AZUSA PACIFIC UNIVERSITY

HISPANIC NURSES PERCEPTION OF PAIN

ASSESSMENT AND MANAGEMENT

by

Carol Bloch

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A dissertation submitted to the
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School of Nursing

in partial fulfillment of the requirements

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for the degree of Doctor of Philosophy in Nursing

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Azusa, California

December, 2012
 UMI Number: 3548295

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 AZUSA PACIFIC UNIVERSITY

HISPANIC NURSES PERCEPTION OF PAIN

ASSESSMENT AND MANAGEMENT

by

Carol Bloch

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has been approved by the
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School of Nursing

in partial fulfillment of the requirements

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for the degree Doctor of Philosophy in Nursing

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John A. Doyle, Ph.D., MFCC, Committee Chair

Lina K. Badr , DNSc, RN, Committee Member

Major L. King, Ph.D., RN, Committee Member

Aja Tulleners Lesh, Ph.D., RN, Dean, School of Nursing

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Copyright by Carol Bloch 2012

All Rights Reserved

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 DEDICATION

This dissertation is dedicated to my parents, George Mathewson Bloch (1916-

2007) and Mary Pearl Bloch (1919-2011). I love you both. Thank you for a wonderful

life!

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 ACKNOWLEDGMENTS

Thank you all for coming along with me on this journey: AnnMaria De Mars,

Ph.D., Dixie Fisher, Ph.D.; Claire Gulino, Ph.D., R.N., CTN; Beverly Horn, Ph.D., R.N.;

Madeleine Leininger, Ph.D., LHD, D.S., R.N., CTN, FRCNA, FAAN, LL; Lois Lowery,

DNSc, R.N., ANEF; Ildaura Murillo-Rohde, Ph.D., R.N., ND, FAAN; Betty Neuman,

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Ph.D., R.N., FAAN; Grayce Roessler, Ph.D., R.N., CTN; and Helen Rueda, M.A., R.N.

A special thank you goes to my brother, George H. Bloch, Ed.D., for being the

pathfinder for educational excellence.

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 ABSTRACT

HISPANIC NURSES PERCEPTION OF PAIN

ASSESSMENT AND MANAGEMENT

Carol Bloch
Doctor of Philosophy in Nursing, 2012

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Azusa Pacific University
Advisor: John A. Doyle, Ph.D.
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The purpose of this study is to identify cultural beliefs of Hispanic nurses and how they
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approach pain management in the clinical setting. This study was a descriptive, cross-

sectional correlation design using 3 survey instruments. Using selected tools to assess the

Hispanic nurses perception of pain assessment and management, the results showed the
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average nurse had inadequate knowledge levels in these areas in general. However, a

specific strength in this sample of Hispanic nurses was accurate pain assessment.

Regardless of acculturation, Hispanic nurses demonstrated a high degree of accuracy in

pain assessment for both non-Hispanic and Hispanic patients; however, they had higher

pain management decision-making scores for Hispanic patients. Wong-Bakers pain

assessment tool predicted correct assessment and management of pain. Nevertheless,

neither acculturation nor years of experience were significant predictors. Because the

sample included only Hispanic nurses, these results cannot be generalized to the general

population of nurses. Results of this study were inconsistent with literature asserting a

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relationship between healthcare decisions and acculturation. It is possible that this lack

of relationship may be due to the generally high level of acculturation of this sample.

This study is consistent with other empirical findings that nurses in general have

inadequate knowledge of pain management, with important implications regarding the

need for further research and training in this area. Future research should also examine

whether other ethnic groups (e.g., non-Hispanic White, African American) are more

likely to make correct decisions in pain management for members of their own ethnic

group.

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KEYWORDS: Hispanic, nurses, pain assessment, pain management
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 TABLE OF CONTENTS

Dedication .......................................................................................................................... iii

Acknowledgments.............................................................................................................. iv

Abstract ................................................................................................................................v

List of Tables ..................................................................................................................... xi

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List of Figures ................................................................................................................... xii

Chapter Page
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1. Introduction .....................................................................................................................1
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Study Purpose ..........................................................................................................5

Theoretical Framework ............................................................................................5

The Neuman Systems Model .......................................................................6

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The Sociocultural Variable ........................................................................10

Prevention as Intervention: Secondary Prevention ...................................11

Application of the Neuman Systems Model ..............................................11

Strengths and Limitations of the Neuman Systems Model ........................14

Summary ................................................................................................................17

2. Review of the Literature .............................................................................................18

The Healthcare Provider and Pain Assessment .....................................................24

Research Gap .............................................................................................27

Pain Outcome Measures and Survey Instruments ....................................27

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Chapter Page

The Hispanic Pain Treatment Survey ........................................................29

Acculturation..........................................................................................................31

Definition of Study Concepts.................................................................................33

The Studys Variables of Interest ..........................................................................34

Research Questions ................................................................................................34

3. Methods.........................................................................................................................36

Design ....................................................................................................................36

Sample Selection ....................................................................................................36

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Instruments .............................................................................................................39
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The KARP Instrument ...............................................................................40

The Hispanic Pain Treatment Survey (HPS) Instrument ...........................42

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The Short Acculturation Scale for Hispanics (SASH) ...............................44

Data Collection ......................................................................................................45

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Data Analysis .........................................................................................................46

Human Subjects Protection ....................................................................................49

4. Results ...........................................................................................................................51

Data Coding and Analysis .....................................................................................51

Reliability and Validity Analysis KARP ................................................54

Reliability and Validity Analysis HPS ...................................................55

Reliability and Validity of Short Acculturation Scale for Hispanics .........57

Answers to Research Questions .............................................................................59

5. Discussion ......................................................................................................................68

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Chapter Page

Strengths of the Study ............................................................................................68

Discussion of Research Questions .........................................................................69

Research Question 1 ..................................................................................70

Research Question 2 ..................................................................................71

Research Question 3 ..................................................................................72

Research Question 4 ..................................................................................72

Research Question 5 ..................................................................................73

Research Question 6 ..................................................................................74

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Discussion of Literature Related to Results ...........................................................74
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General Summary on Pain Assessment and Management

in Diverse Patients .........................................................................74

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Hispanic Nurses .........................................................................................79

Implications of the Study .......................................................................................81

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Acculturation and Its Implication to Hispanic Nurses ...............................81

Implications to Nursing Practice ................................................................82

Implications of Cultural Impact on Practice ..............................................84

Implications for Nurse Educators ............................................................. 84

Limitations of the Study.........................................................................................91

Recommendations for Future Studies ....................................................................92

Conclusion .............................................................................................................95

References ..........................................................................................................................97

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Appendix Page

Informed Consent.................................................................................................109

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 LIST OF TABLES

Table 1: Sample Demographics ........................................................................................52

Table 2: Comparison of KARP Results Using Different Methods of Calculation

of Percentage Correct ..........................................................................................53

Table 3: Cronbachs Alpha Measures of Internal Consistency Reliability of HPS ...........56

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Table 4: Correlations of SASH with Spanish Fluency Measures ......................................58

Table 5: Descriptive Statistics of KARP Total Score and Subscale ..................................59

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Table 6: Health Professional Survey Mean Subscale Scores.............................................60
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Table 7: Cross-Tabulation of Pain Assessment and Pain Management ............................62

Table 8: Regression of KARP Total Score on Job, Experience, and Education

in Pain Management, Years of Experience, and Use of Pain Assessment

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Measures ..............................................................................................................66

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 LIST OF FIGURES

Figure 1: The Neuman Systems Model ..............................................................................8

Figure 2: Conceptualization of the Neuman Paradigm of Man/Person ............................13

Figure 3: Representation of the Pain Experience and Bi-Direction Influences of

Nurse and Patients..............................................................................................14

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Figure 4: Histogram of Attitudes of Cultural Factors Influence Score ...........................61

Figure 5: Pain Assessment Scores ....................................................................................64

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Figure 6: Pain Management Scores ..................................................................................65
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Figure 7: Distribution of KARP Item on Cultural Considerations ...................................67
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 CHAPTER 1

INTRODUCTION

With the increase in diverse patient populations in the United States (Ortman &

Guarneri, 2009; U.S. Census Bureau, 2000), particularly in the greater Los Angeles

metropolitan area, many cultures and ethnic groups within the healthcare system have

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divergent cultural beliefs and attitudes regarding health, illness, and disease. The cultural

systems of diverse patient populations pose a challenge to healthcare professionals who

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seek to understand the cultural beliefs and values that affect the behavioral and emotional
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response to the healthcare pain issue, the most common reason a patient requests

healthcare treatment in the United States (Al-Shaer, Hill, & Anderson, 2011; Singh,

Patel, & Gallagher, 2010).

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For the racially diverse and multicultural patient populations seen in clinical and

hospital settings, pain, in particular, may be undertreated, undermedicated, or

misdiagnosed in severity by healthcare providers (Calvillo & Flaskerud, 1993; Green et

al., 2003; Pletcher, Kertesz, Kohn, & Gonzales, 2008; Shavers, Bakos, & Sheppard,

2010; Ulene, 2010). Thus, understanding the pain experience from differing racial and

ethnic perspectives is a clinical imperative, as culture may inhibit some individuals from

seeking treatment.

A qualitative study by Villarruel (1995) of Hispanics and their pain experience

and expression revealed themes of stoicism when experiencing pain, pain as a solitary

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experience, pain as a part of lifes suffering, and an obligation to endure pain to care for

ones family, which substantiated the cultural beliefs identified in a review of the

literature by Calvillo and Flaskerud (1991). For these reasons, Mexican-Americans may

endure more pain and report it less frequently (Villarruel & Ortiz de Montellano, 1992).

Research studies of non-White cultures and multiracial and ethnic groups have

demonstrated that the pain experience is screened through cultural and ethnic beliefs

regarding pain; thereafter, the response to pain entails culturally appropriate behaviors

and attitudes (Lovering, 2006). This dualism as to the meaning of pain as symptom or

cultural pain experience may impede the healthcare professional in assessment and

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treatment because the providers are working with multicultural patient populations that
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have their unique interpretations of the pain experience (Kaegi, 2004).

Members of ethnic minority groups may evidence culturally-based differences

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from the mainstream American culture in interpretation and pain expression. Those

health professionals not familiar with treating patients from ethnic minority groups may
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find it difficult to communicate the need to describe the pain experience, evaluate the

pain on a pain scale (that is American-based), and accept pain treatment. It is not unusual

for multicultural patients to be deemed difficult or noncompliant (Kaegi, 2004) when, in

fact, miscommunication is a result of cultural differences.

In a literature survey, Kaegi (2004) found many healthcare disparities in how pain

is perceived and treated in a multicultural society. In their review of 187 articles and

informational sources, Shavers et al. (2010) concluded that racial/ethnic disparities in

pain management are fairly well documented and cited culture as one of the sources of

emotional and behavioral responses to the pain experience. They also noted that among

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areas of cultures influence on the pain experience is the individuals pain-related

behavior and emotions, the social meanings of pain, and the roles of family and

healthcare professionals in pain experience and management. Healthcare professionals

from racial and ethnic minorities can serve as cultural brokers for their patients because

of their understanding of cultural nuances, especially those regarding pain. In their

examination of peer-reviewed articles on pain and ethnicity in the United States from

1990 to 2005, Cintron and Morrison (2006) found that most of the studies demonstrated

racial and ethnic disparity in access to medical services, including disparity in access to

effective pain treatment. This literature review clearly indicates the need for providers

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cultural perspectives to be included in pain studies to identify if the providers cultural
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values and beliefs do, in fact, influence their assessment and management of pain with

multicultural patients.
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The Hispanic population is the largest ethnic minority group in the United States.

(U.S. Census Bureau, 2010); thus, the need to address the cultural differences of
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Hispanics in the healthcare setting is accentuated. The assessment and treatment of pain

is one aspect of healthcare that has been documented for cultural differences that impact

the pain experience for the Hispanic patient. A study by Alvarado, Jester, Harris, and

Whitaker (2008) found that Hispanics and other minorities were under-medicated for

pain management no matter the injury or medical condition for both acute and

chronic pain. It was further noted that Hispanic patients were less expressive about pain,

and these differences were greater for less acculturated patients. Alvarado (2008) studied

pain beliefs of Hispanics and found a cultural preference for stoicism in managing pain

and a bias against pain medication use. The theme of stoicism as a key concept in the

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Hispanic culture was also found by Zacharoff, Zeis, Frayjo, Chiauzzi, and Reznikova

(2009) in their study of patients. They found that pain was perceived to be accepted and

expected as part of life or as a reflection of the will of God. These findings represent

how Hispanics experiencing pain have a certain orientation to the pain experience, which

is documented in the literature (Calatrello, 1980; Calvillo & Flaskerud, 1993).

The Institute of Medicine (IOM) released a report that is a blueprint for pain in

America (Gandey, 2011, p. 1). In a news release announcing its report, the IOM stated

the need for a coordinated and concerted effort in the United States to change attitudes

toward pain and to address the disparities in the pain experience. The gap continues to

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exist between healthcare professionals attitudes toward pain and patients in pain. IOMs
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report calls for pain relief to be a national priority.

Dr. Philip Pizzo, committee chair for the IOMs report, summarized the national
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perception of pain, All too often, prevention and treatment of pain are delayed,

inaccessible, or inadequate. Patients, healthcare providers, and our society need to

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overcome misperceptions and biases about pain (Gandey, 2011, p. 2). Dr. Pizzos

statement reflects the phenomenon of interest for this paper, although he stated it for the

general population. However, what is missing from the IOMs report is that

misperceptions and biases are often culturally based and impact the assessment and

management of pain for the culturally diverse patient populations.

The IOM report noted the key role a primary care provider plays in pain

management. However, it is common that the first person in contact with the patient is

the nurse. It is the nurse who often performs assessment and management of the pain

experience and relays it to the primary care provider. The IOM report requested all

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healthcare providers to maintain current knowledge and pursue continuing education in

pain management and that licensure, certification, and recertification examinations

include pain education (Gandey, 2011). What the IOMs report contributed is validation

of what nursing researchers discovered regarding pain, which is while pain is a universal

experience, it is unique to each individual (McCaffery, 1968).

Study Purpose

The purpose of this study was to identify cultural beliefs of Hispanic nurses and

how they approached pain management in the clinical setting. In particular, this study

sought to provide a better understanding of the cultural beliefs and values of Hispanic

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nurses and how these beliefs and values impact nursing care in relation to pain
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assessment and management. The specific aims were:

to validate the psychometric properties of common pain assessment and attitude

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measures for use with Hispanic nurses.

to determine whether Hispanic nurses differ in their assessment and management of

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pain for Hispanic vs. non-Hispanic patients.

to determine whether relationships exist between measures of acculturation and

Hispanic nurses assessment and pain management.

If inter-ethnic nurse-patient dyads result in less accurate decisions than intra-ethnic

dyads, then education in multi-cultural interpretations and expression of pain would

warrant greater emphasis in the nursing curriculum.

Theoretical Framework

The conceptual model for this paper and research question is the Neuman Systems

Model. The Neuman Systems Model embodies a comprehensive and holistic approach to

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the study of phenomena that affect optimal patient health. Aspects of the model that

address this papers phenomena of interest (pain perception of Hispanic nurses) are the

five client system variables and, more particularly, the sociocultural variable. The

sociocultural variable considers social and cultural elements within which the patient

lives and moves.

A nursing theory considered for this study was the Culture Care Theory by

Leininger (2006). The Culture Care Theory includes culture as a designated factor;

however, the theory does not consider the nurses perception of their own cultural and

ethnic values and beliefs and whether they influence patient treatment. The Culture Care

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Theory also situates the nurse in the capacity of a coordinator for transcultural care and
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actions, as opposed to Neumans theory in which the nurse and patient are in partnership

in confronting the phenomena of pain. The Neuman Systems Model provides a clear
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picture of the impact of culture from both the nurses and patients perspectives. Thus,

on the health-illness continuum, the nurse and patient are equal partners who collaborate,
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coordinate, and communicate in confronting this health issue (i.e., pain assessment and

management; Neuman, 2011).

The Neuman Systems Model

The Neuman Systems Model was developed by Betty Neuman in the 1970s and is

growing in influence and popularity in the United States and worldwide. Schools of

nursing in Canada, the United Kingdom, Sweden, Australia, and Jordan adopted the

theory (Lowry, 2002). The model is designated as a grand nursing theory, because

concepts are broad and not prescriptive. More importantly, the theory includes the four

metaparadigms of nursing: Person, Health, Nursing, and Environment. These

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metaparadigms provide central concepts that identify for the nursing profession and the

public at-large the specialized interest of nurses in their discipline (Fawcett, 2005). The

paradigm of Health is not cited in the Neuman Systems Models conceptual schematic;

however, it is implied and defined by Neuman as a distinct part of the nursing theory

framework and is cited in her schematic for health and illness (Neuman, 2011, p. 24).

The Neuman model is a systems-based perspective that envisions the patient (or

client) in a wholistic (Dr. Neumans spelling preference, as opposed to holistic)

totality, moving on a continuum between the opposites of wellness and illness. The

patient is an energy system that interacts with his or her environment; stressors are

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experienced through intrapersonal (internal), interpersonal (relationships), or
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extrapersonal (external) forces, all of which impact in some measure the patients

wellness level (Yarcheski, Mahon, Yarcheski, & Hanks, 2010). If the patient generates
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enough or more than enough sustained energy, then there is health. If the patient does not

generate enough sustained energy, then there is illness or death. The patients system
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stability, whether through retention, attainment, or maintenance, is the goal of nursing

care (Neuman & Fawcett, 2002). The client system, for the most part, is presented to

nursing in the form of the individual as patient. However, the client system may also be

family, community, or a social issue (Neuman & Fawcett, 2002). Figure 1 illustrates the

Neuman model from a conceptual framework.

The strength of the Neuman Systems Model is the clustering of data into five

discrete areas or variables which are integrated in each person and represent a wholistic

approach to assessment and care. The five variables are physiological (the physical

assessment), psychological (psychological well-being), sociocultural (social and cultural

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Figure 1: The Neuman Systems Model.

patterns and implications), developmental (the individuals appropriate developmental

stages), and spiritual (the essence of being, or the spiritual perspective; Neuman, 2011).

Nursing education has always focused on physiological factors in assessment.

More recently, psychological and spiritual factors have received greater emphasis, as

evidenced, for example, by the dramatic rise in the use of hospice care. In less than 50

years since the first hospice was founded in 1965, the percentage of patients electing end-

of-life care and pain management in a setting with physiological, psychological, and

spiritual emphases has grown from 0% to 25% of patients in fee-for-service plans and

34% of those in managed care (Medicare Payment Advisory Commission, 2004).

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Assessing the impact of all five variables simultaneously is data collection and
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analysis beyond the scope of a single dissertation. The sociocultural variable was

isolated as the focus of this research study to identify if culture impacts the nurses
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assessment and management of pain. Because emphasis in prior research and practice

has been on the physiological and, more recently, psychological and spiritual factors, the
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socio-cultural variable was selected as one of the more understudied aspects of the model.

The Neuman system is an extremely complex model in which variables interact

and constantly evolve (Neuman, 2011). The five variables encapsulate possible stressors

that impact a patients system stability and lend themselves to be assessed individually by

the nurse. The response to stressors depends upon the variables; stressors are affected by

diagnosis, multiplicity, and the variables. It is the nurse who must identify high-risk

factors to prioritize nursing actions. Hence, in discussing the models five variables, their

clinical application as related to pain is as follows. The physical variable affects the

bodily structure and function (e.g., blood pressure and pulse, respiration, and

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perspiration). The psychological variable refers to mental process and relationships

which are influenced by emotional reactions and expressiveness and verbalization of the

pain experience. The developmental variable refers to life developmental process or

stages of development. The sociocultural variable refers to the social and cultural

functions, which means ethnic background, occupation, marital status, family structure,

and educational level. The spiritual variable refers to a spiritual belief structure, which,

depending upon each individual, relates to the patients organized religion or the essence

of their being (Neuman, 1989).

The pain experience can challenge the persons lines of resistance to the point that

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the patient manifests signs and symptoms of spiritual pain and distress. Therefore, pain
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assessment should include an awareness of the patients spiritual variable for the

purposeful intervention of pain management, including spiritual advisement by

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appropriate spiritual guidance or clergy. In the Neuman model, reconstitution is the term

for the redirection and associated increase of energy to a new level of wellness or to
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optimal system stability.

The Sociocultural Variable

Within this complex, dynamic model, all but the most extensive longitudinal

studies represent just a snapshot in time and, generally, only a partial snapshot at that.

This variable is the aggregate of sociological and cultural elements in assessing the

wholistic patient, including educational level, occupation, family and family

relationships, ethnicity, and the broad concept of culture values and beliefs and

boundaries. According to Neuman, the sociocultural variable is not differentiated into

two separate entities of social and cultural factors but combines them as one variable,

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