Investigating the relationship between complementary and alternative therapy attitudes and pain management self-efficacy in surgical nurses: a cross-sectional study

Abstract

Background

Effective pain management is central to surgical nursing, yet nurses often face challenges in practice. Self-efficacy influences nurses’ ability to manage pain, whereas attitudes toward complementary and alternative medicine (CAM) may also shape clinical decision-making. However, little is known about how CAM attitudes are related to surgical nurses’ pain management self-efficacy. This study aimed to investigate the relationships between complementary and alternative therapy attitudes and pain management self-efficacy among surgical nurses.

Methods

A cross-sectional analytical study was conducted with 153 surgical nurses working at a foundation university hospital in a metropolitan city in Turkey. Data were collected using a descriptive questionnaire, the Pain Management Self-Efficacy Questionnaire, and the Holistic Complementary and Alternative Medicine Questionnaire. Associations were analyzed with multiple linear regression.

Results

Higher holistic health attitudes significantly and negatively predicted comprehensive (B = − 0.497, p = 0.001), evaluative (B = − 0.104, p = 0.009), supplemental (B = − 0.072, p = 0.035), and total self-efficacy scores (B = − 0.674, p = 0.001).

Conclusion

This study revealed that surgical nurses’ favorable holistic health attitudes were associated with lower pain management self-efficacy. Recognizing this gap highlights the need to integrate evidence-based CAM content into undergraduate and continuing education and to develop institutional protocols that support holistic approaches. Such strategies may enhance nurses’ competence and confidence, ultimately improving patient-centered pain care. Future longitudinal and interventional studies are needed to confirm whether embedding CAM education strengthens self-efficacy in clinical practice.

Clinical trial number

Not applicable.

Introduction

Pain is a complex phenomenon that varies across individuals. The International Association for the Study of Pain defines it as “an unpleasant emotional sensation related to past experiences, which may or may not be associated with tissue damage originating from a specific part of the body” [1]. Pain is generally classified as acute, which is short-term and often linked to tissue damage, or chronic, which persists beyond the normal healing period [1]. Postoperative pain, a type of acute pain, typically arises after surgery, is well localized, and diminishes as healing progresses [2]. It is a major clinical concern due to its high prevalence and significant impact on recovery and patient outcomes. Globally, more than 300 million surgical procedures are performed annually, and approximately 80% of patients report postoperative pain [3]. Among these, many experience moderate to severe pain, highlighting ongoing inadequacies in pain management [3].

Uncontrolled postoperative pain can result in serious complications, such as delayed wound healing, impaired respiratory function, deep vein thrombosis, prolonged hospitalization, and even chronic pain syndromes [4–6]. A large-scale study confirmed a strong correlation between the severity of postoperative pain and complication rates, underscoring the need for effective pain management [7].

Effective management requires a multidisciplinary approach, with individualized assessment and interventions based on patients’ reports [8, 9]. Outcomes are influenced by surgical factors (type and extent of incision, anesthesia), patient factors (psychological state, pain history, complications), and healthcare system factors (training, resources, provider attitudes) [4–6]. Nurses are central to this process, as they spend the most time with patients in the postoperative period and play a critical role in assessing and managing pain. They also provide nonpharmacologic interventions when pharmacologic treatments are insufficient, such as relaxation, music therapy, meditation, and massage [10, 11]. Nurses’ attitudes toward pain management directly affect care quality: negative attitudes may worsen outcomes, whereas higher self-efficacy enables more effective pain management [12].

Nurses’ competencies in pain management enable them to be more careful and empathetic in patient care. In the recognition, evaluation, and appropriate intervention of pain in the postoperative period, the belief, and confidence of nurses, who are health professionals, in their knowledge, behavior, attitudes and clinical decision-making skills to manage pain are effective and this belief, and confidence constitute their self-efficacy. Pain management self-efficacy is an important indicator of behavior change and improves the quality of nursing care. Pain management self-efficacy refers to nurses’ confidence in their ability to assess, interpret, and intervene in patients’ postoperative pain via both pharmacologic and nonpharmacologic strategies. In this context, self-efficacy reflects not only clinical knowledge and decision-making but also professional autonomy and beliefs about acceptable care methods. Interestingly, some studies suggest that high self-efficacy may not always align positively with attitudes toward complementary and alternative medicine (CAM). This may be due to a stronger reliance on conventional approaches among confident practitioners, who may perceive CAM methods as secondary or less evidence-based. Alternatively, nurses with high self-efficacy might prioritize biomedical models of care and view holistic practices as outside their professional scope or inconsistent with institutional norms. A high level of self-efficacy in pain management seems to be associated with improved pain [12–14]. In the literature, nurses with high pain management self-efficacy use pharmacological methods as well as nonpharmacological methods when appropriate to improve pain [14, 15]. Alzghoul and Chew Abdullah (2020) reported that self-efficacy is a mediator between knowledge and attitudes and that it plays an important role in transforming self-efficacy into curative pain management practices [15]. Another study showed that nurses with good knowledge and positive attitudes toward pain have high self-efficacy in parallel with studies in the literature [16].

Studies have explored nurses’ pain management knowledge, attitudes, and practices, and others have examined the use of complementary and alternative medicine (CAM) in clinical settings; however, there is limited research investigating the intersection of these domains [14–16]. Specifically, the relationships between nurses’ self-efficacy in pain management and their attitudes and behaviors toward CAM remain underexplored, particularly among nurses working in surgical clinics. Understanding this relationship is critical, as integrating evidence-based CAM methods with conventional approaches may enhance pain control, especially when pharmacologic options are limited or insufficient. Furthermore, identifying factors that influence nurses’ confidence and decision-making in pain management can inform targeted interventions in education and clinical training. This study is therefore necessary to address this knowledge gap and to contribute to the development of more comprehensive, multidisciplinary, and patient-centered pain management strategies in surgical settings. The findings are expected to support the enhancement of nursing curricula and continuing professional development programs, ultimately improving patient outcomes through more effective pain care.

In Turkey, complementary and alternative medicine (CAM)—officially acknowledged under the Traditional and Complementary Medicine Regulation (T&CM)—has garnered heightened interest in recent years, bolstered by legal structures instituted by the Ministry of Health. Nonetheless, although regulatory progress exists, the incorporation of CAM into standard clinical practice—especially within university hospitals—continues to be restricted. These institutions, including the foundational university where this study was conducted, frequently prioritize biomedical, evidence-based care and adhere to stringent procedural norms. Consequently, CAM is infrequently integrated into therapeutic recommendations or endorsed by institutional frameworks. The lack of standardized complementary and alternative medicine training in nursing education and the absence of defined implementation pathways hinder nurses’ capacity to practice holistically. These systemic constraints may result in a divergence between nurses’ favorable perceptions of CAM and their actual self-efficacy in implementing these strategies. There are also notable gaps in nursing education regarding evidence-based CAM content, as well as a lack of institutional support for integrating these practices into clinical care. These practical limitations may contribute to nurses’ low confidence in applying holistic approaches, despite positive personal attitudes. This study addresses these gaps by examining how nurses’ attitudes toward CAM are related to their self-efficacy in managing postoperative pain. By identifying this relationship, the findings can inform targeted improvements in both educational curricula and institutional strategies, ultimately supporting the integration of holistic approaches in clinical nursing practice.

To the best of our knowledge, no previous study has specifically explored the relationship between surgical nurses’ self-efficacy in pain management and their attitudes toward complementary and alternative therapies. Considering the growing importance of holistic approaches in nursing care, identifying this relationship may guide educational strategies and improve patient outcomes. Therefore, this cross-sectional study aimed to investigate the relationships between complementary and alternative therapy attitudes and pain management self-efficacy among surgical nurses.

Methods

Study design

The study was a cross-sectional analytical study. The study was conducted between September 15 and November 15, 2024. The STROBE reporting guidelines were used to prepare the manuscript.

Participants

The study was conducted with nurses working in the surgical clinics of a foundation university hospital located in a metropolitan city in Turkey between September 15 and November 15, 2024.

The target population consisted of all registered nurses (n = 160) working in surgical clinics (including surgical inpatient services, intensive care units, operating rooms, and emergency units) at the hospital during the study period. No random sampling was applied; instead, total population sampling was used to include the entire accessible group of surgical nurses.

Data were collected during nurses’ shifts at times that did not interfere with their clinical responsibilities. Of the 160 nurses invited, 153 agreed and completed the survey, yielding a 95.6% response rate. Nonparticipation (n = 7) included two nurses who declined, one on medical leave, and four with less than one month of experience in surgical clinics. There were no dropouts after consent, and all participants completed the questionnaires in full (Fig. 1).

Fig. 1.

Strobe flow diagram

Inclusion and exclusion criteria were based on prior studies of pain management among nursing populations [21–23]. Nurses were eligible to participate if they had at least one month of experience working in a surgical clinic—ensuring adequate exposure to pain management routines—and if they voluntarily consented to participate in the study. Nurses were excluded if they were on medical leave or vacation during the data collection period, or if they had less than one month of professional experience in surgical settings. The demographic characteristics and key clinical variables of the surgical nurses are presented in Table 1.

Table 1.

Demographic characteristics and key clinical variables of surgical nurses (n = 153)

Variables	n (%) or M (± sd)	95% CI
Age (years)	27.85 (7.36)	[26.68 to 29.03]
Gender
Female	125 (81.7)
Male	28 (18.3)
Marital status
Married	58 (39.9)
Single	95 (62.1)
Education status
Health Vocational High School	37 (24.2)
Associate degree	58 (37.9)
Bachelor’s degree	58 (37.9)
Length of service in the profession (years)	6.81 (6.73)	[5.73 to 7.89]
Duration of work in the surgery clinic (years)	4.82 (5.63)	[3.92 to 5.72]
Participation in a training on pain
Yes	74 (48.4)
No	79 (51.6)
Following publications on pain management
Yes	11 (7.2)
No	142 (92.8)
Assessment of the pain of the patient being cared for
Yes	147 (96.1)
No	6 (3.9)
Method used to relieve pain in pain management*
Pharmacological methods Nonpharmacological methods	68 (44.4) 78 (4.6)
Two methods together	78 (51.0)

Note: M, mean; SD, standard deviation; CI, confidence interval

*More than one option is marked

Continuous variables (e.g., age, years of clinical experience) are presented as mean ± SD and 95% confidence intervals. Categorical variables are presented as frequency (n) and percentage (%)

Instruments

Data were collected via self-report using three instruments: the “Descriptive Characteristics Information Form”, the “Pain Management Self-Efficacy Questionnaire”, and the “Holistic Complementary and Alternative Medicine Questionnaire”.

Descriptive characteristics information form

Developed by the researchers based on a literature review, this form included seven items assessing sociodemographic and professional characteristics.

Pain management self-efficacy questionnaire

The Pain Management Self-Efficacy Questionnaire (PMSEQ) was developed by John Rey Macindo et al. in 2018 [17], and its validity and reliability in Turkish were assessed by Sayılan et al. in 2022 [18]. The PMSEQ was developed to measure the confidence that both nurses, and student nurses perceive in providing pain management to a range of patients. The 21-item instrument uses a six-point Likert-type scale (0 = “not at all confident” to 5 = “very confident”). The PMSEQ has three subdimensions: comprehensive pain management self-efficacy (C-PMSE), evaluative pain management self-efficacy (E-PMSE), and supplemental pain management self-efficacy (S-PMSE). The overall scale score ranges from min: 0 to max: 105. There is no cutoff point on the scale. As the score increases, compliance increases. A representative item from the C-PMSE subscale is “I feel confident in selecting the most appropriate intervention on the basis of pain assessment”. The full PMSEQ scale is available in the original publication by Sayılan et al. [18]. The Cronbach’s alpha obtained in this study is 0.80.

Holistic complementary and alternative medicine questionnaire

The holistic complementary and alternative medicine questionnaire (HCAMQ) was developed by Hyland et al. (2003) [19], and its validity and reliability in China were assessed by Erci in 2003 [20]. The Likert-type scale consists of 11 items on a six-point scale: strongly agree (1), agree (2), mildly agree (3), mildly disagree (4), disagree (5), and strongly disagree (6). Items 2, 4, 6, and 9 were scored negatively, and the rest were scored positively. The HCAMQ has two subdimensions: holistic health (HH) and complementary and alternative medicine (CAM). A representative sample item from the Holistic Health subscale of the HCAMQ is “Positive thinking can help you fight off a minor illness.” A lower score on the HCAMQ indicates more positive attitudes toward the HCAM [20]. The HCAMQ items can be accessed from the article by Erci [20]. The Cronbach’s alpha obtained from this study was 0.78. Given that CAM practices hold a culturally significant place in the Turkish Society but are not systematically integrated into clinical protocols in institutional hospitals, participants’ responses to the HCAMQ may reflect both personal beliefs and perceived professional norms. These cultural dynamics should be considered when interpreting attitude scores, as they may introduce variability or response bias.

Data collection procedure

After institutional and ethical approval was obtained, the researchers visited the surgical clinics in person. Paper-based surveys were administered to nurses in break rooms or designated quiet areas to maintain confidentiality and minimize work disruption. The participants completed the questionnaires independently and anonymously, and the estimated completion time was 15–20 min.

Data analysis

Statistical analyses were performed using SPSS Version 27. Descriptive statistics are reported as means and standard deviations (SDs) for continuous variables, and frequencies and percentages for categorical variables. Group comparisons were performed using the Mann–Whitney U and Kruskal–Wallis H tests. Pearson’s correlation coefficient was used to examine bivariate associations. Multiple linear regression was employed to identify predictors of pain management self-efficacy (total and subscale PMSEQ scores). The main predictor was the Holistic Health (HH) subscale of the HCAMQ. Assumptions of regression (normality, linearity, homoscedasticity, and multicollinearity) were tested with residual plots, histograms, and the variance inflation factor (VIF). All assumptions were met, and no multicollinearity was detected (VIFs < 2). There were no missing data; all participants completed the instruments in full. A post hoc power analysis was also performed. With a sample size of 153, an alpha of 0.05, and a medium effect size (f² = 0.15), the study had > 90% power to detect significant relationships in regression models with up to three predictors (G*Power 3.1). This confirmed the adequacy of the sample size.

Ethical considerations

This study was approved by the Başkent University Institutional Review Board and Ethics Committee (KA24/248, 10/07/2024) and the chief physician of the hospital where the study was conducted. The study was conducted in accordance with the principles of the Declaration of Helsinki. Permissions for the PMSEQ and HCAMQ were obtained from the scale developers. Written and verbal informed consent was obtained from all participants.

Results

The total number of samples is 153. The mean age of the surgical nurses was 27.85 ± 7.36 years, and 81.7% were female. Other demographic characteristics of the study samples are presented in Table 1.

Self-efficacy in pain management and attitudes toward holistic complementary and alternative medicine

Although not shown in the table, the mean total score of the pain management self-efficacy questionnaire of surgical nurses was 89.62 ± 13.09, the comprehensive pain management self-efficacy subscale was 59.76 ± 9.38, the evaluative pain management self-efficacy subscale was 17.45 ± 2.47, and the supplemental pain management self-efficacy subscale was 12.39 ± 2.12. The mean total score of the holistic complementary and alternative medicine questionnaire of surgical nurses was 33.01 ± 6.95, that of the complementary and alternative medicine questionnaire was 22.08 ± 4.33, and that of the holistic health subscale was 10.92 ± 4.99.

Comparison of self-efficacy scales for pain management and attitudes toward holistic complementary and alternative medicine according to several variables

As shown in Table 2, surgical nurses who received pain management training or who routinely assessed patients’ pain had significantly higher scores in various dimensions of pain management self-efficacy. Additionally, male nurses reported significantly more favorable attitudes toward CAM, and those without prior pain training scored higher on the holistic health subdimension (Table 3).

Table 2.

Comparison of surgical nurses’ pain management self-efficacy by variables (n = 153)

	Pain management self-efficacy questionnaire
Variables	C-PMSE	E-PMSE	S-PMSE	Total Score
	Med (Q1-Q3)	Med (Q1-Q3)	Med (Q1-Q3)	Med (Q1-Q3)
Gender
Female	61.00 (54–67)	18.00 (16–20)	13.00 (11–14)	92.00 (81–99) 92.00 (82–100) Z = 0.427 p = 0.669
Male	62.00 (54–68)	17.00 (16–20)	12.50 (12–14)
Analysis	Z=-0.759 p = 0.448	Z=-0.339 p = 0.735	Z = 0.024 p = 0.981
Participation in a training on pain
Yes	62.00 (56–67)	18.00 (16–20)	13.00 (12–14)	94.00 (84–99) 90.00 (80–99) Z=-1.575 p = 0.115
No	60.00 (53–67)	17.00 (16–20)	12.00 (11–14)
Analysis	Z=-1.649 p = 0.099	Z=-0.563 p = 0.573	Z=-2.205 p = 0.027
Assessment of the pain of the patient being cared for
Yes	62.00 (54–67)	18.00 (16–20)	13.00 (11–14)	92.00 (82–99) 79.00 (63–89) Z=-2.022 p = 0.043
No	52.50 (40–60)	16.00 (14–17)	11.50 (7–12)
Analysis	Z=-1.911 p = 0.056	Z=-1.981 p = 0.048	Z=-2.029 p = 0.042

Note: Med, median; C-PMSE, Comprehensive pain management self-efficacy; E-PMSE, Evaluative Pain management self-efficacy; S-PMSE, Supplemental pain management self-efficacy

Table 3.

Comparison of surgical nurses’ CAM and holistic health attitudes by variables (n = 153)

	Holistic complementary and alternative medicine questionnaire
Variables	CAM	HH	Total Score
	Med (Q1-Q3)	Med (Q1-Q3)	Med (Q1-Q3)
Gender
Female	21.00 (19–25)	11.00 (7–13)	32.00 (28–36)
Male	24.00 (22–26)	9.00 (7–12)	34.00 (31–36)
Analysis	Z=-2.503 p = 0.012	Z=-0.859 p = 0.391	Z=-1.298 p = 0.194
Participation in a training on pain
Yes	22.50 (20–25)	9.00 (7–12)	32.00 (28–35)
No	22.00 (19–25)	11.00 (8–13)	32.00 (29–37)
Analysis	Z=-0.104 p = 0.917	Z=-2.065 p = 0.039	Z=-1.151 p = 0.250
Assessment of the pain of the patient being cared for
Yes	22.00 (19–25)	10.00 (7–13)	32.00 (29–36)
No	23.50 (21–26)	11.00 (8–12)	33.00 (31–37)
Analysis	Z=-0.764 p = 0.445	Z=-0.246 p = 0.806	Z=-0.570 p = 0.569

Note: Med, median; CAM, Complementary and alternative medicine; HH, Holistic health

Correlations between nurses’ pain management self-efficacy, holistic complementary and alternative medicine attitudes, and demographic variables

Correlation analysis revealed that holistic health was significantly and negatively associated with all dimensions of pain management self-efficacy (C-PMSE, E-PMSE, S-PMSE, and the total score). In contrast, the HCAMQ total score showed a strong positive correlation with holistic health and a moderate positive correlation with CAM attitudes (Table 4).

Table 4.

Pearson correlation coefficients between pain management self-efficacy, CAM attitudes, and demographics in nurses (n = 153)

Variables	Age	Length of service in the profession (years)	Duration of work in the surgery clinic (years)	C-PMSE	E-PMSE	S-PMSE	PMSEQ Total Score	CAM	HH	HCAMQ Total Score
Age	1
Length of service in the profession (years)	0.906**	1
Duration of work in the surgery clinic (years)	0.772**	0.846**	1
C-PMSE	-0.048	-0.007	-0.050	1
E-PMSE	-0.056	-0.002	-0.002	0.749**	1
S-PMSE	0.051	0.105	0.105	0.764**	0.699**	1
PMSEQ Total Score	-0.037	0.011	-0.040	0.983**	0.840**	0.842**	1
CAM	0.108	0.084	0.147	0.098	0.140	0.094	0.112	1
HH	0.016	0.033	-0.018	-0.265**	-0.210**	-0.170*	-0.257**	0.108	1
HCAMQ Total Score	0.079	0.076	0.079	-0.129	-0.064	-0.064	-0.115	0.700**	0.785**	1

Note: C-PMSE, Comprehensive pain management self-efficacy; E-PMSE, Evaluative Pain management self-efficacy; S-PMSE, Supplemental pain management self-efficacy; PMSEQ, Pain management self-efficacy questionnaire; CAM, Complementary and alternative medicine; HH, Holistic health; HCAMQ, Holistic complementary and alternative medicine questionnaire

*p < 0.05, **p < 0.01

Multiple regression analysis of self-efficacy in pain management

Multiple regression analysis showed that holistic health was a significant negative predictor of all dimensions of pain management self-efficacy. The strongest effect was for C-PMSE, where holistic health explained 7% of the variance, followed by 4% for E-PMSE, 2% for S-PMSE, and 6% for the total score. These results indicate that although the explained variance was modest, the negative association was consistent across all models. Model fit indices, including the Akaike information criterion (AIC) and Bayesian information criterion (BIC), were also reported for each model (Table 5) (Figs. 2 and 3).

Table 5.

Multiple linear regression analysis predicting pain management self-efficacy by holistic health (n = 153)

Outcome (DV)	β	SE	95% CI	R²	p-value	AIC	BIC
C-PMSE	-0.497	0.147	[-0.789 to -0.206]	0.07	0.001	676.90	682.96
E-PMSE	-0.104	0.039	[-0.182 to -0.026]	0.04	0.009	273.44	279.50
S-PMSE	-0.072	0.034	[-0.140 to -0.005]	0.02	0.035	229.84	235.90
Total PMSE	-0.674	0.206	[-1.081 to -0.267]	0.06	0.001	780.52	786.58

Note: β, Unstandardized regression coefficient; SE, Standard error; CI, Confidence interval; AIC, Akaike information criterion; BIC, Bayesian information criterion

C-PMSE, Comprehensive pain management self-efficacy; E-PMSE, Evaluative Pain management self-efficacy; S-PMSE, Supplemental pain management self-efficacy; PMSEQ, Pain management self-efficacy questionnaire

All p-values are reported as exact values

Fig. 2.

Forest plot of regression results

Fig. 3.

Conceptual model linking holistic health orientation to pain management self-efficacy components

Discussion

In this section, the results of our study, which investigated the relationship between pain management self-efficacy of surgical nurses and their attitudes toward complementary and alternative therapies, are discussed in line with the literature. Although higher self-efficacy is generally associated with improved pain outcomes, pain management self-efficacy remains critical for ensuring quality patient care. However, only a limited number of studies have investigated nurses’ self-efficacy in this field [21–23].

In our study, surgical nurses who had received training in pain management (p = 0.027) demonstrated higher S-PMSE scores. Similar findings have been reported in the literature. Online training for nurses caring for elderly patients undergoing total knee arthroplasty was shown to improve knowledge, attitudes, and self-efficacy [24]. Achaliwie et al. (2023) also reported that professional pain education enhances nurses’ skills and attitudes, improving both care practices and patient outcomes [25]. Zhang et al. (2025) found that although 76.5% of nurses had received training, more than one-third had not been trained in the past two years, and only 4.9% felt confident that their knowledge was sufficient for clinical practice. Factors such as prior training, frequency of updates, use of multidimensional assessment tools, and academic exposure to pain management courses all had significant effects on self-efficacy [23]. Alzghoul and Abdullah (2020) further showed that nurses with positive attitudes toward pain had higher self-efficacy, supporting the critical role of education in shaping practice [15]. Collectively, these findings highlight the importance of regular and comprehensive training to strengthen nurses’ knowledge, attitudes, and confidence in managing pain.

Accurate pain assessment is another key factor for effective treatment planning. Using standardized tools creates a common language among health professionals and helps evaluate not only the severity of pain but also its impact on recovery [23, 26]. Piyakhachornrot and Youngcharoen (2024) emphasized that educational programs combining assessment tools with management guidelines significantly improve self-efficacy [24]. Zhang et al. (2025) noted that 57.9% of nurses did not use multidimensional tools, focusing only on intensity and location. This limited approach often neglected pain duration or nature, leading to inadequate care [23]. In our study, nurses who routinely assessed pain achieved higher S-PMSE (p = 0.042), E-PMSE (p = 0.048), and PMSEQ (p = 0.043) scores. These results confirm that systematic pain assessment enhances self-efficacy and helps nurses provide higher-quality care.

A paradoxical finding of our study was that the mean score of the holistic health subscale was higher in nurses who had not received training on pain (p = 0.039). Training would normally be expected to foster a holistic perspective, but the opposite pattern was observed. This may reflect training content that emphasized biomedical approaches while overlooking holistic elements. It may also suggest that those without training tend to idealize complementary approaches due to limited knowledge. The quality, duration, and focus of training programs therefore need careful evaluation [27, 28].

The negative correlations between Holistic Health and Pain Management Self-Efficacy (r = − 0.270, r = − 0.210, r = − 0.170, r = − 0.260) suggest that as nurses’ orientation toward holistic health increases, their perceived self-efficacy in pain management decreases. The regression results further support this inverse relationship, with holistic health scores significantly predicting lower C-PMSE (B = -0.497), E-PMSE (B = -0.104), S-PMSE (B = -0.072), and total PMSEQ (B = -0.674) scores. This counterintuitive finding—where nurses with positive attitudes toward holistic health report lower self-efficacy in pain management—warrants deeper interpretation. Theoretically, one might expect that endorsing holistic values would align with greater confidence in the use of a broader range of pain management strategies. However, this relationship appears more complex. The holistic health approach emphasizes the physical, emotional, and social dimensions of care [29], yet surgical nurses often work in environments dominated by the biomedical model, where rapid interventions and standardized protocols prevail [23]. This disconnect may limit opportunities for nurses to practice holistically, reducing their perceived efficacy in applying pain management interventions. Furthermore, nurses with heightened holistic awareness may be more critical of their knowledge and skills, particularly when institutional structures constrain the implementation of multidimensional pain approaches [30]. According to Bandura’s self-efficacy theory, confidence develops primarily through mastery experiences, observational learning, and social reinforcement. In clinical environments where CAM methods are neither formally modeled nor supported, nurses may lack opportunities to gain experiential competence. Additionally, nurses with strong holistic orientations may experience professional role conflict in institutional settings where biomedical models dominate and holistic approaches are not actively encouraged. This disconnect may undermine their perceived ability to implement CAM strategies, despite their favorable attitudes.

In addition, the low R² values (ranging from 0.02 to 0.07) indicate that while holistic health attitudes significantly predict subscales of pain management self-efficacy, they explain only a small portion of the variance. Specifically, holistic health accounted for 7% of the variance in C-PMSE, 4% in E-PMSE, 2% in S-PMSE, and 6% in the total PMSEQ score. This suggests that other factors play a more substantial role, including prior pain management training, institutional culture, clinical experience, and interprofessional collaboration. Future research should adopt broader models that include these factors to better explain the development of pain management self-efficacy.

The observed gap between positive attitudes toward CAM and lower pain management self-efficacy suggests that nurses may theoretically support holistic approaches but lack the confidence or institutional opportunity to implement them in practice, likely due to the biomedical orientation of care settings where CAM is not routinely supported. To bridge this attitude–efficacy gap, targeted interventions are essential. Simulation-based CAM training programs that incorporate evidence-based techniques into realistic scenarios can strengthen both competence and confidence, while structured mentorship from experienced CAM practitioners may enhance the translation of knowledge into practice. In addition, integrating CAM content into undergraduate curricula and continuing education could align holistic beliefs with clinical action and promote more confident and competent use of CAM in pain management. Since our study focused on attitudes rather than actual behaviors, future research should explore how these beliefs translate into practice and how institutional support (or lack thereof) mediates this relationship.

This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines to ensure transparent and rigorous reporting of methods, analyses, and findings. By aligning with the STROBE criteria, this study contributes to the growing emphasis on methodological quality in nursing research. Clear and structured reporting not only enhances reproducibility but also sets a standard for future observational studies in nursing education and clinical practice.

Conclusion

This study demonstrated that although surgical nurses expressed favorable attitudes toward holistic and complementary health approaches, their self-efficacy in managing postoperative pain remained relatively low. This inverse relationship highlights a gap between belief and practice, likely shaped by limited institutional support, insufficient CAM-related training, and professional role constraints. To address this gap, integrating evidence-based CAM education into both prelicensure nursing curricula and continuing professional development is essential. Such integration could provide nurses with the theoretical foundation and practical competence needed to manage pain with greater confidence and a more holistic perspective. Future research should also examine additional factors—including clinical experience, mentorship, and organizational culture—that may further influence self-efficacy in holistic pain care. Although this study achieved a high participation rate, the possibility of selection bias must be acknowledged. The small number of nonparticipants may have held different perspectives, which could limit the representativeness of the findings. Building on these results, longitudinal and interventional studies are warranted to determine whether incorporating evidence-based CAM content into nursing education effectively enhances pain management self-efficacy in clinical practice.

Limitations

This study has several limitations. Because the data were self-reported, the findings may be subject to response bias, including social desirability effects. The cross-sectional design also constrains the ability to draw causal inferences regarding the relationship between holistic attitudes and pain management self-efficacy. Moreover, the single-center setting—limited to surgical nurses in a foundation university hospital—restricts the generalizability of the results to other contexts. Cultural and institutional factors may likewise have influenced responses to the HCAMQ: while CAM practices are embedded in Turkish traditions, their limited institutional acceptance in university hospitals may create discrepancies between personal attitudes and perceived professional expectations, potentially introducing response inconsistencies. Finally, unmeasured confounders such as prior CAM experience, workload, institutional culture, and availability of mentorship may have affected the observed associations. Future longitudinal and multi-center studies, particularly those incorporating targeted educational or organizational interventions, are recommended to better capture causal relationships and changes in self-efficacy over time.

Abbreviations

CAM

Complementary and alternative medicine

C-PMSE

Comprehensive pain management self-efficacy

E-PMSE

Evaluative pain management self-efficacy

HCAM

Holistic complementary and alternative medicine questionnaire

HH

Holistic health

PMSEQ

Pain Management self-efficacy questionnaire

SD

Standard deviation

S-PMSE

Supplemental pain management self-efficacy

Author contributions

All the authors contributed to the research idea and design. SAI is the principal investigator of the study. SAI and SK conducted the statistical analysis and wrote the paper.

Funding

This research received no external funding.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Baskent University Institutional Review Board and Ethics Committee (KA24/248, 10/07/2024). The study was conducted in accordance with the principles of the Declaration of Helsinki. The participants were provided with information about the research and its objectives, the confidentiality of their information, their right to withdraw from the study, and their access to the study findings. Written informed consent was obtained from all participants, and the necessary permissions were obtained from authorities before sampling.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.