1 Introduction

Pain is a multidimensional experience with psychological, behavioural, emotional, and cognitive consequences and an increasingly prevalent health problem that is generally undertreated [1, 2]. Pain is considered the fifth vital sign because everyone experiences it at some point [3]. Pain management requires comprehensive evaluation. Healthcare professionals with more pain knowledge and beliefs will likely manage pain better and make the right clinical decisions [4, 5]. Pain assessment requires a team effort, and nurses are an indispensable part of that team [6]. What distinguishes nurses from other healthcare professionals in pain management is that they spend a long time with patients [7]. Nurses identify patients' pain experiences and methods of coping with it, plan and administer treatment, monitor the effects and outcomes of treatment, sympathise with their patients, use non-pharmacological methods, and resort to therapeutic communication [3, 8, 9].

Comprehensive pain assessment ensures optimal pain management [10]. Cognitive, emotional, behavioural, environmental, cultural, religious, and gender factors affect pain management approaches. One of those factors is pain beliefs [11-13]. Pain beliefs are either organic or psychological. Organic beliefs are beliefs that pain has physiological origins, such as injury, harm, and so forth [14]. People believe that the more injured they are the more pain they experience. Therefore, organic pain management is based on biomedical principles involving activity/exercise to eliminate the factors causing pain. Psychological beliefs are beliefs that pain is of psychological origins, such as anxiety, depression, and so forth. Therefore, psychological pain management involves distraction techniques and relaxation exercises [15-17].

What approach patients adopt to pain and how they manage it depends not only on their experiences, beliefs, and cultural codes but also on the perceived level of pain. Fear of pain results from perceived pain and the bodily damage caused by it, which makes patients believe that they should avoid pain-causing activities [18, 19]. Therefore, pain and fear are inseparable. Pain causes fear, making the patient more sensitive to pain [20-22].

Nurses develop patient-specific coping strategies after identifying pain beliefs and their impact on the way patients cope with pain [11, 23]. The personal characteristics of patients and nurses and the meaning they attribute to pain are vital factors affecting pain management. The success of pain treatment depends on nurses' attitudes toward pain [8, 9]. How nurses manage pain and their decisions to treat it depend on their attitudes, beliefs, and misconceptions about pain. Therefore, the first step to promoting positive behaviour change in nurses is to determine their attitudes, beliefs, fears, knowledge, and behaviour towards pain management. Nurses with negative or false beliefs about pain are likely to provide inadequate pain management and care [24, 25]. Conversely, nurses who reconsider their attitudes, feelings, and beliefs about pain will likely provide better care [8]. Therefore, nurses interested in providing effective care should identify patients' and their own pain beliefs.

Nursing students are the nurses of tomorrow who will play a key role in pain management and treatment. Given that pain beliefs are an indispensable part of quality care, nursing students should recognise their own pain beliefs and fears to provide quality care for patients in pain. However, little published research investigates pain beliefs and fear of pain in nurses who spend a great deal of time with patients with chronic or acute pain [11]. Therefore, this paper investigated nursing students' beliefs and fears of pain. We also think that it will pave the way for further research.

2 Methods

3 Results

Participants had a mean age of 20.22 ± 1.38 years (min: 18, max: 25). A quarter of the participants were first graders (26.6%). The majority of the participants were women (86.3%) and had no family members with chronic diseases (79.2%). Half the participants rated their health status as ‘neither good nor bad’ (49.2%) (Table 1). All participants had experienced pain before. More than half the participants rarely experienced pain (66.4%), mostly headaches (54.1%). More than half the participants experienced moderate pain (64.9%). Most participants stated that pain affected their quality of life (85.7%). More than half the participants used painkillers (64.3%) and gave themselves a massage for pain relief (68.1%). Most participants believed in the effectiveness of non-pharmacological methods for pain relief (86.5%). The majority of the participants stated that they knew how to manage pain (75.5%) and would like to receive training on pain (74.3%) (Table 1).

Participants had a mean PBQ ‘organic beliefs’ and ‘psychological beliefs’ subscale score of 3.50 ± 0.72 and 4.60 ± 0.96, respectively. They had a mean FPQ-III total score of 83.71 ± 19.14 and a mean ‘severe pain’, ‘minor pain’ and ‘medical pain’ subscale score of 32.54 ± 7.97, 24.48 ± 6.89, and 26.68 ± 7.92, respectively (Table 2).

Participants' PBQ ‘psychological beliefs’ subscale and FPQ total and subscale scores significantly differed by gender and grade level (p < 0.05). The reason for this difference according to grade levels in Bonferroni Adjusted Mann−Whitney U test analysis; 1st and 4th grade mean scores, 2nd grade and 4th grade, 2nd grade, and 3rd grade mean scores, and 3rd grade and 4th grade mean scores (significance level for this test, p = 0.05/6) = 0.0083) is due to the difference. Their FPQ-III total scale and ‘medical pain’ subscale scores differed by the perceived impact of pain on quality of life (p < 0.05). Their PBQ ‘organic beliefs’ and FPQ ‘severe pain’ subscale scores differed by their beliefs in the effectiveness of non-pharmacological methods for pain relief (p < 0.05). Their PBQ ‘organic beliefs’ subscale scores differed by their knowledge of pain management (p < 0.05). Their FPQ ‘severe pain’ subscale scores differed by their willingness to receive training on pain (p < 0.05) (Table 3).

There was a moderate negative correlation between Severe Pain and Organic Beliefs (r = −0.40), but this correlation was not statistically significant (p = 0.459). There was a moderate positive correlation between Severe Pain and Psychological Beliefs (r = 0.243), which was statistically highly significant (p = 0.000). There was a weak positive correlation between Minor Pain and Organic Beliefs (r = 0.178), which was statistically highly significant (p = 0.001). There was a weak positive correlation between Medical Pain and Organic Beliefs (r = 0.154), which was statistically highly significant (p = 0.004). There was a very weak positive correlation between Fear of Pain Total Score and Organic Beliefs (r = 0.120), which was statistically significantly significant (p = 0.026). There is a weak positive correlation between Fear of Pain Total Score and Psychological Beliefs (r = 0.149), and this correlation is statistically highly significant (p = 0.006) (Table 4).

In the simple linear regression analysis, the model was generally significant (p = 0.026). Among the independent variables, only the psychological beliefs score significantly affected the total fear of pain score. This value indicates that psychological pain beliefs explain only 2.1% of the total change in fear of pain (Table 5).

4 Discussion

Pain management is part of quality nursing care. The primary goal of pain management is to provide quality care to all patients and use pharmacological and non-pharmacological methods to keep pain under control [6]. Personal characteristics, patient-nurse interaction, and the meaning attributed to pain are key factors affecting pain management [8, 9]. Nurses' and nursing students' beliefs and fears about pain are as important in pain management as patients' beliefs.

All participants stated that they experienced pain, mostly headaches (Table 1), which has been reported by earlier studies as well [11, 25, 30]. The higher prevalence of acute pain (headache and abdominal pain) than chronic pain in our participants may be due to anxiety and stress because they have academic requirements to fulfil, such as taking theoretical courses and studying long hours for exams, and putting theory into practice during lab activities or clinical clerkships. Usually, sudden onset, severe, and non-long-lasting pains are acute pains. Chronic pains are characterised by more than 6 months, continuing throughout life or for a long time, varying in intensity from mild to severe, affecting the quality of life of the individual, and even causing behavioural disorders in the individual [31]. The nursing students in this study were mostly healthy young people (only 6.7% responded that they have a bad health status). Therefore, they are expected to feel acute more often than chronic pain.

More than half the participants stated that they used painkillers (Table 1). Research also shows that students mostly use painkillers [30, 32]. Painkiller use was more common in our participants than reported by other studies. It is thought that students use pain relievers because they are easy to access.

Most participants preferred massaging and warm compression as non-pharmacological strategies for pain relief (Table 1). Research also shows that students give themselves a massage, apply hot/cold packs, or lie down and rest to self-manage acute pain [11, 25, 30]. Non-pharmacological methods are commonly used as complementary methods in the treatment of pain worldwide [33, 34]. Students prefer non-pharmacological strategies for pain relief because they can apply them by themselves without preparation. In addition to being easily applicable and cost-effective, non-pharmacological methods may increase their effectiveness when used together with pharmacological methods.

Participants had above-average levels of organic (3.50 ± 0.72) and psychological (4.60 ± 0.96) pain beliefs (Table 2). This result shows that most nursing students believe that pain is of psychological origin, suggesting that non-pharmacological strategies (distraction and relaxation techniques) are better options for them [35, 36]. Babadağ and Alpaslan [11] found that students had a mean PBQ ‘organic beliefs’ and ‘psychological beliefs’ subscale score of 3.46 ± 0.51 and 4.81 ± 0.76, respectively. Different from our results, Kılıçarslan and Erek Kazan [30] (2021) reported that students had a mean PBQ ‘organic beliefs’ and ‘psychological beliefs’ subscale score of 3.69 ± 0.58 and 2.62 ± 0.83, respectively. The difference in the results may be due to the type, site, severity, and frequency of pain, previous pain experiences, personal characteristics, and beliefs [11, 30]. Organic beliefs are beliefs that pain is associated with physical injury and damage, while psychological beliefs are beliefs that pain is of psychological origin [37]. Studies focus mostly on patients' pain beliefs [38, 39]. However, it is crucial to determine the pain beliefs of future nurses.

Participants had a high FPQ-III ‘severe pain’ subscale score (Table 2). Fear of minor pain is fear related to more common situations in everyday life. Fear of severe pain is fear related to more acute and severe situations. Fear of medical pain is fear related to medical interventions. Higher scores in FPQ-III indicate greater fear. In the study conducted by Kılıçarslan and Erek Kazan [30] with nursing students, the fear of severe pain subscale score was 3.28 ± 0.76, the minor pain fear subscale score was 2.55 ± 0.65, the medical pain fear subscale score was 2.75 ± 0.68 and fear of pain scale total score is 2.86 ± 0.57. Ünver and Turan [20] found students' fear of severe pain subscale score of 34.21 ± 6.66, minor fear of pain subscale score of 22.05 ± 5.05, fear of medical pain subscale score of 26.10 ± 6.80, and fear of pain scale total score of 82.38 ± 16.74. Similarly, in our study, the students' fear of severe pain score was found to be high. The high score of severe pain in nursing students can be explained by many reasons. The degree of pain perceived by the person is related to the meaning of the pain. The relationship between pain and fear is complex. Fear often increases the perception of pain, but pain also evokes fear. It is difficult to separate the two senses [40]. The fear of pain is related to the pain experiences of the individual in the past, and it increases especially as a result of painful situations that cannot be adequately managed. A fear of pain may develop in an individual who has experienced repetitive and intractable pain experiences [20, 41]. Fear of pain can cause one to change one's everyday life activities to avoid pain, which may result in one misinterpreting the severity of the pain one experiences [42]. Previous painful experiences, cultural norms, and the degree of perceived pain affect self-management approaches to pain [43]. We should identify the source of the fear of pain experienced or anticipated by students. In other words, we should determine whether they have a fear of pain associated with minor events, serious situations, or medical interventions to help them develop self-management strategies and provide better pain treatment to their patients in the future.

Table 3 shows the distribution of PBQ and FPQ-III scores by demographic characteristics. Female participants had higher PBQ ‘psychological beliefs’ and FPQ-III total and subscale scores than their male counterparts (Table 3). This result suggests that female and male students differ in whether they attribute pain to organic or psychological causes and why they fear pain. The effect of sex on perceived pain is still to be confirmed. Samulowitz et al. [44] argue that women are more sensitive to pain and more willing to report it than men. Babadağ and Alpaslan [11] also reported that female students had significantly higher ‘psychological beliefs’ scores than their male counterparts. Kılıçarslan and Erek Kazan [30] found that female students had higher PBQ ‘organic beliefs’ and FPQ-III total and severe pain and medical pain subscale scores than male students. However, Akkaya et al. [25] reported no difference in organic and psychological beliefs between male and female students [25]. Akkaya et al. [25] determined that third graders had higher ‘organic beliefs’ scores than first graders and higher ‘psychological beliefs’ scores than other grade levels. Kılıçarslan and Erek Kazan [30] also reported a relationship between grade level and organic beliefs. We also detected a relationship between grade level and PBQ ‘psychological beliefs’ and FPQ-III total and subscale scores. Especially second graders had higher scores than other graders. This result may be due to personal characteristics but also because second graders cope with more stressors during clinical practice as they have less experience. Bhurtun et al. [45] reported high-stress levels during clinical practice in second-grade nursing students. We think that this may have affected second-grade participants' pain beliefs and level of fear of pain. However, Babadağ and Alparaslan [11] reported no relationship between grade level and previous experiences of pain.

Participants who used non-pharmacological methods for pain relief had higher FPQ-III ‘severe pain’ scores than those who did not (Table 3). Kılıçarslan and Erek Kazan [30] also reported that students who used non-pharmacological methods had higher FPQ-III total and ‘severe pain’ subscale scores than those who did not. These results show that as the students' fear of pain increases, the rate of using non-pharmacological methods also increases.

In our study, the total scores of fear of medical pain and fear of pain of students who stated that their quality of life was affected due to pain were higher than those who stated that their quality of life was not affected. In addition, the difference between the groups was statistically significant (Table 3). Today, pain concerns a large part of the society; It has become a problem that significantly affects the physiological and psychosocial status and productivity of the individual. In cases where the pain is not managed well, it can lead to a decrease in quality of life, prolongation of the healing process, and adversely affect comfort levels [46, 47]. It can cause pain, anxiety, and emotional distress, harm well-being, affect functional capacity, and hinder the ability to fulfil family, social, and professional roles [48, 49]. The fear of pain in the individual emerges with pain experiences and/or learned pain behaviours. Repetitive and ineffectively coping pain causes anxiety in the individual [27, 50]. Because fear is a situation that arises when people feel in danger in reality or thought. It is a bad feeling felt in a perceived dangerous or risky situation [51]. The findings of this study, supporting the literature, show that individuals who stated that their quality of life was affected due to previous negative pain experiences are more afraid of experiencing a similar or uncertain situation again. As a result, there is a vicious circle between pain and quality of life. While pain causes a deterioration in the quality of life, the effect of the quality of life causes an increase in the severity of pain. If the nurse knows the effect of pain on patients, she can reveal the presence and characteristics (nature) of pain.

In our study, it was determined that the organic beliefs scores of the students who stated that they did not have knowledge about pain management were higher (Table 3). This suggests that students attribute pain only to organic causes. However, the International Association for the Study of Pain-IASP Taxonomy Committee has defined pain as ‘an unpleasant emotional sensation and behaviour that originates from a certain part of the body, is due to tissue damage or not, and is affected by the past experiences of the individual’ [52]. However, these beliefs and attitudes towards pain can be potential barriers to effective pain management. In studies on pain beliefs and coping strategies, it is stated that the beliefs of individuals experiencing pain about the psychological or organic origin of pain may cause differences in the strategy of coping with pain and the treatment process [37, 53].

Another remarkable finding in the study is that students who want to receive education on pain have high fear of severe pain scores and there is a statistically significant difference between the groups (Table 3). In particular, individuals who have experienced severe pain before may fear that they will experience severe pain again because their pain has not been relieved in the past. Looking at the concept of fear from a different perspective, it is a common, natural, and universal emotional state of all people, which enables people to cope with stressful life events and to take necessary precautions against danger by keeping the organism alert or in a state of alarm [54]. To control a subjective and preventable finding such as pain, the fear of pain should be made objectively visible. This situation suggests that students want to receive training to cope with the pain they experience effectively and to develop appropriate pain management strategies for patients in the clinic.

Psychological beliefs seem to have a stronger effect on the perception of severe pain, especially compared to organic beliefs. These findings suggest that organic and psychological beliefs may play different roles in the perception of pain, and psychological beliefs are more effective, especially in the perception of severe pain (Table 4). According to the regression analysis results, an increase in psychological beliefs was associated with an increase in individuals' fear of pain score. It can be thought that psychological meanings of pain may increase individuals' pain experience and their fear of pain due to this experience. However, the low explanatory power of the model (R² = 0.021) emphasizes that this relationship is weak and other factors affecting fear of pain should be taken into consideration (Table 5). Köse Tosunöz and Deniz Doğan [55] found a moderately positive and statistically significant relationship between FPQ-III and organic beliefs mean scores (r = 0.340, p < 0.001). A weakly positive and statistically significant relationship was found between FPQ-III and psychological pain beliefs mean scores (r = 0.125, p < 0.001). In the regression analysis conducted in the same study, organic beliefs affect the level of fear of pain (p = 0.000). A one-unit increase in the organic beliefs variable increases the probability of fear of pain by 0.36 times, and the results show that as organic beliefs increase, fear of pain also increases [55]. In their study, Kılıçarslan and Erek Kazan [30] also determined that there is a very weak negative relationship between pain beliefs and fear of pain. Accordingly, the fear of pain decreases in students with high pain beliefs [30]. In conclusion, our study findings have both overlapping and divergent aspects with the results in the existing literature.

5 Conclusion

Participants had high ‘psychological beliefs’ and ‘severe pain’ scores. Their pain beliefs and fear of pain were affected by gender, grade level, previous experience of pain, and non-pharmacological pain relief methods. Pain is critical in nursing education. These results can guide us on better developing and implementing nursing education on pain management or incorporate pain education in the nursing curriculum. Therefore, nursing programmes should provide more pain-related content to help students learn pain management, develop clinical decision-making skills, and improve their positive attitudes towards pain. Undergraduate nursing programmes should incorporate interactive training strategies (case-based learning, role-play, brainstorming, etc.) to help students learn effective coping methods and recognise their own pain beliefs and attitudes towards pain. Establishing simulation laboratories where students can experience all pain-related processes is also important in gaining knowledge and skills on pain management.

Author Contributions

All authors have agreed on the final version and meet at least one of the following criteria. Kamile Kırca: study design, data curation, writing review, methodology, investigation. Hüsna Özveren: study design, data curation, writing review, methodology, investigation, writing review and editing. Tuba Karabey: data curation, writing review, methodology.

Conflicts of Interest

The authors declare no conflicts of interest.