Geriatric Nursing 36 (2015) 67e74

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Practice recommendations for pain assessment by self-report with African American older adults Staja “Star” Booker, MS, RN a, *, Chris Pasero, MS, RN-BC, FAAN b, Keela A. Herr, PhD, RN, FAAN, AGSF a a b

The University of Iowa, College of Nursing, 50 Newton Road, Iowa City, IA 52242, USA Pain Management Educator and Clinical Consultant, 1252 Clearview Drive, El Dorado Hills, CA 95762, USA

a r t i c l e i n f o

a b s t r a c t

Article history: Received 26 April 2014 Received in revised form 29 July 2014 Accepted 4 August 2014

Despite decades of education and clinical practice guidelines underscoring disparities in pain management, pain continues to be inadequately managed in older African American adults as a result of patient, provider, and systems factors. Critical factors influencing pain assessment in older African American adults has not been extensively examined, contributing to a lack of data to inform health care providers’ knowledge on culturally-responsive pain assessment in older African Americans. Assessing pain in older African Americans is unique because differences in language, cultural beliefs, and practices moderate how they report and express pain. This paper presents an overview of patient-provider factors that affect pain assessment in older African Americans with a focus on this population’s unique cultural beliefs and practices. Recommendations for best practices for performance of a culturally-responsive pain assessment with older African Americans are provided. Ó 2015 Elsevier Inc. All rights reserved.

Keywords: African American Black American Culture Nursing Older adult Pain assessment Practice recommendations

Introduction Pain is described as a “great equalizer”1 and a universal human experience that is characterized by its subjectivity. Evidence-based guidelines emphasize that all persons have the right to timely and adequate pain assessment based on their self-report of pain, but racially- and ethnically-diverse persons are substantially more likely than others to experience disparities in pain assessment and management. In fact, pain in African Americans is more likely to be under-assessed, under-diagnosed, under-estimated, and undertreated across all health care settings and pain types.2e8 Research has shown that older adults are at higher risk for underassessment and under-treatment of pain,9,10 making older African Americans a

Disclaimers/conflicts of interest: The authors report no conflicts of interest. * Corresponding author. Tel.: þ1 318 533 9076 (mobile); fax: þ1 319 353 5535. E-mail address: [email protected] (S.“Star” Booker). 0197-4572/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2014.08.014

particularly high-risk population. Accordingly, Cavalieri11 proposed assessment of pain as the first vital sign in older adults, given the high prevalence and under-recognition of pain in this population. Understanding pain in specific racial and ethnic groups remains in its infancy; hence, the role of culture in pain assessment is not adequately addressed in textbooks, pain management guidelines and position statements, and pain education programs. While current pain management guidelines provide detail on general pain assessment in older adults, they provide little guidance on pain assessment translation, transferability, and implementation across diverse older populations. Consequently, many health care providers have limited information on culturally-responsive approaches to assessment and treatment of patient symptoms such as pain, and some find pain assessment in ethnically diverse patients challenging12 leading to cultural discordance between the provider and patient. Nonetheless, it is important to understand cultural beliefs and practices of pain because African Americans have expressed the need for health care professionals to tailor pain

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assessment according to their culture.13 Therefore, it is imperative that health care providers are prepared to provide culturallyresponsive pain assessment, and this article provides evidencebased clinical practice recommendations to assist health care providers in performing a culturally-responsive pain assessment in cognitively intact, African American older adults. African American culture and pain Within any culture there are diverse beliefs and experiences, but it is essential to know and understand common African American cultural nuances because they can influence pain assessment (see Box 1). It is useful for health care providers to consider the history of the African American patient’s health care experience when attempting to obtain their self-report of pain. In times past African Americans were incorrectly regarded as insensitive to pain, and current research shows that African Americans are still perceived to feel less pain.14e16 In fact, virtual studies that examined the perception of race, pain empathy, and treatment revealed that African Americans receive less empathy and pain treatment.17,18 These findings are alarming considering that patients’ perceptions of injustice and discrimination increases pain19e22 and contributes to worse physical and psychological outcomes, including

fear of movement, depression, and prolonged recovery and disability.23e27 Yet, “To change health outcomes, historical and religious experiences must be considered when working with African Americans.”28 Therefore, multidimensional cultural skill and knowledge is needed to assess African Americans in nursing practice,28 because in its most complex nature, pain in older African Americans is a biological, emotional, psychological, social, spiritual, existential, historical, cultural, financial, and environmental phenomenon; this shapes how pain is expressed, communicated, and treated. Although pain is frequently perceived as inevitable or a sign of illness (or “something wrong”), African Americans are likely to minimize the expression of pain29 to avoid displacing attention from the true illness. African American culture has traditionally considered illness to result from imbalances, natural sources such as impurities, or unnatural/supernatural forces such as punishment from God or the devil.28,30,31 African Americans believe that pain is a test of faith1,32 and endurance or God’s will.33 Interestingly, African Americans can be both optimistic and pessimistic simultaneously, revealing the normality of dualities in African American culture. Consistent research concludes that African Americans have greater catastrophization, but one has to wonder if this “catastrophization” is “normal” pain behavior for African

Box 1. Cultural considerations for care of older African Americans in pain. Communication  African American elders are highly respected and valued family and community members.33 Greet them by their formal name: Mr., Mrs., Ms., Dr., Pastor, etc. plus either a surname or first name. Older African Americans consider being addressed on a first name basis by a stranger, such as the nurse, inappropriate and disrespectful. They prefer to be called by their surname or professional title because these are sources of pride and respect.28,30,33  Interpersonal relationships are important to African Americans; nurses should take a few minutes to have a short social conversation expressing care and interest in older African Americans’ daily life. Never indicate feeling rushed, this will greatly reduce rapport and subsequent interactions such as pain assessment.98 View pain assessment and patient teaching as a social transaction.102 African Americans respect nurses for their knowledge and ability to provide safe care, but they also desire that nurses and health care professionals communicate and interact with them at their level.  African Americans may communicate using “African Americans English (AAE).” This dialect is generally perceived negatively by many outside the African American culture. Consequently, African American patients’ words may be misinterpreted and select pain descriptors may be misunderstood leading to miscommunication with nurses.  Speaking slowly and clearly to older adults is recommended, but sometimes slower speech of health care providers is perceived by African Americans as offensive and being talked down to. This contributes to lower satisfaction with interpersonal care.103 A stereotypical, biased assumption is that African Americans are less educated and need to be spoken to at a slower pace to ensure they ‘understand.’ To prevent this, speak with normal pace and tone in which explanations are not deliberately drawn-out.  Family and kinship are important to African Americans. Family in African American culture may include “fictive kin”33,104 which means all preferred family members be included when planning care. Interpersonal space  Touch (e.g. hugging or handshaking) is extremely important in African American culture as it communicates approval, caring, trust, and respect28; older African Americans are okay with touching the hand or arm in a caring manner. This type of touch is very spontaneous and natural, and should be implemented during care. Pain  Assessing pain in African American culture involves more than eliciting pain intensity. Because cultural pain often factors into the pain assessment, a pain intensity rating may be reflective of multiple aspects of pain.  Pain is closely linked to spiritual beliefs, practices, and perceptions in older African Americans. Because several Bible scriptures state that we should not complain, but rather be thankful, many African Americans may minimize their self-report of pain because it is viewed as complaining.34  Recognize that race-based and disease-based discrimination impacts the pain and health care experience in older African Americans. Ó 2014. Staja “Star” Booker, MS, RN. “Cultural Considerations for Care of Older African Americans in Pain.”

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Table 1 Pain assessment pearls. Pain assessment task Step 1: Inquiry  Ask patients if they are in pain.  If reluctant to report pain or denies pain, reword the question and empathetically reinforce the importance of reporting pain.  Respectfully explain the difference between complaining of pain and reporting pain, if issues regarding self-report arise.  Encourage older African Americans to discuss their beliefs, perception of pain, past pain experiences, and methods that work best to control the current and past pain.  Prayer, spirituality, and faith are central in the lives of older African Americans. Perform a spiritual assessment of pain.

 Older African Americans view health in terms of ability to carry out activities of daily living, thus a realistic goal for older African Americans may be that pain is tolerable and allows them to remain functional.

 Inform patients that pain assessment and treatment is a right.

Step 2: Measurement  Ask the patient to describe the current pain using their preferred terminology.  Provide examples of a few self-report tools, such as the FPS-R, NRS, and VDS, IPT and allow the patient to choose the best tool for them. After providing clear, simple instructions on each tool, allow the patient to select tool that best allows them to communicate pain.

Step 3: Documentation  Document the assessment of pain.

 Self-documentation is seldom included in patient care, but this activity encourages patients to be active in their care.

Americans. Despite catastrophization, African Americans often are able to find a blessing even in the midst of pain.1 They may even give the pain over to God.34 Consequently, the health care team may misinterpret these actions as fatalistic thinking, maladaptive coping, or peripheral self-care, when, in fact, it is a form of spiritual acceptance of a physical condition and a way to relinquish control to a higher power. Another practice involves placing a place a knife under the mattress or bed to ‘cut’ the pain.33,35 Such cultural beliefs and practices emphasize the need for a culturally-responsive approach to pain assessment. Pain assessment techniques The Institute of Medicine’s8 Relieving Pain in America report recommends that pain assessment be consistent, complete, and documented. When a proactive versus a reactive perspective guides assessment, the goal becomes pain prevention rather than pain control. Thus, both health care providers and patients have a role in pain assessment: the provider’s role is to screen for pain (Table 1), while the patient’s role is to report pain. Likewise, the Joint Commission36 mandates that health professionals assess pain and encourages patients to take an active role in pain assessment and

Example nurse actions “Ms. Jones, are you having any pain?” or “Mr. Davis, are you hurting anywhere?” “Hello, Mrs. Williams. As I care for you today, I want to be sure that I provide you with adequate relief from pain. It is important that you tell me if you are hurting or are uncomfortable in any way.” “Many patients feel that when they report pain, they are complaining and bothering the nurses, but reporting pain helps us to know how to treat your pain. Are you comfortable with telling me you are in pain?” “What does pain mean to you? What are your preferences for managing pain?”

“Many patients find it comforting to pray or participate in spiritual activities when they are in pain. Tell me about any spiritual beliefs related to pain that I should consider in caring for you. Would you like to include any spiritual practices in your plan of care?” Discuss the role of pain control in helping the patient accomplish these functional and quality of life goals. Nurses may want to use the Functional Pain Scale to assess the impact of pain on function.101 “Mrs. Jones, “It is rarely possible to be pain free (zero pain), but we care about pain and will do everything we can to control your pain so that you can remain mobile and functional with relative ease. Please let me know what more I can do to help you feel better” Explain and provide a copy of the Pain Care Bill of Rights and explain each item. Teaching should be done on a level congruent with patient’s literacy level. http://www.caringinfo.org/i4a/pages/index.cfm?pageid¼3513 Only offer example words when the patient is unable to describe pain in their own words. Older African Americans prefer the FPS-R and a longer NRS scale (0e100). Explanation of the FPS-R: “These faces show how much a person can hurt. As you move left to right, the faces show increasing pain [point to each from left to right]. This first face [point to left-most face] shows no pain, while this last face [point to right-most face] shows unbearable pain. Point to the face that describes how much you are hurting right now” Make pain documentation visible in an accessible location for the whole health care team to review. Nurses are encouraged to document “report of” pain instead of “complaint of” pain; this strategy is more objective. Also document patient’s preferred pain terminology. “Mrs. Jones, I brought you a note pad and a pen if you would like to write down your pain severity ratings and medications. We could also write this on your white board. You don’t have to do either, but may be helpful in deciding which treatments you would like.” Nurses should provide a wide pen with a cushioned grip device for easy holding and manual manipulation for patients with painful hand conditions, such as osteoarthritis.

management through promotion of the recently developed “SPEAK UP: About Your Pain” initiative.37 Patients’ role: self-report Self-report is an essential patient role in pain assessment, and it is recognized as the single most reliable indicator of the patient’s pain and the gold standard for pain assessment.38 While seemingly simple, pain self-report is a complex process,39 and older African Americans may be reluctant or unable to report pain due to cognitive impairment, aphasia, intellectual disabilities, and cultural beliefs, and this contributes to assessment difficulties. Nonetheless, older adults with mild-moderate cognitive impairment should be provided the opportunity to self-report pain since research shows that most are able to provide self-report of pain.10 Inconsistency in verbal communication of pain and their recording on a pain scale may suggest the need for other approaches. A discussion of approaches to assess pain in those with questionable ability to selfreport is beyond the scope of this paper (other articles discuss this issue, Paulson et al, 2014,40 Herr, 201141). Self-report is obtained directly from the patient, and consists of 1) articulation of pain, 2) appraisal of pain intensity and impact, and 3) self-documentation.

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Articulation of pain African Americans’ verbal communication style is dynamic and expressive, especially in close social settings where it often consists of a louder tone33 and variations in voice inflection. The opposite may be true when in clinical settings where they may be less expressive in an effort to prevent being stereotyped as loud, aggressive, angry, or psychotic.28 Consequently, older African Americans in pain may appear stoic, underreport and delay reporting pain,42 and feel less inclined to disclose or initiate selfreport of pain.43 Although the accepted clinical definition of pain is: “Pain is whatever the experiencing person says it is, existing whenever he/ she says it does,’’44 it is important to recognize that “pain may also be whatever the person does not say it is.”34 For example, alexithymia in pain, which is the lack of words and difficulty identifying and describing one’s feelings, is common in African Americans,45 and consequently, African Americans use fewer words and more nonverbal communication than verbal messages.46 Recent research corroborates that non-White nursing home residents were less likely to report or show signs of pain compared to White residents.47 Therefore, health care providers’ attention to nonverbal reactions to pain inquiry, such as head nods, use of hands to signify yes/no, facial expressions, requests for rest, and limited movement and activity is critical. These examples remind health care providers to be sensitive to variations in communication styles and recognize that reporting and discussing pain may be unacceptable or difficult within some cultures.48 Specific reasons for underreport of pain are related to past discriminatory health care treatment or inadequate pain management, negative perception of reporting pain, distorted perception of the ideal patient, and feeling uncomfortable reporting pain to persons perceived to have higher professional and social status. Studies show that African Americans fear rejection, not being believed, and being negatively labeled as malingering or drugseeking by family, friends, and health care providers if they report or continually talk about their pain.49e51 Many older African Americans have a pre-conceived notion of the ideal patient as one who refrains from bothering health care providers in order to be viewed as the “good” or “perfect” patient.31,49,52,53 Like so, older African Americans may perceive that communicating pain is complaining of pain, when in fact it is reporting pain. Historically, older African Americans were taught to be strong, endure the pain, avoid complaining or talking about pain and not to be “worrisome” or “needy”; that is, “be seen and not heard.” Such beliefs likely arose from family and church teachings54 to be strong55,56 because in African American culture expressing pain is a sign of weakness.33 For that reason, older African American patients may bear pain privately based on the belief that talking about it gives “power” to the pain experience and increases the intensity of the pain. This illustrates the psychological impact of pain49; and refrain from talking or reporting pain distracts the mind from the physical pain. Health care providers may elicit a better pain self-report response from older African Americans if they provide a clear explanation of the difference between complaining about pain and reporting pain, by communicating that reporting pain accurately is not viewed as complaining, but helps inform providers’ decision making in treating pain. African Americans are also more likely to underreport pain to an individual perceived as being of higher professional and social status, such as a physician or nurse.57 In fact, African Americans view the health care provider as a stranger in the initial meeting, and this feeling may continue if there is a subsequent lack of rapport between the two.28 African American patients may envision health care providers’ assessment of pain as a “test” and feel obliged to report a socially desirable intensity in order to remain

the “good” patient. This is detrimental because it leads health care providers to underestimate and discount the true magnitude of pain.6 The difference in communication with family/friends as compared to higher status individuals is referred to as “codeswitching”58 or “dialect-shifting”59 whereby people use alternating grammatical systems. For example, African Americans may communicate amongst each other using ‘Black dialectal stylistics,’ but when speaking to a health care provider (i.e., someone of high education and power), they may attempt to use more refined (or socially and grammatically correct) English. Cultural and language differences (e.g., cultural word choices for pain, verbal fluency) impact pain assessment,43 and underscores the importance of understanding older African Americans’ pain terminology. Unconscious or conscious bias exists against African Americans who speak African American English (AAE), such as Black English (Ebonics), Gullah/Geechee, pidgin, and Creole, because these dialects are perceived to be inferior to standard American English.33 “As a result, many African Americans are misunderstood, misinterpreted, and often viewed as uneducated. Conflicts in communication may hinder the providerepatient/family relationship and prevent effective cultural encounters.”28(p228) Intensity appraisal Health care providers often ask patients to rate the intensity of pain using a 0e10 numeric pain scale; however, some patient populations find it difficult to reduce the experience of pain to a single number.60,61 In fact, some African Americans believe that a numeric pain rating is meaningless because an uni-dimensional number inadequately reflects the multidimensional pain experience50; hence, older African Americans preferred more comprehensive assessments and extended scales, such as the 0e100 pain scale (e.g., Box-21 scale).62 When pain is reported by older African Americans, the intensity is consistently higher than intensities reported by Caucasian Americans.63e66 When verbal descriptors are used to describe pain intensity and quality, patients’ preferred pain terminology are to be documented and used consistently.67 In general, older adults may use words such as “hurt,” “ache,” “sore,” “stiff,” or “discomfort” rather than the word “pain.”68 Studies have repeatedly shown that African Americans across the lifespan use a common set of pain descriptors which include: “aching,” “tiring,” “exhausting,” “sharp,” “stabbing,” “tender,” “throbbing,” “nagging,” “pulling,” “terrifying,” “miserable,” and “hurt.”29,69e72 Other ethnic-specific pain descriptors include “miseries” (or misery),31 “paining,”73 “jooking,”74 as well as lesser-known words such as: “keen,” “drawing,” “feeble,” “writhing,” “ailing,” and “worrisome.” Older African Americans also use metaphors, euphemisms, idioms, similes, and stories to convey pain. For example, “body wracking with pain” describes intense widespread physical and/or emotional pain, “sap is rising” describes increasing pain, and pain as a “thorn in the flesh” describes persistent, nagging, and bothersome pain. Self-documentation Self-documentation, especially within acute care, is rarely used or encouraged. However, in light of the current emphasis on patient-centered care, self-documentation might be a mechanism that would allow patients to be more active in their care. While African Americans were able to complete pain diaries,61 there have been concerns that pain diaries may look like a test.13 Researchers suggested that the pain diary be constructed to look more informal and non-threatening.13 Health care providers can, however, educate and encourage older African American patients to use tools such as diaries or logs to record their pain levels, associated events, and treatments. These can then be shared with the health care provider to identify trends, evaluate the

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effectiveness of the current treatment plan, and determine whether or not adjustments are necessary. For older African Americans unable to self-document, health care providers can use a simple white board to write the patient’s pain intensity at initial and subsequent assessments. Considering that African Americans appreciate visual depictions,75 a white board allows them to visualize their pain trends and evaluate which pain treatments are effective and which are not. Providing a visual like this will reinforce to patients that the health care providers are committed to providing the best possible pain control. Permission from patients is needed to publicly display their pain level, considering that some may not want others, such as family or visitors, to know they are in pain or the intensity of their pain. Health care providers’ role: screening Screening for pain consists of 1) inquiry, 2) intensity measurement, and 3) documentation (see Table 1), and anyone on the health care team can be trained to perform a pain screening.76 In other words, pain screening may be done by nurses, nursing assistants, and other health care providers. Although unlicensed staff cannot perform a comprehensive pain assessment, nursing assistants in some institutions are trained to ask patients to rate their pain intensity using a numerical pain rating scale (e.g., 0e10), document it in the care tracker, and promptly report the pain rating to the primary nurse who will follow up with a thorough assessment, if indicated. Inquiry An initial step in pain assessment is to obtain self-report by simply asking patients if they have pain, but research shows that health care providers are less likely to ask African Americans about their pain.56,77 Furthermore, many patients do not provide information about their health unless they are asked, warranting health care providers to intentionally ask about pain and also reinforce the importance of providing accurate self-report of pain and explain the consequences of unrelieved pain. Unless this is done, self-report may be “fools gold”78 in older adults since they are less vocal about their pain and may deny pain.41 Likewise, Herr and Garand67 recommend, “After denial of pain, a reworded question such as ‘Do you hurt anywhere?’ or ‘Are you uncomfortable?’ is important to verify the absence of discomfort.” (p461) Intensity measurement Pain measurement tools such as the 0e10 NRS and verbal rating scale (VRS) are common in clinical practice. But the selection of the appropriate pain assessment approach and tool varies depending on a patient’s unique characteristics,79 necessitating institutions to have available a variety of pain tools appropriate for age, health status, and culture.80 A number of older African Americans may have limited education and familiarity with assessment tools, and this could impact the accurate reporting of pain. One strategy to promote culturally-responsive assessment of pain is to utilize valid and reliable pain measurement tools granted that patients may have difficulty using a pain tool that is inconsistent with their cultural beliefs.60 However, there are significant gaps in best practices for pain assessment using self-report pain measurement tools in ethnically diverse older adults.81 The task of identifying culturally-preferred assessment tools was undertaken by Stuppy82 who discovered that older African Americans preferred the Faces Pain Scale (FPS). Other research confirms that both cognitively intact and impaired older African Americans prefer the FPS-revised (FPS-R) compared to the Verbal Descriptor Scale (VDS), the Numeric Rating Scale (NRS), and the Iowa Pain Thermometer (IPT).43,83,84 African American children also prefer a faces-based

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assessment tool,85 further suggesting a common African American cultural thread in a preferential assessment tool. African Americans’ preference for a face-based pain tool is likely due to their cultural orientation which involves invocation of emotions, nonverbal communication, and demonstrative facial expressions to convey feelings.28,33 Because low correlations between the FPS and FPS-R with other scales have been reported in several studies,43,83,84,86 some posit that faces-based tools may measure a more extensive construct beyond pain.84 Perhaps, this another reason why African Americans prefer the FPS and FPS-R because they symbolize multiple dimensions of pain such as mood and distress as opposed to pain intensity only; this is the multidimensionality of pain conveyed by African Americans.50 Pain measurement tools are sometimes ineffective because these tools have predetermined norms that prevent patients from describing pain in their own words.87 Health care providers may want to ask patients to describe the intensity and quality of pain in their own words, and offer prompts of general categories of pain intensity (e.g., mild, moderate, severe, or unbearable) only if the patient is unable to find the words to describe it. This method of pain assessment is referred to as a non-elicited verbal pain language assessment because it uses open-ended or semi-structured questions to elicit a more descriptive response.87 One research study found that when African Americans were allowed to individualize the VRS by arranging the pain descriptors in order of their perceived increasing magnitude, there was no significant effect in pain intensity as compared to a significant effect using the standard VRS.88 This example illustrates the need for reliable and valid pain assessment tools. Documentation Documentation of pain is a critical component of pain assessment and management and serves as a record of care that highlights health care providers’ decision-making and yields data for performance improvement and pain disparities projects. Although health care providers report assessing pain, chart records do not always reflect this.89 In fact, ethnic minorities, such as African Americans, are less likely to have a pain score documented.23,90 A recent retrospective study found discrepancies between the numeric pain intensity documented in the electronic medical record and numeric pain rating reported on a survey completed by African Americans.91 Documentation of pain assessment includes: an accurate intensity, location, duration, quality, aggravating and alleviating factors, pain behaviors, patient’s preferred pain terminology and pain tool, goals for management, cultural pain beliefs, interventions, and patient/family education. Implications for practice, education, policy, research Pain assessment remains an ongoing issue in clinical practice, with numerous implications for practice, policy, research and education. Although this paper focuses on older African Americans, some recommendations can be applied across the African American adult lifespan and to other racial and ethnic minority populations. Given documented disparities in populations such as Hispanic/ Latino Americans, Asian Americans, and American Indians, understanding their unique needs and characteristics and developing population-specific recommendations are needed. Practice One way to become more culturally-competent and culturallycomfortable is to have health care providers evaluate their capacity to care for African Americans by using the Model for Culturally Competent Care for African Americans,46 and understand,

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implement, and adhere to culturally and linguistically appropriate services (CLAS) standards in patient care http://minorityhealth.hhs. gov/templates/browse.aspx?lvl¼2&lvlID¼15.92 Culturally specific practice implications and theories that inform our understanding and development of pain interventions for African American will, in return, encourage greater patient engagement in patient care. At the very least, it is essential that general evidence-based guidelines for pain management in older adults be implemented for all patients regardless of race and ethnicity.93,94 Education It is essential that health care providers understand how to respond to the pain needs of culturally diverse patients in a culturally-responsive and sensitive manner. Health care providers are challenged to become educated and educate others (i.e., students, colleagues, caregivers). This calls for a concerted effort to ensure that more content on pain in diverse racial and ethnic cultures is taught by incorporating the recently endorsed national pain management core competencies into curriculums.95 Several core competencies identify pain assessment and management skills related to pain in diverse cultures. Although there are training programs available regarding pain in older adults, there are limited programs focusing in pain in culturally diverse populations. For those interested in learning more about pain in older adults in general and pain in diverse older populations, and African American older adults, here are a few resources, Geriatric Pain http://www.geriatricpain.org/Pages/home.aspx,96 Tufts University course on ethical and sociocultural aspects of pain http:// publichealth.tufts.edu/Academics/MS-Pain-Research-Educationand-Policy/MS-PREP,97 and Stanford School of Medicine https:// geriatrics.stanford.edu/ethnomed/african_american.html.98 Policy One approach to address the disparity in pain assessment in acute care, primary care, and long-term care in older African Americans involves health care providers engaging in advocacy work that ensures that pain management regulatory standards are not only met, but exceeded. Another step involves a deliberate effort to engage African American and Black health care providers in leading practice and policy boards to develop standards and protocols that meet the needs of African Americans. This would be responsive to the IOM’s Future of Nursing Report recommendation that health care providers [nurses] lead improvement initiatives.99 Moreover, pain assessment disparities may be lessened by integrating screening programs similar to the preventative screening campaigns promoted in the Affordable Care Act. Evidence of disparities in pain assessment must be shared at national health policy hearings, meetings and organizations, showcasing a greater focus on ways to reduce health disparities and improve health outcomes.100 Research Last, but certainly not least, there remains a great need for research to advance the understanding of culturally-responsive pain assessment in older African Americans. First, researchers are highly encouraged to include more older African Americans in research. There is also a crucial need to identify specifically what older African Americans’ deem important to acute and chronic pain assessment and management, in addition to further research on pain measurement and biopsychosocial barriers and facilitators in this population. Not much is known about acute care pain management for older African Americans, placing them at higher risk

for underassessment and treatment in inpatient settings. It is our duty to conduct ethical research with older African Americans in order to advance quality pain care. Conclusion Pain assessment is the first step in providing effective pain management with older African American adults. While pain assessment in older adults requires time and patience, health care providers are obliged to ensure that pain is assessed during the first patient encounter and frequently during care. This process is made easier when health care providers have an understanding of older African Americans’ cultural beliefs. Health care providers can meet their moral, ethical, and professional obligation to advocate for older African Americans when they focus on providing pain control that maximizes function and quality of life outcomes in this highrisk population. Nurse scientists can engage with older African Americans by conducting needed research to improve their quality of pain care and quality of life. Acknowledgments Ms. Booker is a 2013e2015 National Hartford Center of Gerontological Nursing Excellence Patricia G. Archbold scholar. The authors are thankful for Dr. Pao-feng Tsai’s review of this manuscript. References 1. Buck HG, Meghani SH. Spiritual expressions of African Americans and Whites in cancer pain. J Holist Nurs. 2012;30(2):107e116. 2. Bernabei R, Gambassi G, Lapane K, et al. Management of pain in elderly patients with cancer. J Am Med Assoc. 1998;279(23):1877e1882. 3. Burgess DJ, Gravely AA, Nelson DB, et al. A national study of racial differences in pain screening rates in the VA health care system. Clin J Pain. 2013;29(2): 118e123. 4. Chibnall JT, Tait RC. Racial/ethnic disparities in the assessment and treatment of pain: psychosocial perspectives. Am Psychol. 2014;69(2):131e141. 5. Green CR, Anderson KO, Baker TA, et al. The unequal burden of pain: confronting racial and ethnic disparities in pain. Pain Med. 2003;4(3):277e294. 6. Staton LJ, Panda M, Chen I, et al. When race matters: disagreement in pain perception between patients and their physicians in primary care. J Natl Med Assoc. 2007;99:532e537. 7. Won A, Lapane K, Gambassi G, et al. Correlates and management of nonmalignant pain the nursing home. J Am Geriatr Soc. 1999;47(8):936e942. 8. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington: National Academies Press; 2011. 9. American Geriatrics Society. The management of persistent pain in older persons. J Am Geriatr Soc. 2002;50(S6):S206eS224. 10. American Geriatrics Society. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57(8):1331e1346. 11. Cavalieri TA. Management of pain in older adults. J Am Osteopath Assoc. 2005;105(3, suppl 1):S12eS17. 12. Alpers LM, Hanssen I. Caring for ethnic minority patients: a mixed method study of nurses’ self-assessment of cultural competency. Nurse Educ Today. 2013;34(4):999e1004. 13. Lasch KE, Wilkes G, Montuori LM, et al. Using focus group methods to develop multicultural cancer pain educational materials. Pain Manag Nurs. 2000;1(4): 129e138. 14. Wandner LD, Stutts LA, Alqudah AF, et al. Virtual human technology: patient demographics and healthcare training factors in pain observation and treatment recommendations. J Pain Res. 2010;3:241e247. 15. Wandner LD, Scipio CD, Hirsh AT, et al. The perception of pain in others: how gender, race, and age influence pain expectations. J Pain. 2012;13(3): 220e227. 16. Trawalter S, Hoffman KM, Waytz A. Racial bias in perceptions of others’ pain. PLos One. 2012;7(11):e48546. 17. Kaseweter KA, Drwecki BB, Prkachin KM. Racial difference in pain treatment and empathy in a Canadian sample. Pain Res Manag. 2012;17(6):381e384. 18. Drwecki BB, Moore CF, Ward SE, et al. Reducing racial disparities in pain treatment: the role of empathy and perspective-taking. Pain. 2011;152: 1001e1006. 19. Sullivan MJ, Scott W, Trost Z. Perceived injustice: a risk factor for problematic pain outcomes. Clin J Pain. 2012;28(6):484e488.

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