The cultural background and genetics affect the pain threshold and the psychological attitude towards the phenomenon of pain in general. Ethnicity and the view of both the world and oneself in this world are directly related. This also applies to the characteristics of pain perception and pain responses. On the example of the Sikh culture, it can be traced how the attitude towards pain is dependent on ethical affiliation. Since people in this culture perceive pain differently, such patients require a unique approach.
The Different Natures of Pain
Pain is a subjective and personal experience, but it is uniformly described in terms of sensory and emotional characteristics. Pain is also an important defense mechanism, which protects the human body. Pain can be psychogenic (caused by emotional distress), neuropathic (resulting from damage of central nervous system), and nociceptive pain (caused by injury, burns, surgery, and all kinds of diseases). Pain caused by different reasons is perceived and treated in different ways. The perception of this pain can be just as diverse, including among representatives of different cultures.
The Relationship between Ethnic Background and Pain
Pain threshold, among other things, is a genetic factor, and can be inherited. It turned out that in people who most easily endured pain, the DRD1 gene is most often found, and those who suffered more from pain than others have a genetic combination of DRD2. However, much serious and significant difference lies not in the genetic code but in the influence of the cultural environment on a person in principle. Attitudes toward life and death, the religion of the ethnic group, and the culture of upbringing — all these factors have a much more profound effect on the formation of attitudes toward pain.
Ethnic Differences in Pain Perception and Pain Responses
The perception of pain largely depends on the socio-cultural context that accompanies the injury (injury sustained during a battle, expected / unexpected injury), perceptions, thoughts of a person about the causes and consequences of the injury (is there a threat to life, threat of disability), his emotional state (anxiety, depression enhance the perception of pain) and other psychological and socio-cultural factors (gender, age, cultural traditions, religious views). For example, the proliferation of mutilating medical practices in some cultural paradigms (the sacred needle piercing festival in Indonesia or the ‘lotus feet’ tradition in China) affects the pain threshold of this culture representatives’. The fact is that the psychological state of the patient influences the perception of pain. Pain can seem both as a way of cleansing from vices and approaching God (common in African tribes) and as a standard practice (mutilating rituals); respectively, attitudes change due to the cultural paradigm.
The Interpretation of Patients’ Pain Experience
Physicians’ and patients’ general perceptions of illness and health are based on prior experience and social and cultural transmission of beliefs and expectations. Ethnicity influences the perception, labeling, response, and reporting of various symptoms, also from whom patients prefer to receive care when needed, and the types of treatment. Socio-cultural factors influence how the patient’s family and other environment interact. Moreover, ethnic expectations, age stereotypes, gender norms can affect the relationship between doctor and patient.
The practitioner should be aware that discussing impending death may be considered inappropriate and culturally insensitive. Lack of understanding of the beliefs of patients and families can potentially damage the patient-provider relationship (Giezendanner et al., 2017, p.12). While religion and spirituality have a significant impact on patient health decisions, many healthcare providers may not consider this factor or its functional impact on pain assessment and treatment, and palliative care. For example, Taiwanese may consider bad luck to occur if someone loudly discusses impending death and, as a result, avoids discussing death to tempt fate. Cultural differences between doctor and patient regarding different perceptions and attitudes towards pain can lead to the worst consequences. Therefore, each patient needs a unique approach, including considering their cultural background.
Variations in Assessment of Pain (Sikh culture), Verbal and Non-verbal Cues
Sikhism is one of the national religions of India, predominantly in the Indian states of Punjab and Haryana. Most of the Sikhs are Punjabis, forming a compact ethnic and confessional community; it has a significant impact on the entire history of North India. The essential Sikh holidays are celebrations of the birth or death of one of ten gurus. Sikhs do not share traditional ideas about the afterlife, heaven or hell, sins, and karma. The teachings of retribution in the future life, repentance, and cleansing from sins, asceticism, and chastity are, from the point of view of Sikhism, are an attempt by some mortals to manipulate others. After death, the human soul dissolves in nature and returns to the creator, but does not disappear, and remains like everything that exists. Morning and evening prayers take about two hours a day, starting in the earliest morning.
Pious Sikhs are encouraged to begin their day with personal meditation in the name of God. From an early age, both boys and girls are taught to handle weapons. Thus, to assess the cultural background concerning pain, there are enough facts: this is the culture of warriors who do not believe in the traditional idea of the afterlife, and from childhood, are subjected to physical stress: long prayers and training in the use of weapons.
Sikhs are taught from childhood to overcome physical suffering to become a worthy warrior. There is no data on whether their pain threshold is overestimated or underestimated. However, it is obvious that people from the warrior culture can ignore alarming pain symptoms for a long time. It is also important that they have rather calm attitude to death as to natural law. Of course, a personal questioning of the patient is the beginning of any diagnosis, but one cannot rely only on its result when assessing pain. Verbal and non-verbal cues are understood as a part of qualified patients’ care (Pautler & Gagné, 2005, p. 111). However, concerning patients belonging to Sikh culture, it is necessary, first of all, to take into account non-verbal signals, since the severity of pain from the patient’s words is likely to be underestimated.
Possible Pain Assessment Tool
As previously discussed, the culture under study may underestimate pain symptoms. The first tool to access patient self-reporting of pain intensity is a numeral scale (Barreveld, 2019, p. 60). The NRS can be used in such a case but the results need to be double-checked. The patient is asked to make three pain assessments corresponding to the current, most severe, and most painful moment experienced in the last 24 hours. The average of the 3 scores was used to represent the patient’s pain level over the previous 24 hours. A visual analogue scale (VAS) is a measuring instrument that attempts to measure a characteristic or ratio that is believed to vary over a range of values and cannot be readily measured directly. It is often used in epidemiological and clinical research to measure the intensity or frequency of various symptoms. If the patient cannot adequately identify the intensity of pain, it will be possible to understand its frequency thanks to the scale.
Variations of Nursing Interventions in Management of Pain
Diagnosing a patient who represents the Sikh culture can be challenging. That is why it would be correct to use the approach of interprofessional collaboration. An example of interprofessional collaboration would be a doctor, nurse, physiotherapist, occupational therapist, and pharmacist, working together to implement a personalized care plan to improve a patient’s health. The interprofessional collaboration method has proven effective for different patients (Melnyk & Fineout-Overholt, 2019, p. 10). The advantages of this method are obvious: pain symptoms that the patient himself can ignore will definitely not be missed by a team of specialists.
It becomes clear that the reaction on pain and its perception develops individually for each person, and the cultural background plays an important role in this process. In Sikh culture, pain is perceived differently, as children learn to overcome suffering from a very young age, which is why such a patient can ignore pain symptoms. People accustomed to long prayers and martial arts training will definitely be more tolerant to pain. Of course, every person needs a special approach during treatment. However, one of the main aspects during diagnosis and care should be an understanding of patient’s cultural background. In this regard, choosing a special approach and relying rather on non-verbal signs is required.
Barreveld A. M. (ed.). (2019) Pain care essentials. Oxford University Press.
Giezendanner S., Jung C., Banderet H.R., Otte I.C., Gudat H., Haller D., Elger B.S., Zemp E. & Bally K. (2017) General practitioners’ attitudes towards essential competencies in End-of-Life care: A cross-sectional survey. PLoS One.
Pautler K. & Gagné M. (2005). Annotated bibliography of collaborative mental health care. Canadian Collaborative Mental Health Initiative.
Melnyk, B. M., Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice. United Kingdom: Wolters Kluwer.