Pain is the most common reason for seeking medical attention, and pain management is a key aspect of nursing. For example, 88.0% of surgical patients report pain of above-moderate intensity [1,2]. Inadequate pain control can negatively affect patient’s physical and psychological health, as well as recovery progress and outcomes. Despite advances in medicine and technology, pain management remains insufficient. Insufficient knowledge and attitudes about pain among nurses have been identified as contributing factors [1,3]. Nurses are central to patient care and education in pain management; however, effective pain management is unlikely if nurses lack adequate knowledge and a positive attitude toward pain [3-5].

To improve pain management quality, nurses with appropriate knowledge must accurately assess patient’s pain and educate them on proper pain management [2,3,6]. Achieving this requires pain management education that connects nursing college curricula with clinical practice. Newly graduated nurses encounter patients experiencing pain of varying intensity and characteristics caused by diseases, procedures, and surgeries. Therefore, nursing students who will assess and manage patients’ pain should receive education and practical opportunities in pain management within the clinical curriculum [7]. Nurses who received pain management training often experienced a significant gap in clinical practice after graduation because of insufficient undergraduate education [4,8-10]. Over the past 20 years, numerous studies have assessed and evaluated the status and improvement of knowledge and attitudes regarding pain management among nursing students. These studies have shown that students’ lack of knowledge is a barrier to effective pain management [11,12].

Nursing students’ insufficient knowledge of medications and heightened concerns about opioid-related addiction and respiratory depression are major barriers to effective pain management [2,3,9,10,12]. This study examined the current status of nursing students in South Korea. The findings may inform the development of undergraduate nursing curricula and provide guidance for clinical educators to enhance nursing students’ and new nurses’ knowledge of pain management.

Achievement level of knowledge and attitude toward pain according to the general characteristics of nursing students

A total of 126 nursing students enrolled in four nursing universities participated in this study. The mean age of the participants was 22.94±2.78 years, with 61.1% being under the age of 23. The majority of participants were women (81.0%), and fourth-year students accounted for 59.5% of the total. Among the participants, 88.1% had experience with pain education, 82.5% had experience with pain assessment, 75.4% had experience with pain intervention, and 72.2% had received education on medications. The most common source of pain education was supplementary instruction within major undergraduate nursing courses, as reported by 88.3% of the participants (Table 1).

The total score for knowledge and attitudes regarding pain was 20.40±4.06 out of 41 points. The converted score was 48.0%. Knowledge and attitudes among nursing students differed based on the method of pain education. Post-hoc analysis revealed that students who received incidental education integrated into core subjects scored higher than those who received education from nurses (F=7.70, p<.001). There were no significant differences according to other general characteristics (Table 1).

When classifying the achievement level of knowledge and attitudes toward pain into three categories, 60 (47.6%) were classified as poor and 66 (52.4%) as fair. When examining whether there was a difference in achievement level according to the general characteristics of the participants, it was found that the group that received training incidentally through core subjects had a significantly higher level of achievement (χ²=12.58, p=.006) (Table 1).

This cross-sectional survey examined the knowledge and attitudes toward pain among nursing students. Nursing students, who will directly assess and manage patients experiencing pain, require adequate knowledge and appropriate attitudes [10]. In this study, the mean knowledge score was 20.40±4.06 out of 41 (converted score: 48.0%), and 47.6% of participants were classified as having poor knowledge, which was lower than in previous studies using the same tool [3,14,15,17,18]. These results should be interpreted within the context of South Korean nursing education, where students complete clinical practicums in their third and fourth years but their clinical exposure is limited by the curriculum’s predetermined clinical hours. More importantly, institutional and legal barriers prevent students from directly participating in key aspects of pain management, such as assessing patients’ pain, administering opioid or non-opioid analgesics, or providing patient education on additional interventions. Consequently, their practicum was largely limited to observing nurses’ activities, which may have made clinical training superficial. These systemic limitations in South Korean nursing education likely influenced students’ responses to survey items related to clinical practice.

Previous studies reported differences in knowledge and attitude scores based on participants’ the general characteristics [7,9,10,18,19]; however, in this study, the only significant difference was associated with the method of receiving education. Despite 88.1% of students indicating they had received pain education, the mean score remained very low. This finding suggests that university-provided education has not been delivered in a way that is directly applicable to clinical practice. Universities should therefore determine which aspects of current pain education programs—such as methods or content—are insufficient, and develop targeted improvements to better prepare students who will become new graduate nurses.

The most vulnerable areas in nursing students’ knowledge and attitudes were cancer pain (33.3%) and drugs (47.6%). Inadequate knowledge about drugs has been consistently reported in previous studies [2,3,10,15,20,21], this issue is also common among nurses [7,20,22]. Lack of drug knowledge can result in inaccurate interventions. The high incorrect response rates for questionnaire items 38b and 39b in this study indicate that insufficient knowledge of opioid analgesics leads to inadequate pain interventions, which may cause various adverse patient outcomes. Addressing these educational gaps is essential to ensure that nursing students are prepared to assess and manage pain effectively, thereby improving patient safety and clinical outcomes. Most students in this study demonstrated incorrect knowledge regarding the respiratory suppression associated with opioid analgesics. Although clinically significant respiratory depression occurs in fewer than 1.0% of patients who use opioid analgesics at appropriate doses over extended periods [23,24], 90.5% of participants disagreed with this fact. Excessive concern about addiction or respiratory suppression among medical personnel remains the primary barrier to effective pain control in patients requiring opioid analgesics [11,23], a finding also confirmed in this study. Excessive concerns about opioid analgesic side effects combined with insufficient knowledge, may cause nurses to hesitate to administer these medications, impeding effective pain management for patients. Universities should recognize that students’ lack of drug knowledge interferes with proper pain management and should shift toward practical education including types of drugs used in specific cases, administration methods, side effects, and strategies or managing adverse reactions. Students also demonstrated a high rate of incorrect answers regarding symptoms of physical dependence (77.8%). Nursing students’ misconceptions about opioid analgesics—such as addiction, physical dependence, tolerance, and respiratory depression—may be conveyed to patients, potentially resulting in inadequate pain management. Therefore, universities should provide education that ensures students acquire accurate knowledge and are well-prepared for clinical practice.

In addition to knowledge of drugs and pain interventions, the ability to assess both verbal and nonverbal patient communication and accurately evaluate pain is essential [10,11]. Pain assessment, the critical first step in pain management, showed a low correct response rate among participants in this study (57.9%). If a patient reports a pain score is 8, but shows no nonverbal signs and does not after receiving pain medication, the patient’s report should be taken seriously, and further interventions should be provided. However, 54.0% of nursing students in this study did not believe the patient’s reported pain, and 27.0% recorded pain scores below 3, which would not prompt additional intervention. Among patients who displayed painful expressions, 40.5% of students did not believe the pain reported by the patient. Although student confidence in patients’ pain reports was slightly higher than in previous studies [2,7,9], this level remains insufficient for effective pain management. When asked who could most accurately assess a patient’s pain, 60.0% of students identified a doctor or nurse. Accurate pain assessment is essential for appropriate pain interventions. Educators should provide nursing students with case examples representing various types of pain in diverse clinical settings and incorporate role-playing exercises that connect pain assessment with suitable interventions. This strategy enables reassessment of students’ knowledge correction of misconceptions and guidance toward appropriate clinical practice.

Eighty-six percent of participants reported wanting specialized pain education relevant to their nursing practice. Students perceived that current undergraduate pain education is insufficient for their clinical practice. They require accurate knowledge of pain assessment and intervention, particularly regarding medications such as opioid analgesics. However, significant challenges remain in addressing barriers within nursing colleges. Universities facing limited resources, may consider existing undergraduate pain education and clinical practicums adequate. Nevertheless, even in a tertiary hospital in South Korea believed to offer comprehensive pain management programs for new nurses, nurses’ knowledge and attitudes toward pain, especially opioid analgesics, remained very low [22].

E-learning, simulations, and their combination with classroom lectures are as effective as traditional face-to-face education [5,17]. These methods are particularly valuable for pain management education because they allow students to select appropriate interventions for patients reporting pain in a virtual, safe environment rather than in real clinical settings [17]. Actively inviting guest speakers specializing in pain management is also important to provide education on pathophysiology, pain assessment, interventions (including pharmacological and non-pharmacological therapies), and common misconceptions about pain. However, current systemic constraints require significant changes. Even if nursing schools implement various educational strategies to improve students’ knowledge, these efforts may be ineffective if not integrated with clinical practice. Therefore, a direct clinical practicum system should be established to enable students to apply university-acquired knowledge in real clinical settings. Additionally, improvements in the licensing examination system—such as developing question types that promote critical thinking and clinical judgment—are necessary to support these educational initiatives.

The findings of this study illustrate how characteristics of South Korea’s clinical education system and sociocultural resistance to opioid analgesics may contribute to inadequate knowledge and attitudes regarding pain management. However, previous international studies have also identified nursing students’ knowledge deficits and suboptimal pain management, indicating that this issue requires broader international attention. Fundamental improvements in the quality of pain nursing should begin at the undergraduate level.

The study has several limitations. It used a convenience sample of third- and fourth-year nursing students from four nursing colleges in Jeonbuk State, South Korea introducing sampling bias and limiting generalizability to all nursing students nationwide. Although the questionnaire is widely used among nursing students globally, some items require knowledge beyond the students’ current educational level because the tool was originally developed for nurses. As a result, some students may have selected answers without knowing the correct responses.

This study is significant because it reveals the current level of knowledge and attitudes toward pain among nursing students in South Korea and identifies particularly vulnerable areas. Additionally, the study examined students’ educational needs regarding pain and suggested ways to address these needs.

The level of knowledge and attitudes toward pain among nursing students in South Korea was below average. Knowledge related to drugs and pain interventions was particularly inadequate, and pain assessment skills were also insufficient. Despite having prior educational experience in pain management, this did not significantly impact the scores, highlighting a disconnect between academic content and clinical practice. However, students who received pain education through undergraduate courses achieved better results than those educated by clinical nurses. Many students expressed the need for more intensive and clinically relevant education. Therefore, nursing schools should revise their pain education programs to better prepare students for effective pain management in clinical settings.