How can cultural barriers lead to wars?
A question of culture
The daily work of many caregivers is multicultural. More and more patients come from different countries. Language barriers and ignorance of foreign cultures can quickly lead to misunderstandings that seriously jeopardize the success of the care.
Caring for pain patients is generally a challenge because pain is a highly subjective sensation. But all the more so for patients from other cultures, because the subjective perception of pain is strongly influenced by the patient's cultural affiliation. It is therefore essential to pay attention to the cultural dimension of pain, because the factors influencing pain experience are different both within one's own culture and across cultures. According to current scientific knowledge, the pain threshold is the same in all people and in all cultures (Kohnen 2007), but the way in which pain is expressed, described and managed is to a large extent influenced by sociocultural factors.
Nurses undoubtedly play a key role in the interdisciplinary team in the context of pain management. They have frequent and intensive contact with patients and are usually the first addressees for expressions of pain. It is therefore helpful if you know about culture-specific expressions of pain.
Different cultures, different expressions of pain
In every culture, there are social norms about when feelings are shown, how clearly they are shown, and where they are shown. These presentation rules not only determine the form of expressions of feeling, but also determine what is considered appropriate or inappropriate. In our Western European culture, it is common to keep feelings under control in public, to show self-controlled behavior and not to express the pain expressively. Sentences like “tough men don't cry”, “an Indian knows no pain” or “clench our teeth” shape our behavior.
In contrast, in other cultures it is socially accepted to show spontaneous feelings and present pain more strongly than we do.
Since nurses have an idea of which expressions of pain are appropriate and which are inappropriate based on their own socio-cultural perspective, expressive expressions of pain can be perceived as strange or even viewed as exceeding norms in patients from other cultures.
If, for example, patients from the Mediterranean or the Middle East expressively express their expressions of pain, this often leads to uncertainty and a feeling of helplessness among caregivers: they are unfamiliar with both the intensity of the expression and the long-lasting lamentation. In everyday nursing, this type of pain expression is sometimes dismissed as an exaggeration, and sometimes there is even a tendency to mistake such patients for simulators. Among other things, this usually happens when the patient shows no signs of relief despite an adequately sufficient dose of pain medication, but continues to show clear pain behavior. Lightly used mocking terms such as “Mama-Mia-Syndrome”, “Morbus Bosporus” or “Morbus Balkan” clearly express the lack of understanding of the caregivers regarding the strange behavior.
Even if the patient's expressions of pain do not always seem objectively appropriate to the internal reality or the organic findings of the pain condition, nurses must take these expressions seriously. Because pain is also interpreted symbolically. Sometimes the presentation of pain is more important than the pain sensation.
In many southern European and Near Eastern countries, pain is expected to be a sign of illness: Only someone who expresses pain expressly is considered sick. Someone who describes pain rationally is not taken seriously as a sick person. Patients from these cultures also have a strong external conviction of control: They are convinced that they can only cope with the pain with the help of the family. In order to activate family support and care, it is necessary to express the need for help loudly and clearly. In these patients, visiting relatives or friends can subjectively exacerbate the pain. But language barriers can also be the cause of severe expressions of pain. People who, due to insufficient language skills or educational barriers, are not sure whether their needs have been understood, tend to clarify their concerns through drastically exaggerated descriptions.
Patients from Asian, Latin American, African and Arabic-speaking countries often do not express their need for painkillers out of cautious respect for nurses and doctors. They are seen as higher-ranking people who are neither asked for nor asked for anything.
In China especially, it is considered rude to accept something that is offered to a person for the first time. So if this person declines the first offer of a pain reliever, it is advisable to repeat the offer again.
The way in which pain is portrayed is just as strongly influenced by cultural affiliation. Not only are the words used to describe the pain itself, but also the description of its location are different.
For example, patients from Southeastern European and Near Eastern countries express pain very close to the body and holistically. The idea that only one organ or only part of the body can be diseased without impairing the entire physical, emotional and social well-being is inconceivable for these people. Patients from these cultures will therefore neither limit the pain to a painful area or to a specific body region, nor describe how the pain feels.
From this holistic point of view, it is understandable that these patients on the one hand use paraphrases such as “everything is sick” or “pain everywhere”, but on the other hand also experience emotional pain close to the body. It is not uncommon for psychological conflicts to be expressed as somatic whole-body pain.
In Arab and Asian countries, but also in Turkey, the stigmatization of mentally ill people is still widespread. Patients from these countries tend to express their mental health problems in terms of physiological symptoms in order to circumvent this stigma. In contrast to somatic complaints, mental symptoms are rated as "socially disadvantageous". Mental illness is not seen as a medical problem, but as something abnormal, something crazy. If it becomes known that someone is being treated for a mental illness, this can mean the end of society for the person concerned.
Turkish patients tend to express pain in organ metaphors. The expression "my liver is on fire" is an expression of sadness, worry and a depressed mood. In this country it is roughly synonymous with "It tears my heart apart".
Formulations such as “my arms are broken” as a synonym for feeling unstable, “the gallbladder has burst” to convey that I am very scared about something, or “my belly button has fallen” for a disturbed mental equilibrium express psychosomatic sensitivities. The idea behind “organs falling” is the idea that complaints arise because an organ is no longer in the right place and the body is out of balance as a result.
Pain Management Strategies
Pain is not only endured in different life situations, but also differently according to religious or cultural values. Different types of behavior are observed. The five best-known pain management strategies according to Kohnen (2007) should be briefly explained:
Fatalistic pain management: This form of pain management is particularly common among traditional Filipinos. Even if they lament their pain, they suffer it devotedly. In their view, pain corresponds to God's will and God gives them the strength to endure this pain.
Religious coping with pain: The patient sees the pain as a sign from God to take a more healing path in life. He is convinced that God has sent him pain to test whether he is steadfast in the faith. For the believer, pain is a unique opportunity to change his life and to go other ways. One treats the pain in such a way that it must be endured and endured so that the sign and the associated message of God can be recognized. Pain is very much perceived as unpleasant and can be uttered - even aloud; however, it should not be eliminated or completely suppressed by medication. Pain should make you think about your own life. For example, pious Jewish patients accept pain and reject pain relieving medication because they see pain as a test of God. In some cases, Christian patients also forego pain relief in view of Christ's suffering on the cross, since pain suffered voluntarily is perceived as a way of following Christ.
Muslim patients also interpret pain as a sign of their God. Buddhist patients, on the other hand, believe that pain in this lifetime can improve their karma. He who endures much suffering on earth now acquires advantages for the following life. Likewise, with Hindu patients, suffering is part of life that must be endured. Here, too, pain is viewed as a karmic compensation and therefore pain relieving medication is rejected.
Willful coping with pain: The general guiding principle of this coping strategy is not to let the pain happen. If it occurs anyway, it is suppressed. These patients are convinced that it is not appropriate to express pain and therefore withdraw into solitude and endure the pain in silence. The control conviction is: "I alone will cope with the pain with my will."
Family coping with pain: This type of pain management is particularly widespread in collectivist societies such as the Mediterranean, Turkey and the Middle East. In this coping strategy, pain is processed collectively: the patient receives unrestricted attention and support from the family. In order for family support to be activated, the patient must express his or her suffering loudly and clearly. Because help can only be given to those who clearly express their need for help, so the conviction. In these patients, the expression of pain can therefore be far stronger and more emotional than is usual in our Western European culture.
Rational coping with pain: This coping strategy, which is widespread in Central and Northern Europe as well as in North America, is associated with a high level of internal control. Pain is seen as something that can be scientifically controlled. The patient describes the pain as objectively as possible, assumes that the pain has a physical origin and that a doctor can find out the cause through a precise description and treat it in a targeted manner.
This diversity of cultural, ethnic and religious components, which is only partially shown here, reveals the different factors that can influence the experience of pain. At the same time it becomes clear that in transcultural care a culturally competent, individually differentiating approach to the pain experience is required. This is not least because of the avoidance of misjudgments due to one's own cultural background.
Kohnen, N. (2007): Painful and Non-Painful Patients. Transcultural aspects of experiencing pain. Trauma and occupational disease 9 (Suppl 3), 323–328
Lenthe, U. (2016): Transcultural Care. Recognize - understand - integrate culture-specific factors, 2nd edition, Vienna: Facultas
Lenthe, U. (2016): Transcultural Nursing Practice. Raising needs - considering - fulfilling, Vienna: Facultas
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