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Culture has been defined as the beliefs, values, behaviour and material objects that define people’s way of life (Standage, 2005). Culture also encapsulates how people act and behave when they experience different phenomena in their social lives (Elazia, 2012). In this context, culture defines the social conditions of pain and gives it meaning. It also has a bearing on people’s experience of pain and how they will deal with the problem of pain based on their cultural experiences (Low, 1985).

Despite being a small-scale study, Lovering (2006) presented evidence on the influence of culture on the experience of pain based on the knowledge and experiences of a group of culturally diverse nurses working in a Saudi Arabian hospital. Saudi Arabian, Asian, Filipino,

Irish and South African cultures were represented. The methodology of the data collection was based on Herron’s (1996) model of cooperative inquiry and comprised a series of meetings with the 10 participants. The findings showed that the cultures shared some beliefs about pain, but were mostly different in their perceptions of the causes and expressions of pain and the necessity for medical intervention.

Low (1985) suggested a three-dimensional view of pain, comprising medical, social and psychological perspectives. The social perspective is rooted in the socio-cultural background of the healthcare giver and the patient or individual suffering the pain. Callister (2003) explained further that the pain experience is complex and based on multiple factors that influence the perception of pain and behaviours within the premises of the socio-cultural context of the individual experiencing it.

Magnusson and Fennell (2011) viewed pain as a multidimensional experience and explained it in terms of sensory, emotional, motivational and social factors. Pain is a universal

experience and the experience is felt differently by individuals, both within and between varied cultural groups (Davidhizar & Bartlett, 2000). The interpretation of pain is based on cultural experience and a system of meanings that act as a reference for such interpretation (Elwell, 2000). In this case, social factors determine how pain will affect the individual in line with the meaning they derive from the experience of pain. Davidhizar and Giger (2004) argued that culture is pivotal in shaping the values, beliefs, norms and practices of people as individuals in the way they respond to pain.

The ‘culture of pain’ refers to the way a society construes the meaning and treatment of pain, while the ‘culture in pain’ refers to how the perceptions of individuals and their expressions of pain are developed by their cultural orientation. Culture therefore provides the patterns of

behaviour to express pain based on the significance attached to it by society. This has a

bearing on the individual’s perception of the experience of pain (Magnusson &Fennell, 2011). The fact that people are social in nature implies that they are:

Greatly influenced by each of the cultural groups we belong to…Each of the groups influences the way we think and act by instilling in us both general and specific expectations of how the world works and how we should interact with it (Narayan, 2010, p. 38).

Pain will therefore be perceived from a specific cultural orientation to which the individual has been socialised, leading to the suggestion by Fenwick (2006) that pain is ‘culturally constructed’. From earlier observations, Fenwick (1998) indicated that Indigenous people in Australia do not attract attention to themselves when in pain; as a result, non-Indigenous nurses considered them as ‘unobtrusive’ when experiencing pain. Therefore, nurses and other healthcare personnel must develop a sensitivity to the different cultural perceptions of patients relating to pain (Callister, 2003; Blaxter, 2010).

Understanding the cultural orientation of an individual will help a healthcare giver design effective pain management strategies for the patient, where the patient’s cultural practices can be incorporated in the pain intervention program (Narayan, 2010; Richardson, 2012). Ignoring the cultural background of the patient may result in the failure of the applied strategies, as the patient may negatively perceive the strategy and refuse it.

Pain supersedes cultural limitations and affects everyone, but how an individual responds to pain is influenced by the individual’s previous encounters in his or her experience with life, age, socioeconomic status and gender, among other factors. The expression of pain invariably differs according to the cultural settings and backgrounds of people. In some cultures, people

want to know and understand the origins of their own pain, and at the same time be concerned about its implications for healthcare professionals and consequently under-report (Fenwick, 2006). Thus, understanding the phenomenon of pain in an individual is important; however, the health professional must develop a cultural competence, especially when working in communities that are not of his or her cultural orientation (IASP, 2013). Cultural competence has numerous characteristics and involves knowledge and skills, as well as:

Developing an awareness of one’s own existence, sensations, thoughts, and environment without letting it have an undue influence on those from other backgrounds; demonstrating knowledge and understanding of the client’s culture; accepting and respecting cultural differences; adapting care to be congruent with the client’s nature (Purnell, 2005, p. 8).

In this context, it is important for nurses and other healthcare givers to improve their knowledge about the variety of cultures in order to understand and interpret these cultural foundations and how they influence patients. This is relevant to understand the health-seeking behaviours of patients and exploit the motivations that led them to seek healthcare services (Jones, Brownlee & Cantor, 2002; Mazzilli &Davis, 2007). This is a way of making pain intervention strategies effective in the context of the patient’s perspective and interpretation of the meaning of his or her pain in his or her milieu (Narayan, 2010).

In building culturally competent care for patients, understanding the cultural orientation of the patient in the context of his or her pain is not enough. Cultural competence enables nurses to distinguish their own cultural backgrounds from those of patients, which have influenced the cultural patterns in which patients’ pain is projected (Callister, 2003). Cultural competence enables healthcare givers to satisfy the diverse needs of patients in a multicultural society. Its greatest advantage is that it enables nurses to design healthcare delivery packages that meet

people’s needs (Callister, 2003; Flowers, 2004). In this way, the safety of patients is enhanced and the quality of healthcare delivery improves, while medical errors are reduced—especially those that may arise out of misdiagnosis. Generally, for many adult patients with pain,

cultural competence eliminates the feeling of a paternalistic relationship with healthcare givers, as they are recruited into designing the pain intervention to which they become the objects (Habiba, 2000; Williams, Haskard & DiMatteo, 2007). Nurses therefore have an ethical duty to afford their medical clients’ correct appraisal of their pain and administer suitable pain relief interventions (Fenwick, 2006; Macintyre, 2001).

Cultural competency is a response strategy to the multicultural and multilingual needs of an emerging diverse population globally, and it is becoming an important approach in handling healthcare diversities and disparities (Flowers, 2004). Cultural competency is therefore a key way of improving patient outcomes in the treatment and management of pain, regardless of any cultural differences between healthcare workers and patients(IASP, 2013).

Learning about pain begins in one’s childhood. In this learning and socialisation process, an understanding develops regarding the ‘normal’ and ‘right’ ways to deal with pain, as well as ‘abnormal’ or ‘wrong ‘ways (Davitz & Davitz, 1985). During their training, nurses receive additional knowledge and skills regarding the ‘right’ way to care for patients in pain. These lead to a strong, albeit unconscious, sense of how competent nurses think and practice (Ludwig-Beymer, 2008). The complete and thorough assessment of pain, which is a

prerequisite for its successful management, requires effective nurse–patient communication. Clinicians do not generally use an interpreter service when interviewing patients, regardless of whether there is language incompatibility. Such situations make it almost impossible for caregivers to adequately assess pain and consequently treat patients and provide information on pain management principles (Wilson-Stronks et al., 2008). This problem can be overcome

to an extent by using tools designed to assess pain in children or cognitively impaired

patients, but this may also be ineffective and may result in suboptimal pain outcomes. Nurses can use many cues in addition to direct communication, such as facial expression, body posture and activity level, to assess patients’ pain (McCaffery, Ferrell & Pasero, 2000). However, it is well known that nonverbal communication patterns also vary across cultures and are therefore also likely to be misinterpreted (Brinkus& Narayan, 2002).

Nowadays, in most healthcare settings, accreditation and regulatory standards require

healthcare providers to use competent medical interpreters for effective communication with patients whose language differs from that of the doctor or the nurse (Wilson-Stronks et al., 2008). Such formalisation is a timely need because of existing cultural diversity among healthcare providers, and it is no longer appropriate to depend on family members or other informal interpreters that may compromise patients’ ability to understand and be understood (Divi, Koss, Schmaltz & Loeb, 2007). Communication lapses will invariably result in inadequate pain assessment and management.

2.4.2. Conceptual Framework of Leninger`s Cultural Care Diversity and