Chapter 4 – Pain Assessment
Racism and Pain Assessment
Racism is killing people, and the silence around racism is killing people (Jones, 2021).
Some Canadians, including leaders, are beginning to recognize racism as real, present, and as a public health issue, but many remain silent on the issue and deny the presence of systemic racism in Canada and in healthcare.
Systemic racism includes processes embedded in practices and policies that disadvantage and oppress non-dominant racialized groups (Williams et al., 2019). Social institutions perpetuate racial hierarchies and socialize members of society to accept that non-dominant racialized groups are inferior (Williams et al., 2019). Racism, such as anti-Black racism, affects non-dominant groups from birth to death, and is evidenced in Canadian healthcare by the disparities affecting non-dominant racialized groups (Dryden & Nnorom, 2021).
Some examples to reflect upon:
- Disparities are visible through elevated risks of prematurity and low birthweight, lower income, and lack of access to education, resources, and opportunities for non-dominant racialized groups – all affecting their health and well-being (Williams et al., 2019).
- The stress of racism is very real. It is a vicious circle that perpetuates racial inequities negatively affecting mental and physical health in many ways for nondominant racial groups (Levy et al., 2013).
- A specific example is research funding. Cystic fibrosis mainly affects white people and receives 7–11 times more funding than sickle cell disease, which mainly affects Black people with sub-Saharan African ancestry (Power-Hays & McGann, 2020). This is a clear example of systemic racism: sickle cell disease affects substantially more North Americans, but receives substantially less research funding.
- Some racism is blatant (verbal slurs), but it is also important to consider subtle racism, such as a healthcare professional’s overuse of medication as a restraint or way to control a client.
It is essential to keep in mind that racial disparities can NOT be explained by biological differences (Dryden & Nnorom, 2021). Yet, racism – and accompanying ideas about biological differences – continues to be systemically engrained in healthcare practices and perpetuates inequities. This includes practices surrounding pain assessment and pain management. Racism and systemic inequities have led to undiagnosed pain in non-dominant racialized groups (Morais et al., 2022), including sub-optimal and even catastrophic outcomes for Black people when their pain is not believed or recognized (Akinlade, 2020). Racism and inequities in pain assessment and management is clearly manifested in the treatment of Black clients with sickle cell disease (Power-Hays & McGann, 2020). Pain among this population is often dismissed, leading to reduced quality of life and increased mortality rates: Black people describe being labelled as drug seekers when reaching out for pain management and purposefully dressing nicely before seeking help to minimize racist attitudes (Power-Hays & McGann, 2020).
These general racist attitudes contribute to racialized disparities in pain assessment and pain management (Morais et al., 2022). Additionally, long-held myths and stereotypes that Black people are subhuman were historically used to justify slavery, and these beliefs have also led to pain practices that are clearly not evidence-based.
Reflect on the following examples:
- Hoffman and colleagues (2016) discuss the false and dangerous belief that Black people are different biologically (e.g., thicker skin, fewer nerve endings) and thus, feel less pain. This will lead to an inaccurate assessment of pain and also to disparities and inequities in pain management (Hoffman et al., 2016).
- Another example highlights the existence of racial bias in pain perception. In a multi-stage experiment, participants were shown a series of Black and white faces in pain. The researchers found that white participants had more stringent thresholds to perceive pain on Black versus white faces and would perceive pain earlier on white versus Black faces (Mende-Siedlecki et al., 2019). In addition to affecting assessment practices in terms of observations, this effect is likely to result in Black clients being provided less medication, or to be given non-narcotic pain medication, compared to white clients who often receive narcotic pain medications (Mende-Siedlecki et al., 2019).
- Another study found that Indigenous clients in Canada reported feeling judged by healthcare providers and reporting discrimination when in pain or requesting medication for conditions involving chronic pain (Nelson & Wilson, 2018). This kind of experience has negative effects on the quality of care that Indigenous clients receive, and may result in them choosing not to access needed services.
- Another example of anti-Indigenous racism involves Joyce Echaquan, an Atikamekw client in Quebec. She had gone to the emergency room for stomach pain and described being overmedicated by healthcare providers (APTN News, n.d.). The coroner concluded that systemic racism played a role in how Joyce was treated and in her death (Richardson, 2021). This case highlights the importance of individualized pain assessment and listening, believing, and responding to the client.
These are just some of many examples of systemic racism that the nursing profession must challenge. It is important to recognize that pain in non-dominant racialized people may go undetected, undiagnosed, untreated, and undertreated. Moreover, these individuals may be fearful to seek out healthcare services because of past treatment and . Many Black and Indigenous people fear hospitals due to the stigma and institutionalized racism they face.
When assessing pain, healthcare providers must be aware of and remain sensitive to racism. When we see racism, we need to name it. It’s killing people. We need to speak up. Have a discussion. Act and advocate. Advocating takes courage. Start with reflecting and having conversations with others. Voice what you are seeing and collaborate with others to challenge racism.
Clinical Tip
Always remember: pain is what the client tells you it is.
This is important for all nurses and healthcare professionals to recall because people hold unconscious biases without evidence to support them. A beginning place for change is to identify and sit with your bias – even if you believe people from all races are equal, you may still have bias (Akinlade, 2020).
Anti-racist training can help you understand and address your biases, understand how privilege (such as white privilege) perpetuates pain inequities in care, and learn how to take a critical perspective in your practice (Morais et al., 2022). In fact, anti-racist training can help you understand more than just privilege related to race, but other types of privilege too. In addition to recognizing each other’s humanity, we must advocate against racist practices including pain assessment. Remaining silent in the face of racism is the “sound of privilege”, and with racism – “silence is loud” (Jones, 2021, p. 5).
Activity: Check Your Understanding
References
Akinlade, O. (2020). Taking Black pain seriously. The New England of Journal of Medicine, 383(1), 68. https://doi.org/10.1056/NEJMpv2024759
APTN News (n.d.). Joyce Echaquan. https://www.aptnnews.ca/topic/joyce-echaquan/
Comas-Diaz, L., Hall, G., Nevilled, H., & Kazak, A. (2019). Racial trauma: Theory, research, and healing: Introduction to the special issue. American Psychologist, 74(1), 1-15. https://doi.org/10.1037/amp0000442
Dryen, O., & Nnorom, O. (2021). Time to dismantle systemic anti-Black racism in medicine in Canada. CMAJ, 11(193), 55-57. https://doi.org/10.1503/cmaj.201579
Hoffman, K., Trawalter, S., Axt, J., & Oliver, M. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences of the United States of America, 113(16), 4296-4301. https://doi.org/10.1073/pnas.1516047113
Jones, B. (2021). The loud silence of racism: It is killing us all. The American Journal of Bioethics, 21(2), 4-6. https://doi.org/10.1080/15265161.2020.1864107
Levy, J., Ansara, D., & Stover, A. (2013). Racialization and health inequities in Toronto. Toronto Public Health. www.toronto.ca/legdocs/mmis/2013/hl/bgrd/backgroundfile-62904.pdf
Mende-Siedlecki, P., Qu-Lee, J., Backer, R., & Van Bavel, J. (2019). Perceptual contributions to racial bias in pain recognition. Journal of Experimental Psychology: General, 148(5), 863-889.
https://doi.org/10.1037/xge0000600
Morais, C., Aroke, E., Letzen, J., Campbell, C., Hood, A., Janevic, M., Mathur, Merriwether, E., Goodin, B., Booker, S., & Campbell, L. (2022). Confronting racism in pai research: A call to action. The Journal of Pain, 23(6), 878-892. https://doi.org/10.1016/j.jpain.2022.01.009
Nelson, S., & Wilson, K. (2018). Understanding barriers to health care access through cultural safety and ethical space: Indigenous people’s experiences in Prince George, Canada. Social Science & Medicine, 218, 21-27. https://doi.org/10.1016/j.socscimed.2018.09.017
Power-Hays, A., & McGann, P. (2020). When actions speak louder than words–Racism and Sickle Cell Disease. New England Journal of Medicine, 383, 1902-1903. https://doi.org/10.1056/NEJMp2022125
Richardson, L. (2021). Would Joyce Echaquan still be alive if she were white? Quebec coroner says ‘I think so.’ APTN News. https://www.aptnnews.ca/national-news/would-joyce-echaquan-still-be-alive-if-she-were-white-quebec-coroner-says-i-think-so/
Williams, D., Lawrence, J., & Davis, B. (2019). Racism and health: evidence and needed research. Annual Review of Public Health, 40, 105-125. https://doi.org/10.1146/annurev-publhealth-040218-043750
refers to the cumulative and traumatic effects of racism and its continual reoccurrence, including psychological and physical effects (e.g., stress, nightmares, flashbacks, headaches, heart palpitations) (Comas-Diaz et al., 2019).
