Health & Medicine
August 12, 2020

Pain care: The role of social class on nurses’ patient management

Research on social disparities in pain care has so far mainly been focused on issues such as racism and sexism in the way healthcare professionals assess and manage patients’ pain. Professor Sónia Bernardes of Iscte-Instituto Universitário de Lisboa, Portugal, is interested in how social class impacts nurses’ care and attitudes toward their patients. The research she and her associates conduct seeks to understand the role of ‘classism’, that is, class-based inferences regarding a person’s social status. These inferences can create differences in the behaviour and actions of nurses when caring for patients from a lower socioeconomic background compared to those from higher socioeconomic groups.

Chronic pain is a huge, but often invisible burden to many patients and their families. Previous studies show that certain groups are of higher risk for developing chronic pain during their lifetime – among these are women, elders, minorities, unemployed and individuals with low educational levels and household incomes, revealing that there is a social component to this issue. While many research projects have focused on racism and sexism in pain assessment and management, classism has received much less attention.


The aim of the project SOS_Pain is to understand the role of patients’ social status on nurses’ pain assessment and management practices. Classism can be understood in a similar way to racism, sexism, or disablist attitudes; it stereotypes and discriminates against individuals and groups according to their perceived social class. These perceptions regard them as having certain attributes. In the case of classism, the stereotyping categorises people according to their social and economic status (SES).

Sónia Bernardes, Principal Investigator of the project and Professor at Iscte-Instituto Universitário de Lisboa, Portugal, and her colleagues have sought to improve understandings of this issue, which have been scarce and inconsistent. Some evidence has shown that physicians hold negative views toward lower-SES patients, who they perceived to be demanding, while other studies have not shown clear differences in attitudes toward low-SES patients. This uncertainty calls for further research, and because nurses are central figures in providing patient care, the research team focuses on nurses’ pain assessments and management of low-SES patients.

Women, elders, minorities and individuals with low educational levels and household incomes are at increased risk of developing chronic pain during their lifetime. Paul Hakimata Photography/

Perceptions of lower-SES groups
A well-documented phenomenon in social psychology demonstrates that perceptions of lower-SES groups are more dependent on contextual cues than are higher-SES groups. For example, patients of high SES are more likely to be immune to assessments based on either the presence of distress caused by pain, or by the absence of pathology evidence, such as test results. In other words, this suggests that patients from lower-SES groups are assessed differently, due to their perceived status, depending on the presence of distress or absence of pathology evidence. Higher-SES patients are less likely to have their pain undervalued, while lower-SES patients are more likely to be assessed as less able to cope with pain, and therefore more frequently assigned to psychoeducation.

In the presence of pathology evidence, the higher-SES patient was regarded as having more intense pain than the lower-SES patient.

Whose pain is credible?
To test these notions relating to nurses’ attitudes based on patient SES, two experimental studies were conducted. One study was to test patient SES and distress, and the second to test patient SES and evidence of pathology; the aim being to assess the effects of SES on nurses’ pain assessment and management. Nurses were given four vignettes to read that all depicted a white female with lower back pain. The vignettes presented the woman as having either a low school educational attainment, or a doctorate, and she either worked in a factory, or was a judge. She goes to an emergency room where she is either portrayed as agitated or calm, while waiting to be seen. An accompanying video also depicted the patient completing a pain-inducing activity such as lying on a bed and standing up. The outcome of this test revealed that nurses slightly underestimated the pain of the patient they perceived to be low-SES compared to the patient perceived as high-SES patients, and the former’s pain was more attributed to psychological factors, rather than physical factors. In the presence of distress cues, low-SES women’s pain was considered less credible than high-SES patients’ pain.

The aim of SOS_Pain is to understand the role of patient social status on nurses’ pain assessment and management practices.

Discrimination due to classism can impair nurses’ attitudes toward the patient and, for example, reduce feelings of empathy. PHTGRPHER_EVERYDAY/

A second study, similar to the first one, had an additional paragraph which depicted the female patient, who could be perceived as high-SES or low-SES, as having had an X-ray, a CAT scan and an MRI, which either showed evidence of a herniated disc, or no evidence of a herniated disc. The patient who was perceived as higher-SES was regarded as having more intense pain than the low-SES patient.

The two studies showed that perceptions of patient SES influenced nurses’ pain assessments; in the presence of evidence of pathology such as the X-ray, nurses judged the pain as more intense and attributed it less to psychological factors for higher-SES patients. However, the studies did not confirm that nurses’ management of patients’ pain was affected, perhaps indicating that biases do not impact the actual treatment behaviours of nurses, such as the advice they give to patients. The findings imply that a patient with high SES is protected from the negative effects of pain credibility judgements; therefore, nurses are more likely to take their pain seriously.

Assessment of pain severity can be difficult to judge as it relies on effective communication between patient and nurse. Rocketclips, Inc./

Long-term impacts
Nurses’ assessments and management of pain and their attitudes toward patients can have long-term impacts due to patients’ close contact with nursing staff when they are experiencing chronic pain. It is, therefore, important to understand nursing staff’s perceptions of patients’ SES, which can trigger classism that then shapes their assumptions about the patient and their pain. Assessments of pain severity can be particularly difficult to judge, as they rely on effective communication between the patient and nurse. The role of classism and its potential for discrimination can impair nurses’ attitudes toward patients, reducing feelings of empathy and influencing patient care. Particular groups of people may be considered to be less human than others. This dehumanisation perceives them as passive and lacking higher-order reasoning, impacting how their pain is assessed. When dehumanisation and the associated negative attribution of traits occur, those from lower-SES groups may be blamed for their pain, and their unique humanness devalued.

The studies did not confirm that nurses’ biases due to classism had any impact on their treatment behaviours. antoniodiaz/

The imagination and classism
In another study, nurses’ imaginative responses were examined as a means of understanding the class-based inferences they might make about the women portrayed. As there is a higher prevalence of female patients with chronic pain, and in Portugal – where the study was conducted – the majority of nurses are also female, only female nurses were invited to take part. The nurses watched short videos featuring two women in pain, who carried out pain-inducing movements such as lifting a box; one woman could be perceived as being low-SES and the other as being middle-SES. The nurses were asked to write a short story about the women in which they should attribute each a profession and describe how pain affects their life. Frequently used words in the stories were analysed for their attributions of class-based inferences.

Nursing staff’s perceptions of patients’ SES can trigger classism that then shapes their assumptions about the patient and
their pain.

Overall, the nurses’ depictions attributed simpler definitions to the low-SES woman that were mainly negative, assigning her a restricted range of emotions, having less adaptive coping strategies, and limited competence. The middle-SES woman was mostly presented as autonomous and using coping strategies for her pain. Psychoeducation – providing information regarding pain and pain management strategies – was only prescribed to the low-SES patient, although other treatment recommendations were the same for both women. Using these imaginative exercises helped researchers to explore the complex role classism has in healthcare. In the case of the two women, the middle-SES patient was seen as having agency and a future, while the low-SES woman was regarded as needing rehabilitation, education and training.

The researchers were able to demonstrate that the pain lower-SES patients experience is more often attributed to psychologicial causes and, in turn, psychoeducation is prescribed.

Classism and pain management
These innovative studies provide insight into the role of classism in pain assessment and management and can help to improve clinical practices through ensuring social equity in pain care. Health professionals should provide patient-centred care; however, the inferences they make, such as perceiving low-SES patients as having limited competence, influence the support they provide. The dehumanisation of patients denies human traits like rationality and competence and this undermines communication, limits shared decision-making, and tends toward paternalistic approaches.

Research relating to classism and dehumanisation has been lacking in health-related contexts, and the research conducted by Prof Bernardes and colleagues demonstrates that the pain of patients from lower SES is more often attributed to psychological causes. The work of the research team is helping to address this gap, and it highlights that further study is needed in order to comprehend the ways in which classism impacts clinical practices. Promoting social equity in pain care is significant in ensuring patients are treated fairly, as the dehumanisation of patients infringes their rights to autonomy and informed decision making.


Personal Response

How can your findings be used to improve nursing care and practices?

<> These findings can be used to raise nurses’ awareness for the potential detrimental role of classism and dehumanisation processes in their pain assessment and management practices. Nurses will be better able to prevent class-based disparities in pain care by acknowledging that: (1) classism and dehumanisation are everyday, pervasive and often automatic processes that occur in interpersonal interactions in general, and clinical encounters in particular, and (2) there are socially shared class-based belief systems regarding pain and pain care.

This feature article was created with the approval of the research team featured. This is a collaborative production, supported by those featured to aid free of charge, global distribution.

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