Objective To explore the current status and influencing factors of gastrointestinal surgery patients′ participation in posto- perative pain treatment decision-making,to provide references for improving the level of the participation. Methods A survey was conducted among 107 gastrointestinal surgery patients using a general information questionnaire, the Patient Participation in Treatment Decision-Making Questionnaire, Decision Self-Efficacy Scale, and the Numerical Rating Scale. Univariate analysis and logistic regression analysis were conducted to identify factors influencing patient participation in postoperative pain treatment decision-making. Semi-structured interviews were conducted with 11 patients selected from the quantitative study, and content analysis was used for the analysis. Results Pain treatment decision-making, while 34 (31.78%) had a negative attitude. In terms of actual participation, 26 patients (24.30%) were actively involved, whereas 81 patients (75.70%) were not actively involved. Logistic regression analysis revealed that age and pain score on postoperative day 2 were factors influencing patients' attitudes towards participating in postoperative pain treatment decision-making; age and self-efficacy were factors influencing patients′ actual participation in postoperative pain treatment decision-making (all P<0.05). The qualitative study identified five themes: the physical and mental constraints during the acute phase of postoperative pain, the cognitive misconception of "normalizing" postoperative pain, the information gap and comprehension barriers, the lack of self-efficacy and the relinquishment of power, and the economically driven avoidance of active decision-making. Conclusion Healthcare professionals should emphasize patients′ active participation and prefe-rences in postoperative pain managementin order to enhance the effectiveness of postoperative pain management, promote patient recovery, reduce complications caused by pain, and improve patient satisfaction.