarding pain and pain management. In this study, the nurses expressed the importance of being non-judgmental, non-discriminatory, and accepting of diversity, yet juxtaposed to these ideas were the comments from the nurses to “treat everyone alike”. This negates the importance of diversity of needs, attitudes, preferences, involvement in deciding care options, and providing individualized care to meet the unique needs of patients. The implications and recommendations are for an emphasis on the importance of discussions between nurses and their patients in understanding health concerns, preparing patients for the surgical and post-operative experience, and offering guidance in a range of treatment options for pain.
What does this paper contribute to the wider global clinical community? (1) It identifies the concerns of culturally diverse nurses in providing pain management for post-operative patients; (2) it indicates nurses’ challenges and recommendations regarding pain assessment and management; and (3) it highlights the issue of culture and cultural competence as it relates to standardization of pain management of patients verses individualized, patient-centered care.