Pain knowledge and personal experiences can influence clinical pain management attitudes: a cross-sectional study

Abstract

Background

Pain management is one of the important issues of health care since it affects the individual physically, mentally and socially by hindering daily activities and it is affected by individual characteristics. To investigate the association of nursing students'pain experiences and knowledge levels with their clinical pain management attitudes.

Methods

This descriptive cross-sectional study included 245 nursing students. Research data were collected between February and June 2022 in the nursing department of the State University Health Science Faculty in Central Anatolia/Türkiye. Data were collected using a questionnaire form that comprised three sections, ‘Demographic and pain characteristics of students,’ ‘Pain knowledge of students,’ and ‘Clinical pain management attitudes.’

Results

The mean age of students was 20.6 ± 1.61 years, 65.7% of students were female and 58.8% resided in student dormitories. In general, students achieved a poor score (7.72 ± 3.01) on the pain knowledge test and an quite good score (21.55 ± 2.82) on the clinical pain management attitudes test. The results showed a positive and moderately significant relationship between students'socio-demographic and pain experiences and their knowledge and attitude scores. Female gender (knowledge:7.90 ± 3.01/attitude:21.85 ± 2.66), persistent pain at certain intervals (knowledge:8.06 ± 2.78/attitude:22.09 ± 2.34) and a family history of chronic disease (knowledge:7.80 ± 2.96) were associated with higher knowledge and attitude mean scores.

Conclusions

Experiencing pain at regular intervals, not wanting to perform activities requiring physical strength when in pain, and having family members treated for pain and chronic diseases positively influenced students’ pain knowledge and clinical pain management attitude scores, particularly among females. Furthermore, the knowledge scores increased for students who experienced pain due to chronic conditions and have experienced pain for longer periods and those who used pharmacological methods to manage pain. Attitude scores also increased for students who experienced pain due to stress, measured pain intensity, and used non-pharmacological methods to manage pain.

Graphical Abstract

Keypoints

Nursing students’ (NS) pain experiences on clinical pain management (PM) is unknown.

This study contributes to this gap in literature by identifying the personal experiences of NS.

The study examined the effect of personal experiences on NS’ PM knowledge and attitude scores.

In Central Anatolians, experiencing pain or disease positively influenced the scores.

Highlights

• An important gap in the literature is the impact of nursing students'own experience of pain on clinical pain management.

• Pain is a subjective experience. Nursing students will be the future leaders in clinical pain management. This study contributes to this gap in the literature by identifying the personal experiences of nursing students in relation to pain and examining the effect of these personal experiences on their pain management knowledge and attitudes.

• The results show that in the Central Anatolian region there is a statistically significant relationship between the socio-demographic characteristics and pain experiences of nursing students and their pain knowledge scores and attitudes towards clinical pain management.

• The results show that in the Central Anatolian region having people with pain and chronic disease management in the family positively influenced students'pain knowledge and clinical pain management attitude scores.

Background

Pain, which varies based on individual characteristics, is a distressing experience that affects people physically, mentally, and socially, and interferes with daily activities by reducing quality of life [20, 28]. A systematic review and meta-analysis on the prevalence of pain in developing countries (specifically, Latin American, Asian, and African countries) found that the prevalence of pain among adults ranged from 13 to 51% [36]. Regarding the Anatolian region, studies conducted across Turkey reported that the prevalence of pain among adults ranged from 64 to 93% [18]. Poor pain management is associated with increased pain risk in people with chronic conditions (such as depression, osteoporosis, arthritis, hypertension, and dementia) [12]. Studies show that acute pain management for adults in hospitals is inadequate, with 30.0–70.0% of admitted patients experiencing moderate to severe pain [10, 25, 44]. Furthermore, 44.0–86.0% of individuals with ineffective acute pain management experience long-term chronic pain [7]. Therefore, pain management is a fundamental and critical issue in health care [25]. Pain management requires multidisciplinary team care and nurses are an integral part of this team [20]. Successful pain management is particularly relevant to nursing practice as nurses play a central role in the effective assessment and management of pain in many healthcare settings [23, 29]. Therefore, nursing students who are candidates for this profession should have sufficient knowledge and skills regarding pain and how it should be assessed and managed, as they will play an active role in the pain management process [3, 17]. Consequently, nursing candidates should be well-trained in effective pain management as a priority in health care [42]. Studies measuring nursing students'knowledge and attitudes toward pain and its management have reported that their pain knowledge scores ranged from 34.0% to 67.0% [3, 22]. It was reported that students'knowledge of pain, willingness to provide pain care, and positive attitudes were significantly positively correlated,students who had experience caring for someone with pain scored higher on the pain knowledge and attitudes test [22]. As in adults, pain is common among university students, with a prevalence rate of 30–54.7% [19, 40]. Furthermore, a study of nursing students in Turkey found the incidence of pain to be 52.3%, with the highest prevalence being headache [42]. The findings of these studies indicate that nursing students attempt to manage the pain they experience while pursuing their rigorous theoretical and practical coursework [9, 42]. The success of nursing students in managing pain in clinical care is believed to be influenced by their history of correct pain management. Therefore, effective pain management that nursing students learn through educational programs is crucial for their success in managing pain in clinical care [5]. This study was based on the idea that nursing students can effectively manage their pain by possessing appropriate knowledge and attitudes toward pain management, which consequently leads to the successful management of pain in clinical situations. The current study explored how nursing students’ pain experiences and knowledge levels affect their attitudes toward clinical pain management. Furthermore, the study aimed to highlight the impact of nursing students'pain experiences on their knowledge and attitudes toward pain management based on the study results. Therefore, it is anticipated that the research will provide a new perspective for future studies and educational processes regarding pain management among nursing students. Consequently, the present study attempted to answer the following research questions:

      What are the students'pain characteristics?

• Is there an association between nursing students' knowledge of pain and their sociodemographic and pain-experience characteristics?

• Is there an association between nursing students' clinical pain management attitudes and their sociodemographic and pain-experience characteristics?

• Is there a negative or positive correlation between nursing students’ pain knowledge levels and their attitudes toward clinical pain management?

Materials and methods

Design

This cross-sectional descriptive study examined the association of nursing students' demographics and pain characteristics with the pain knowledge acquired during their education and their attitudes toward clinical pain management. The STROBE guidelines were followed while conducting this study.

Sampling and setting

Nursing students were selected from a pool of 670 students enrolled in the Nursing Department of the Faculty of Health Sciences at the university using a convenience sampling method (N = 670). The inclusion criteria for nursing students were as follows:

• (1) enrolment in the university's nursing programs;

• (2) age ≥ 18 years;

• (3) ability to gain case experience by participating in clinical practice in internal medicine and surgical diseases nursing in the second year of the nursing curriculum and gain case experience by participating in clinical practice in child health and diseases nursing and obstetrics and gynecology nursing in the third year of the nursing curriculum;

• (4) being actively involved in the hospital and participate in patient care as part of the clinical application of these courses (Internal Medicine Nursing, Surgical Disease Nursing, Child Health and Disease Nursing and Obstetrics and Gynaecology Nursing) on the dates of the study;

• (5) ability to read and understand Turkish.

The exclusion criteria for nursing students were as follows:

• (1) being in the first year in the nursing curriculum and taking only basic science courses (including anatomy, physiology, and biochemistry);

• (2) being in the fourth year in the nursing curriculum and participating in practice in public health nursing and mental health nursing in the fourth year of the nursing curriculum (because the practical parts of these nursing courses are conducted in centers that do not include clinical patient care, are not actively involved in the hospital, and participate in patient care); and

• (3) having pain for over 1 year. (As students who have experienced pain for more than one year will be categorized as chronic pain sufferers, those experiencing acute pain will be included in the study).

Power analysis was conducted using Cochran’s formula for categorical data [11]. The analysis indicated that 245 participants were required when employing p < 0.05 (95% confidence interval) criterion for statistical significance. In total, 161 females (65.7%) and 84 males (34.3%) participated in the study.

To find the sample size using Cochran's sample size formula for a population of 670, the sample size was first calculated for infinite size and then adjusted to the required size.

For infinite size;

$$\mathrm{n}_{0}=\mathrm{z}^{2}\cdot\mathrm{p}\cdot(1-\mathrm{p})/\mathrm{e}^{2}$$

e: desired level of precision, the margin of error (0.05)

p: the fraction of the population (as percentage) that displays the attribute

z: Standard error with the chosen level of confidence; the z-value, extracted from a z-table

It is considered a 95% confidence level (leading to an α= 0.05) and a ± 5% precision. From the z-tables, the value for z is 1.96. Therefore,

$$\mathrm{n}_{0}=\;1.96^{2}\cdot 0.5\cdot(1\;-\:0.5)/0.05^{2}=\;384$$

For required size;

$$\mathrm n=\;{\mathrm n}_0/1+\lbrack({\mathrm n}_0-\;1)/\mathrm N\rbrack$$

n₀: Cochran’s sample size computed using the formula for ideal sample size (n₀= 384);

N: the size of the population (N= 670)

$$\mathrm n=\;384/1+\lbrack(384\;-\:1)/670\rbrack=\;244.33\;\approx\;245$$

Ethical approval and consent to participate

This study was conducted following the Declaration of Helsinki and the Ethical Principles for Medical Research. Ethical approval was obtained from the Institutional Review Board of Eskişehir Osmangazi University, Non-Interventional Clinical Research Ethics Committee (E- 25403353–050.99–243,695/2021–185/02.11.2021). Institutional permission was obtained from the Faculty of Health Sciences of Eskişehir Osmangazi University (E- 93213427–605.01–246311/08.11.2021). Informed consent was obtained from the participants, who were informed that the data would be used for scientific purposes and would remain confidential. All methods were performed following relevant guidelines and regulations.

Data collection

Questionnaires were collected as follows:

• -Firstly, in order to identify the students who met the first inclusion criterion, a list of the names of all students from the first to the fourth year of study in the Nursing Department of the Faculty was obtained. A total of 670 students were included in the list.

• - Secondly, from this list, the students who met the third inclusion criterion were identified and 497 students were included in the list (165 students were excluded because of the first exclusion criterion and 8 students were excluded because they did not meet the fifth inclusion criterion).

• -In order to identify the students who met the fourth inclusion criterion, the lists of students who actively participated in clinical placements within the specified courses were obtained from the relevant lecturers responsible for clinical placements. A total of 292 students were included in the list (144 students were excluded because of the second exclusion criterion, 3 students were excluded because they did not meet the fifth inclusion criterion, and 58 students were excluded because their names were not included in the clinical placement lists).

• - These 292 students who met the inclusion criteria were then numbered using a random number table in Excel.

• -The selected students were contacted in a classroom environment, where they spent their free time at school outside of class hours and were personally informed about the study's aims face-to-face. If a student wished and agreed to participate in the study, a Google Forms link used to collect the questionnaires was shared with the student. A total of 260 students consented to participate in the study and the link was shared with these students. Students could not access the study questions without confirming the tab in the Google Forms link stating that they"read the informed consent for the study and agreed to participate in the study.” Therefore, students were instructed to be mindful of this issue when completing the questionnaires. Appropriate written information about the study's aim and their rights as participants were also included in the questionnaire.

• - In addition, the students were given one of the numbers from the random number table along with the link to the Google form. Students were asked to write this number in the number section that appeared after they had confirmed the tab agreeing to participate in the study while filling in the questionnaire. In this way, it was ensured that each student completed a questionnaire only once.

• -They were assured that the questionnaires would be completed anonymously and all information would remain confidential throughout the study. Furthermore, students had the opportunity to complete the questionnaire within 5 months, between February 1 and June 30, 2022, and the time required to complete the questionnaire was approximately 15–17 min.

• - Five of the 260 students were excluded on the basis that they had reported experiencing pain for a period exceeding one year in the questionnaires (in accordance with the third exclusion criterion). Due to missing data in the knowledge and attitude test, 10 students were excluded from the study.

Instruments

The survey design was descriptive, using a self-administered questionnaire specifically designed for this study based on the literature and similar studies on pain knowledge [3, 13, 16, 20, 24],Özveren, et al., 2016; [39]. A questionnaire prepared by the researcher was used as the data collection tool. The questionnaire, with 39 questions, had three parts:

• 1. First part of questionnaire: Demographic and pain characteristics of students (17 questions),

• 2. Second part of questionnaire: “Pain knowledge of students (13 questions),”

• 3. Third part of questionnaire: “Clinical pain management attitudes (9 questions)” (Table 1).

Table 1 Pain knowledge of nursing students

The full English Questionnaire is presented in supplementary material (Supplementary file 1).

The first part of the questionnaire: Demographic and pain characteristics of nursing students: In the first part of the questionnaire, 17 questions were asked to determine the sociodemographic characteristics (age, gender, and current residency) of the students, their personal experience of pain (having pain that persists at certain intervals, the duration of pain that persists at certain intervals, the body location where pain is experienced the most, the condition that causes pain, measuring pain intensity, if he/she measures the severity of the pain, he/she marks it on the Visual Analogue Scale (VAS) scale (1- no pain, 10- unbearable pain), the time with the most pain, undesirable activity during pain) and the pain experience of their family members (chronic illness in the family, the duration of chronic illness treatment in the family, family’s history of pain, and the treatment duration of pain history in the family). Four of these 17 questions, such as those on gender (female/male) and current residency (family, dormitory, single), having pain that persists at certain intervals, measuring pain intensity contained questions with a tick box option. One question about pain intensity was assessed using a VAS scale (1 = no pain, 10 = unbearable pain). Two question (chronic illness in the family, the duration of chronic illness treatment in the family, family’s history of pain, and the treatment duration of pain history in the family) contained questions with a tick box option and open-ended, allowing the students to write their answers. The remaining 10 questions were open-ended, allowing the students to write their answers (Supplementary File 1_The questionnaire).

The second part of the questionnaire: Pain knowledge of nursing students: The second part of the questionnaire contained 13 multiple-choice questions about pain management knowledge. The questionnaire was prepared based on the literature and similar studies on pain knowledge [3, 13, 16, 20, 24, 34, 39]. The 13 questions included five questions about the students'assessment of pain (questions 1, 2, 4, 5, and 13), three about the correct choice of scale when assessing pain (questions 3, 7, and 12), and five about the accuracy of analgesic use and administration (questions 6, 8, 9, 10, and 11) (Supplementary File 1_The questionnaire). The answers given to these questions were coded as “1″ if correct and “zero” if incorrect. Accordingly, the highest score obtainable is"13″ (Table 1). Modified Bloom’s cut-off points were utilized to categorize the students’ pain knowledge level [8]. The total pain knowledge scores were categorized into four levels based on modified Bloom's cut-off:"excellent,”"quite good,”"quite poor"and"poor". Therefore, knowledge scores of 11–13 (% 85-% 100) were considered as"excellent,” 8–10 (% 60-% 84) as"quite good,” 5–7 (% 40-% 59) as"quite poor"and < 5 (< % 40) as"poor"level of knowledge. In addition, the students'scores in the assessment of pain, scores in the choosing the right scale for pain assessment and scores in the usage and administration methods of analgesics were categorized based on modified Bloom’s cut-off criteria (Supplementary File 2_Modified Bloom’s cut-off categories).

Content validity of the second part of the questionnaire: Expert opinions were obtained for the Content Validity Index (CVI) for these 13 questions. These opinions were used to assess the appropriateness of each item in the measurement tool for the subject area and domain being measured, the necessity of the questions, and the measurability of the students'level of pain knowledge. The second part of the prepared questionnaire form was submitted to the opinions of seven experts, including four faculty members (two associate professors and two assistant professors) from the Department of Surgical Nursing, two expert nurses who are actively working in the field of Surgical Nursing, and one who works as a Turkish language expert. The expert opinions were scored using the Davis technique with a four-point rating of (a) appropriate, (b) to be slightly revised, (c) to be seriously revised, and (d) not appropriate. In this technique, the number of experts who reported options (a) and (b) was divided by the total number of experts, and the CVI for the item was obtained. A value of 0.80 indicates an acceptable level [15], and the mean CVI for the pain knowledge test was calculated as 0.95. Following feedback from the experts, a final version of the knowledge questionnaire was produced, which included 13 positive statements.

Face validity of the second part of the questionnaire: The draft knowledge test was then administered to a group of 10 participants with the same characteristics as the sample group to obtain their opinions on the comprehensibility of the statements, response time, general comprehensibility, and applicability of the form. These participants were not included in the sample group, and no changes were made to the knowledge test based on the positive feedback from the pilot group. The average time taken to complete the test was 10–15 min.

Difficulty and discrimination index of the second part of the questionnaire: The data obtained after administering the knowledge test were analyzed using a Test Analysis Program (TAP). Difficulty coefficients and item discrimination were calculated using the TAP. The item analysis revealed a wide range of item difficulty coefficients, ranging from 0.32 to 0.78, and item discrimination indices, ranging from 0.40 to 0.74 (Table 1).

Reliability of the second part of the questionnaire: The Kuder-Richardson- 20 (KR- 20) coefficient was used to evaluate the internal consistency of the knowledge test, which was finalized by passing through the mentioned stages to reveal its consistency and reliability with the data obtained. KR- 20 was developed for use in achievement tests, and it assigns 1 to items with correct answers and 0 to items with incorrect answers. A KR- 20 coefficient > 0.70 indicates good internal consistency [26]. In this study, the KR- 20 coefficient was 0.74., and the significance level was set at α = 0.05 (Table 1).

The third part of the questionnaire: Nursing Students'Attitude towards Pain Management: In the third part of the data collection form, nine questions were asked to assess the students'attitudes toward clinical pain management based on their educational training. The third part of the data collection form was prepared based on the literature and similar studies on pain attitudes [3, 5, 6, 16, 22]. These nine questions contained a tick-box option (excellent, moderate, or none). They were asked to indicate their responses as'excellent, moderate, or none’(Supplementary File 1_The questionnaire). The nine questions in the third part were evaluated as"1 point for none,”"2 points for moderate,” and"3 points for excellent.” Accordingly, the highest score obtainable from the questionnaire is"27.” Modified Bloom’s cut-off points were utilized to categorize the students’ clinical pain management attitudes level [8]. The total clinical pain management attitude scores were categorized into four levels based on modified Bloom's cut-off:"excellent,”"quite good,”"quite poor"and"poor". Therefore, attitude scores of 23–27 (% 85-% 100) were considered as"excellent,” 16–22 (% 60-% 84) as"quite good,” 11–15 (% 40-% 59) as"quite poor"and ≤ 10 (< % 40) as"poor"level of attitude (Supplementary File 2_Modified Bloom’s cut-off categories).

Content validity of the third part of the questionnaire: For the CVI, expert opinions were obtained for this nine-item part of the questionnaire, similar to the knowledge test. The third part of the questionnaire was also submitted to the opinions of the same seven experts who evaluated the second part (four academic experts from the Department of Surgical Diseases Nursing, two nurses who are specialized and actively working in Surgical Diseases Nursing, and one expert working as a Turkish Language Expert; seven experts in total). Expert opinions were evaluated using the Davis technique as in the second part [15]. The CVI for the clinical pain management attitude test was calculated as 0.96. Following feedback from the experts, the final version of the attitude questionnaire, which included nine positive statements, was produced.

Face validity of the third part of the questionnaire: The attitude questionnaire draft was then administered to the same group of 10 participants who had the same characteristics as the sample group and who had completed the knowledge test to obtain their opinion on the comprehensibility of the statements, the time taken to answer, the general comprehensibility and the applicability of the form. These participants were not included in the sample, and no changes were made to the attitude test based on the positive feedback from the pilot group. The average time taken to complete the test was 9–13 min.

Data analysis

Data were analyzed using IBM SPSS (V23). The Kolmogorov–Smirnov test was used to test for normality. The variables did not exhibit a normal distribution. The Kruskal–Wallis H test was used to compare pain knowledge and attitude scores based on three or more groups, and the Mann–Whitney U test was used to compare pain knowledge and attitude scores between two groups. The Dunn's test was used for multiple comparisons. The relationships among age, pain severity, pain knowledge, and attitude scores were analyzed using Spearman's rho correlation coefficient. Results are presented as mean ± standard deviation for quantitative data and as frequencies and percentages for categorical data.

Results

Demographic and pain characteristics

Most study participants were female students (65.7%). They had an average age of 20.6 ± 1.61 years and most lived in residence halls (58.8%) (Table 2). The students experienced persistent pain at certain intervals (45.3%) and most had a history of pain lasting over 6 months (63.9%). The pain was mostly felt in the upper body region and extremities (77.6%), and the pain was primarily due to insomnia/fatigue (28.2%) and stress (27.8%).

Table 2 Distribution and descriptive statistics of students’ demographic and pain characteristics (N = 245)

The present study found that pain was mainly experienced during the evening (47.8%). Severity measurements were uncommon (60.4%), and pain affected daily activities such as eating, drinking, bathing, and sleeping in 40% of the cases. Most students (76.7%) used non-pharmacological techniques to manage pain. The students had a family history of chronic diseases such as hypertension, diabetes mellitus, rheumatoid arthritis, and cancer (34.7%), which had been treated for ≥ 10 years (66.0%). Furthermore, students had a family history of pain associated with diseases such as migraine, rheumatism, fibromyalgia, lumbar disc hernia, and kidney stones (24.9%), which had been treated for 1–5 years (11.4%) (Table 2).

Nursing students'pain knowledge and clinical pain management attitudes

General pain management knowledge: The students achieved an average score of 7.72 ± 3.01 on the total score of the pain knowledge test, out of a maximum of 13 points. The correct answer rate of students for questions associated with the pain knowledge test varied between 31.8% and 77.6% (Table 3).

Table 3 Students’ pain knowledge and clinical pain management attitudes

Pain assessment: The students scored an average of 2.76 ± 1.34 on this part of the pain knowledge test out of a maximum of 5 points. The students had the least information on'what to ask the patient when assessing pain'(31.8%) (Table 3).

Choosing the right scale for pain: The students scored an average of 1.81 ± 1.00 on this part of the pain knowledge test, out of a maximum of 3 points, and gave the most correct answers, with a rate of 77.6% to the question of the first step to take in assessing the pain of patients with cognitive disability who could not report their pain correctly (Table 3).

Usage and administration methods of analgesics: The students scored an average of 3.14 ± 1.31 on this part of the pain knowledge test, out of a maximum of 5 points, and gave the most correct answer to the question"the patient who is at risk of respiratory depression when taking an opioid"with a rate of 73.5% (Table 3).

Clinical pain management attitudes: The students achieved an average score of 21.55 ± 2.82 on the total score of the clinical pain management attitudes, out of a maximum of 27 points. Most of the students (86.5%) knew that pain assessment was crucial; however, very few stated that they could use unidimensional (22.4%) or multidimensional (29%) pain assessment scales. Furthermore, while the students stated their attitudes towards interpreting the patient's facial expression (56.7%) and groaning (55.1%) as pain indicators as"excellent,” they stated their attitudes towards interpreting the patient's body language (49.4%), restlessness (61.6%), body rubbing (59.6%) and respiratory parameters (64.5%) as"somewhat"(Table 3).

Relationship between students'demographic/pain characteristics and clinical pain management attitudes and pain knowledge

Relationship between students'demographic/pain characteristics and pain knowledge: Pain knowledge mean scores were significantly higher (p < 0.05) in students who were female (7.90 ± 3.01), had pain that persisted at specific intervals (8.06 ± 2.78), used pharmacological methods to manage pain (8.08 ± 3.00), and had a family history of chronic disease (7.80 ± 2.96) (Table 4).

Table 4 Comparison of demographic characteristics with pain knowledge scores and attitudes toward pain management

Relationship between students'demographic/pain characteristics and clinical pain management attitudes: Clinical pain management attitude mean scores were significantly higher (p < 0.05) among students who were female (21.85 ± 2.66), had persistent pain at regular intervals (22.09 ± 2.34), measured pain intensity (22.11 ± 2.50), used non-pharmacological methods to manage pain (21.84 ± 2.90), and who did not want to perform activities requiring physical strength when in pain (22.20 ± 2.67) (Table 4).

Relationship between attitude toward clinical pain management and pain knowledge

Students'pain knowledge scores showed a statistically significant positive correlation to clinical pain management attitudes. Students'pain assessment, choice of the correct pain assessment scale, knowledge of analgesic use and application, and total pain knowledge scores increased with an increase in their clinical pain management attitudes (Table 5).

Table 5 The relationship between knowledge of pain and attitudes towards clinical pain management

Discussion

The complexity of pain, its learning and behavioral consequences, and the influence of personal and social variables on people who suffer from pain have led to the development of several behavioral pain theories (Staats, Hekmat, & Staats, 1996). Therefore, pain knowledge and its relationship with attitudes toward pain management have also been the subject of other studies. This study examined how nursing students can effectively manage pain in clinical situations based on their own experience by having appropriate knowledge of and attitudes toward pain management. The results of the study predicted that this would bring new perspectives to future studies and educational processes associated with pain management in nursing students. The study explored the relationship between pain knowledge and previous pain experiences.

Knowledge regarding pain

The current study results showed that the students had quite poor knowledge of pain assessment, and this lack of pain knowledge is supported by the literature consistent with the results of this study [3, 39]. A systematic review examining the level of pain knowledge and attitudes of nursing students showed that nursing students believed they had sufficient pain knowledge. However, most lacked pain knowledge and did not have appropriate attitudes toward pain [13]. Another study reported that, in Ghana, the correct response rate of a knowledge and attitude questionnaire on pain among nursing students was as low as 42.1% [27]. Hroch et al. found that only 4.5% of Canadian students in their study scored ≥ 80% on The Knowledge and Attitudes Survey Regarding Pain, demonstrating optimal pain knowledge and positive attitudes [22]. An integrative review of 29 studies reported poor or inadequate knowledge of pain management among nursing students [4]. Therefore, ignoring cultural factors in pain assessment in culturally diverse societies can lead to the misinterpretation of patient pain reports, resulting in inadequate or inappropriate pain management interventions. In addition, pain is a complex phenomenon influenced by biological, psychological, and sociocultural factors [41]. This situation was reflected in this study and resulted in poor pain knowledge among students from different geographical regions. This is because, although the university where the study was conducted is located in the Central Anatolia region, students from seven different geographical regions (Aegean, Mediterranean, Black Sea, Marmara, and Eastern, Southeastern, and Central Anatolia) are educated in the faculty's nursing department. In this study, the fact that the students gave the highest number of correct answers, ranging from 47.8% to 73.5%, to the questions under the sub-heading"usage and administration methods of analgesics"among the questions associated with pain knowledge supports this information stated in the literature. Contrary to this study, Amponsah et al. found that nursing students gave 39.2–43% correct answers to questions about the use and methods of administration of analgesics [27]. Similarly, Cousins et al. found that students did not receive sufficient information about the effects of analgesics, side effects, and clinical use of adjuvants during their education [13]. This finding in the present study, which differs from that in the literature, may be due to the fact that the students were present in clinical practice during data collection, actively participated in drug administration in clinics, and a small proportion (24.9%) had a family history of pain and were receiving pain treatment.

Attitude toward clinical pain management

Studies have shown that nurses tend to underestimate rather than assess patient pain [35, 37]. Omotosho et al. reported that 69.6% of nurses had negative attitudes toward pain management [32]. Furthermore, Adams et al. found that only 10.4% of nurses had adequate attitudes, and most nurses (89.6%) had negative attitudes toward pain management [2].

Contrary to the literature, this study found that students'attitudes toward clinical pain management were quite good at a high level, with a total mean attitude score of 77.7% (21.55 ± 2.82). Considering that 66% of the students in the study had a family member with a chronic disease, this finding may be because the students believe that effective pain management is very crucial in alleviating the conditions patients struggle with. Similarly, this finding is attributed to the fact that the students are from different regions of Anatolia, have different cultures, and have positive attitudes toward providing culturally competent care. This is because the ability of healthcare providers to understand and respect patients from different cultural backgrounds requires acknowledging and addressing the cultural factors that influence patients'health beliefs and treatment preferences. Regarding pain management, cultural competence is essential for tailoring treatment approaches to individual cultural needs and preferences [30]. The systematic review by Cousins et al. reported that students did not believe that a patient who did not grimace was in pain, even if the patient stated that they were in pain [13]. In this study, students expressed positive and strong attitudes toward the importance of pain assessment and the interpretation of patients'facial expressions and groaning as pain. However, they showed poor attitudes toward interpreting the patients’ body language, restlessness, body rubbing, and respiratory parameters as pain indicators.

Contrary to the results of this study (49.4–64.5%), Majeed et al. reported that the rate of pain assessment based on patient behavior and physiological changes was 82%. This finding is consistent with the literature; however, the students might have ignored other parameters associated with pain control. However, cultural variability has a significant effect on pain assessment and management in healthcare settings. When managing pain, nurses should recognize and understand how cultural beliefs, values, and practices influence patients'experiences and pain expressions [30]. However, the results of this study showed that the students underestimated this critical detail when assessing pain. This finding from the study is crucial because it is consistent with the literature and shows that the attitude toward this incorrect behavior may be a wrong attitude learned during the student years. In this study, students showed inadequate attitudes toward the use of unidimensional and multidimensional pain scales in pain assessment. However, the literature suggests that culturally sensitive pain assessment tools need to be developed to accurately assess pain in culturally diverse populations [1], and these tools should consider cultural differences in pain expression, communication styles, and interpretation of pain intensity. It is also emphasized that the inclusion of culturally appropriate language, imagery, and response options can increase the validity and reliability of pain assessments in different cultural contexts [30].

Furthermore, the fact that the students who participated in this study had a low level of attitude in this regard, despite being from different regions of the country and cultures, explains the cultural deficiency of pain assessment tools. Consistent with the current study, the literature indicates that nurses use the pain scale at a low rate for pain assessment in clinics where they work [31], and accurate identification of pain is the first step in pain management. Based on the study findings and literature [25, 31], this study found that the nursing students'inadequate pain assessment will negatively affect pain management. These findings are crucial in explaining why increasing the knowledge and attitude levels of pain assessment in nursing students who are future nurses may also improve patient safety, comfort, and satisfaction.

Relationship between students'demographic/pain characteristics and attitude toward clinical pain management and pain knowledge

This study found that knowledge and attitudes were higher among female students. Some studies have indicated that pain knowledge scores and clinical pain management attitudes of nursing students vary significantly according to gender [21, 39], whereas other studies have found that gender does not affect pain knowledge [3, 24, 39]. The high level of knowledge and attitudes obtained in this study, particularly among female students, may be because most students were female and had a maternal structure according to the culture of the country in which they lived.

In the literature, there are studies conducted with nursing students indicating that the duration of individual pain experience and the history of pain in family members are associated [33] and not associated with knowledge of pain management [14]. In another study, although students (95.9%) and their first-degree relatives (55.4%) experienced pain, no relationship was found between pain experience and knowledge of pain management [20]. In this research, the fact that the knowledge and attitude levels of the students were affected by the pain they experienced and the presence of individuals with chronic diseases in their families revealed that the students were already oriented toward assuming the role of health professionals and were making efforts to manage the side effects of chronic diseases experienced by family members. Moreover, this finding was reflected in the clinical field and resulted in a positive level of knowledge and attitudes. Conversely, genetic factors are crucial in determining an individual's susceptibility to pain and response to painful stimuli [38]. In addition, dietary habits, lifestyle choices, and traditional cultural practices may influence gene expression and contribute to differences in pain sensitivity across cultures [43]. Cultural beliefs and expectations may also influence how individuals perceive and interpret painful stimuli by shaping their cognitive appraisal of pain [1].

In the literature, some studies indicate that student nurses'pain knowledge scores significantly increase with the methods they use when they have pain and the status of measuring pain intensity [34], whereas there are studies that found no significant relationship between them [14, 21]. The current study found that students'pain knowledge scores were not affected by measuring pain intensity, which is consistent with the literature. Contrary to the literature, this study found that students'clinical pain management attitude scores significantly increased by using non-pharmacological methods to manage pain and not wanting to perform activities requiring physical strength when they had pain and the measurement of pain intensity. The measurement of pain intensity is necessary to evaluate the effectiveness of pain management,however, the fact that 60.4% of the students in the study did not measure the intensity of their pain suggests that they did not understand the importance of pain assessment.

Relationship between attitude toward clinical pain management and pain knowledge

Effective pain management requires solid knowledge of pain and treatment. Research has shown that nurses'incomplete pain knowledge and inadequate attitudes toward pain management significantly affect patient care and treatment [32, 35]. It was determined that students'scores on knowledge about pain assessment, choosing the right scale for pain assessment, the use and administration of analgesics, and total scores on pain knowledge increased with increasing skills and attitudes toward clinical pain management. Previous studies have confirmed the relationship between pain management and knowledge [4, 13]. Similar to the literature, over half of the students who participated in the research had insufficient knowledge about pain assessment, choosing the right scale, the use of administration methods of analgesics, and scores on attitude toward pain management, and the lowest score was obtained in effective pain assessment.

Implications for practice

This study has several practical implications for educators. First, the students'own experiences or family history of pain and chronic illness positively influenced their level of knowledge and attitude toward clinical pain management. Individual and sociocultural characteristics are crucial in changing attitudes toward pain and pain management; therefore, it is imperative to promote the experience of pain among nursing students. This approach can be effective in showing students how to achieve greater pain control. Therefore, the inclusion of educational topics in the curriculum to provide accurate pain assessment and personalized pain management plans for culturally diverse patient populations, and the use of culturally sensitive assessment and communication strategies can help to effectively identify and manage pain influenced by culture and gender, as well as the meaning and importance patients attach to pain.

Limitations of the study

This study provides insights into the association of individual pain characteristics with clinical pain management attitudes and pain knowledge levels of nursing students toward pain, which is a subjective experience in the Anatolian region. The data collected from the study were restricted to students of the health sciences faculty. Therefore, the findings of this study cannot be extrapolated to all nursing students. In this study, pain knowledge and clinical pain attitudes were restricted to the data collection tools created by the researcher. However, despite the high reliability and validity of data collection tools, self-reported measurements are susceptible to subjectivity and bias. Pain knowledge, experience, and clinical pain management attitudes were confined to data collection tool items, nursing students'personalities, and descriptive characteristics.

Conclusions

Overall, the findings of the current study revealed that clinical pain management attitudes can be improved by increasing pain knowledge. In addition, this study showed that students'pain knowledge and clinical pain management attitudes are dependent on variables such as gender, having pain experience, having a family history of chronic disease, the choice of pain-coping technique and the activities not want to perform while experiencing pain. Being female and experiencing pain at specific intervals positively affected students'knowledge and attitudes.

As the duration of pain experience increased, pain knowledge levels increased, and clinical pain management attitudes decreased. In addition, students with chronic pain demonstrated enhanced pain knowledge, while those with stress-related pain exhibited more positive attitudes. Measuring pain intensity increased clinical attitudes to pain management, but this was not reflected in pain knowledge. The use of pharmacological methods to cope with pain led to an increase in knowledge, while the use of non-pharmacological methods led to an increase in attitude. The pain history and chronic disease status of family members increased students'pain knowledge and clinical pain management attitudes. Therefore, there is a need to integrate demographic variables and characteristics of individual pain experience into the curriculum and design an intensive and comprehensive educational initiative on pain management while educating nursing students on pain.