Background: Effective pain management is closely related to nurses' knowledge and attitudes toward pain. Limited studies have been performed related to nurses' knowledge and attitudes toward pain in hospitals in low-income areas. Aims: This study surveyed the knowledge and attitudes of nurses toward pain management in county hospitals from low-income areas in Hunan Province, China. Setting and participants: The study included 4,668 registered nurses working in 48 county hospitals in low-income areas in China. Methods: A cross-sectional study examined the knowledge and attitudes of nurses with regard to pain using the Chinese version of the Knowledge and Attitude Survey Regarding Pain (KASRP) via the WeChat application. Results: The 4,668 registered nurses completed the survey; of these, 43.6% indicated they had never received continuing education for pain. The mean percentage score for KASRP was (40.3 ± 7.95), and none of the respondents achieved a percentage score of >80%. Further, of the 40 items, only two had a correct rate of >80%. Continuing pain education did not significantly affect KASRP. Multiple stepwise linear regression showed that education level, ethnicity, professional title, position, and department were independent influencing factors for KASRP scores. Conclusion: Almost all nurses in county hospitals of low-income areas had deficiencies in various aspects of pain management knowledge. Better educated nurses with higher professional title or management position, those from the Han ethnicity, and those from the oncology department had higher mean KASRP scores. Current continuing education programs for pain did not improve the pain management capability of the nurse. High-quality and standardized pain educational programs should be implemented to improve pain management.