Nursing Student’s Knowledge of and Attitudes Towards Pain Management: A Cross-Sectional Study

A cross-sectional survey of 393 third- and fourth-year nursing students in Saudi Arabia found a mean score of 44% on an Arabic survey of pain-management knowledge and attitudes, with 78.4% of respondents classified as having poor performance. The students were enrolled at four public universities in the country’s northern region and completed the online survey between October 2023 and January 2024. <

The participants were 197 men and 196 women with a reported mean age of 21.6 years and a standard deviation of 1.5 years. Fourth-year students formed the largest group, numbering 229, or 58.3%, while 164 students were in their third year. Most respondents, 358 or 91.1%, were enrolled in a regular bachelor of nursing program, and 35 were in a bridging program for people who already held nursing diplomas.

Only 35 respondents, or 8.9%, had worked in a healthcare setting before entering the bachelor’s program, while 15, or 3.8%, reported attending an extracurricular pain-management course. Prior use of a pain scale was much more common: 329 students, or 83.7%, said they had used one. Learning about pain across laboratories, simulation and clinical placements was reported by 260 students, or 66.2%.

< Researchers used the Knowledge and Attitudes Survey Regarding Pain, a tool developed in 1987 and updated in 2014, with the original authors approving an Arabic translation for the study. The translation process included recruitment of translators, forward translation, backward translation, consolidation by a committee and pilot testing.

Minor contextual changes included replacing acetaminophen with paracetamol and replacing a reference to the United States with Saudi Arabia. Ten nursing experts with pain-management expertise evaluated the content validity of the translated survey. The scale-level content validity index was 0.98, the universal-agreement scale-level index was 0.85, and the Arabic instrument’s Cronbach’s alpha was 0.70.

Scores below 50% were classified as poor, scores from 50% to 75% as fair, and scores above 75% as good. < Students performed relatively well on selected statements about opioids.

A total of 92.4% correctly identified the definition of drug or opioid analgesic addiction, 89.8% said subsequent opioid doses should be adjusted according to the patient’s response, and 88.8% recognized the need to assess analgesic effects to avoid over-analgesia and respiratory difficulty. Yet these strengths were not consistent across the survey: only 16 of its 41 questions were answered correctly by more than half of the participants. The lowest results involved routes and doses of opioid administration, expected respiratory effects, tolerance and dependence, and two clinical case scenarios.

The survey therefore captured a mixture of correct factual knowledge and substantial gaps in applying that knowledge. < Several responses differed from the correct answers recorded by the survey.

Three-quarters of students incorrectly believed that patients should be encouraged to endure pain as much as possible before receiving opioids. Ninety percent did not identify oral administration as the recommended method for morphine in persistent cancer pain, and 86% believed that clinically evident respiratory distress was likely when an intravenous morphine dose was increased. Only 44.3% chose the patient as the person most capable of assessing pain severity; 26% selected the nurse, 19% the physician and 5% the patient’s spouse or family member.

More than 80% regarded administration of sterile water as an effective test for determining whether pain was real. These findings describe students’ survey responses rather than their behavior in clinical care. <

The two case studies tested assessment and intervention decisions in patients of the same age who had undergone the same surgical procedure and reported the same pain score, but who displayed different outward behavior. In case study A, the patient was smiling and relaxed; in case study B, the patient was grimacing and uncomfortable. About 30% of participants correctly scored pain in each scenario.

Only 5% selected the appropriate intervention involving 3 mg of intravenous morphine for the relaxed patient, and 8% selected it for the grimacing patient. The corresponding case-study responses produced some of the lowest correct-answer rates in the survey, indicating difficulty applying pain assessment and analgesic decisions even when the scenarios shared basic information. <

Survey performance was not significantly associated with gender, year of enrollment, type of nursing program, previous healthcare work, attendance at an extracurricular pain-management course, prior pain-scale use, learning context, or frequency of pain-scale use. Educational institution was the only demographic characteristic associated with performance in at least one analysis. A Kruskal–Wallis test found differences among the four universities when scores were treated as continuous.

Post hoc testing with Bonferroni correction showed that University A had significantly lower performance than Universities B and C. In robust linear regression, Universities B and C had higher continuous scores than the reference institution, while University D did not reach the conventional significance threshold. In the categorical logistic model, University C was associated with higher odds of a fair or good score than University A, but the corresponding categorical test across institutions had a p-value of 0.09.

< The findings extend earlier Saudi surveys that also reported low mean scores. The current study’s mean of 44% was similar to the approximately 42% reported in one earlier English-language survey and the 43% reported in another.

Those earlier investigations also identified language as a possible limitation for students whose first language was not English. By using an Arabic translation and recruiting senior male and female students from several institutions, the present survey addressed part of that concern and expanded the sample beyond the 150 participants in one earlier study. It did not test whether translation or any other methodological change improved learning, however, and the absence of a longitudinal or interventional design means that the causes of the low scores remain undetermined.

< The results provide a baseline for examining how pain management is incorporated into Saudi nursing programs. In the universities studied, pain management was addressed within selected subjects rather than as a discrete subject, using lectures, tutorials, simulation and clinical-placement experience.

The researchers recommended that educators and policymakers review curricula, resources and teaching methods, while suggesting particular attention to simulation, analgesic pharmacology, opioid administration and safety, patient-centered pain assessment, and communication with people experiencing pain. They also recommended broader studies involving additional institutions, practicing nurses and qualitative methods to investigate the factors associated with students’ low performance. These recommendations follow from the measured survey gaps, but the study did not implement or evaluate an educational intervention.

Several limitations constrain the interpretation of the findings. Because the study was cross-sectional, it can identify associations but cannot demonstrate causation. The sample came from only four purposively selected universities in one geographic region, so the results cannot be generalized to all Saudi nursing students.

Online self-reporting through the Knowledge and Attitudes Survey Regarding Pain may also introduce social-desirability bias, while the study’s recruitment and university selection were not described as nationally representative. The survey’s scoring system combines knowledge and attitudes, limiting the extent to which either can be isolated. Within those boundaries, the clearest reported findings are the low average score, the concentration of incorrect answers in pain assessment and opioid-related cases, and the absence of statistically significant relationships with most measured demographic and educational variables.

Subject of Research: Pain-management knowledge and attitudes among senior nursing students in northern Saudi Arabia

Article Title: Nursing Student's Knowledge of and Attitudes Towards Pain Management: A Cross‐Sectional Study

Article References: Alshehri, F. A., Levett‐Jones, T., Pich, J., & Alamri, A. S. (2026). Nursing Student's Knowledge of and Attitudes Towards Pain Management: A Cross‐Sectional Study. Nursing Open, 13(10), Article e70880. https://doi.org/10.1002/nop2.70880

Image Credits: AI Generated

DOI: 10.1002/nop2.70880

Keywords: pain management, nursing education, Saudi Arabia, nursing students, opioid safety, pain assessment, clinical decision-making, survey research, medical simulation, Nursing, Student's, Knowledge