Critical incidents and post-traumatic stress symptoms among experienced registered nurses during the COVID-19 pandemic: A cross-sectional study.

Background: Registered nurses working on the frontline during the COVID-19 pandemic encountered significant challenges, including exposure to critical incidents. Critical incidents refer to sudden unexpected clinical events that surpass an individual's ability to cope, leading to considerable psychological distress, which could potentially result in the development of post-traumatic stress disorder symptoms. Research has shown a high prevalence of post-traumatic stress disorder symptoms among healthcare workers, particularly those in close contact with COVID-19 patients. Objective: To assess the levels of post-traumatic stress symptoms among registered nurses in relation to exposure to working conditions during the COVID-19 pandemic, such as how much their work was affected by the pandemic, re-deployment, working hours hindering sufficient recovery between shifts and critical incidents. Design: Cross sectional study. Settings: The registered nurses working in multiple health care services covering all 21 geographic regions in Sweden. Participants: A total of 1,923 registered nurses, who are part of a Swedish national cohort and have been followed since their nursing education, were invited to participate in a survey in late September 2021 (15 to 19 years post graduation). Methods: The data were analyzed using descriptive statistics, unpaired t-tests, and one-way analysis of variance. Cohen's d was employed to quantify differences in mean levels between subgroups. Results: The response rate were 56.5 %. Over 50 % of experienced registered nurses reported significant disruptions to their work environments. In total, 85 % of registered nurses were exposed to at least one critical incident in their work during the pandemic, with 60 % facing organisational changes and nearly 50 % experiencing emotionally distressing situations. The exposure to work situations involving critical incidents consistently demonstrated strong associations with higher levels of post-traumatic stress disorder symptoms compared to those not exposed, with effect sizes ranging from moderate to high. Conclusions: This study underscores the profound impact that working conditions, such as redeployment and exposure to critical incidents, have on the mental health of registered nurses. We offer valuable insights into registered nurses' pandemic-related challenges, highlighting the need for support and interventions to prevent and manage critical incidents, ultimately promoting their well-being. We also highlight the significance of thorough workforce readiness planning for future pandemics and other challenging health care scenarios, such as staff shortage.

Long-term impact of COVID-19 on nursing and care delivery: A national survey among anaesthetic and critical care nurses.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has put an exceptional strain on intensive care delivery and has significantly impacted nursing practice in the intensive care unit, consequently affecting nurses' working environment and health. Little is known about the long-term impact on the nursing workforce and care delivery in intensive care and anaesthetic departments. AIM/OBJECTIVE: This cross-sectional study aimed to describe the long-term impact of the COVID-19 pandemic on the nursing profession and nursing care from the perspectives of anaesthetic and critical care nurses. METHODS: In this study, an online questionnaire with open- and close-ended questions was distributed to registered nurses working in anaesthesia and intensive care between February 8 and March 7, 2022. The data were analysed using content analysis and descriptive statistics. RESULTS: Of the 514 registered nurses who responded to the questionnaire, 256 (50%) worked in anaesthesia care and 215 (42%) in intensive care. The long-term impact of COVID-19 was expressed in three categories: nursing care on hold, insights and experiences forming a new professional identity, and the impact of organisational conditions on the profession. Critical care nurses considered nursing care comparable to that before the COVID-19 pandemic. Nurse anaesthetics experienced changes in nursing tasks and activities compared to that before the COVID-19 pandemic. CONCLUSIONS: Nursing care is still influenced by the pandemic due to the lack of resources and persistent high workload and needs to be reclaimed and prioritised. Re-establishing high-quality nursing care is a shared responsibility of the organisation and nursing profession, and the organisation needs to create prerequisites for this. Furthermore, nurses' views and insights into their profession developed both positively and negatively during the pandemic, which must be further considered, including the profession's values.

Missed nursing care in relation to registered nurses' level of education and self-reported evidence-based practice.

BACKGROUND: Patient safety is one of the cornerstones of high-quality healthcare systems. Evidence-based practice is one way to improve patient safety from the nursing perspective. Another aspect of care that directly influences patient safety is missed nursing care. However, research on possible associations between evidence-based practice and missed nursing care is lacking. AIM: The aim of this study was to examine associations between registered nurses' educational level, the capability beliefs and use of evidence-based practice, and missed nursing care. METHODS: This study had a cross-sectional design. A total of 228 registered nurses from adult inpatient wards at a university hospital participated. Data were collected with the MISSCARE Survey-Swedish version of Evidence-Based Practice Capabilities Beliefs Scale. RESULTS: Most missed nursing care was reported within the subscales Basic Care and Planning. Nurses holding a higher educational level and being low evidence-based practice users reported significantly more missed nursing care. They also scored significantly higher on the Evidence-based Practice Capabilities Beliefs Scale. The analyses showed a limited explanation of the variance of missed nursing care and revealed that being a high user of evidence-based practice indicated less reported missed nursing care, while a higher educational level meant more reported missed nursing care. LINKING EVIDENCE TO ACTION: Most missed nursing care was reported within the subscales Planning and Basic Care. Thus, nursing activities are deprioritized in comparison to medical activities. Nurses holding a higher education reported more missed nursing care, indicating that higher education entails deeper knowledge of the consequences when rationing nursing care. They also reported varied use of evidence-based practice, showing that higher education is not the only factor that matters. To decrease missed nursing care in clinical practice, and thereby increase the quality of care, educational level, use of evidence-based practice, and organizational factors must be considered.

Differences between Registered Nurses and nurse assistants around missed nursing care-An observational, comparative study.

BACKGROUND: From a nursing perspective, tasks that are not carried out, and the consequences of this, have been studied for over a decade. The difference between Registered Nurses (RNs) and nurse assistants (NAs) regarding qualifications and work tasks, and the profound knowledge around RN-to-patient ratios, warrants investigating missed nursing care (MNC) for each group rather than as one (nursing staff). AIM: To describe and compare RNs and NAs ratings of and reasons for MNC at in-hospital wards. METHODS: A cross-sectional study with a comparative approach. RNs and NAs at in-hospital medical and surgical wards for adults were invited to answer the MISSCARE Survey-Swedish version, including questions on patient safety and quality of care. RESULTS: A total of 205 RNs and 219 NAs answered the questionnaire. Quality of care and patient safety was rated as good by both RNs and NAs. Compared to NAs, RNs reported more MNC, for example, in the item 'Turning patient every 2 h' (p < 0.001), 'Ambulation three times per day or as ordered' (p = 0.018), and 'Mouth care' (p < 0.001). NAs reported more MNC in the items 'Medications administered within 30 min before or after scheduled time' (p = 0.005), and 'Patient medication requests acted on within 15 min' (p < 0.001). No significant differences were found between the samples concerning reasons for MNC. CONCLUSION: This study demonstrated that RNs' and NAs' ratings of MNC to a large extent differed between the groups. RNs and NAs should be viewed as separate groups based on their different knowledge levels and roles when caring for patients. Thus, viewing all nursing staff as a homogenous group in MNC research may mask important differences between the groups. These differences are important to address when taking actions to reduce MNC in the clinical setting.

Nurse staffing levels in critical care: The impact of patient characteristics.

BACKGROUND: Intensive care is one of the most resource-intensive forms of care because seriously ill patients are cared for in units with high staffing levels. Studies show that the number of registered nurses (RNs) per patient and nurse education level affects patient outcome. However, there is a lack of studies that consider how nurses/patient ratio with an advanced educational level of specialized nurses in intensive care, affect the intensive care performed in different patient populations. AIM: To investigate if differences in patient characteristics and nurse-patient ratio have an impact on the quality of care. STUDY DESIGN: This is a retrospective observational study with a review of all patients >15 years receiving care at two general intensive care units with different nurse/patient ratio (unit A, 1:1 nurse/patient ratio and unit B, 0.5:1 nurse/patient ratio). RESULTS: There was no significant difference in the initial severity of illness between the units. However, younger patients, male patients and patients requiring surgery entailed a higher workload and a longer intensive care unit (ICU) stay despite a 1:1 critical care nurse/patient ratio. A small difference, but not significant, with more unplanned re-intubations occurred at unit A compared with unit B. CONCLUSION: The differences in the nurse/patient ratio did not reflect a difference in the severity of illness among admitted patients but might be explained by patient characteristics with different needs. RELEVANCE TO CLINICAL PRACTICE: Health care managers should consider not only the number of nurses but also their educational level, specific competencies and skills mix and nursing-sensitive measures to provide high-quality ICU care in settings with different patient characteristics. Nursing-sensitive patient outcomes should be considered in relation to nurse/patient ratio, as important to measure to ensure a high quality of patient care in the ICU.

Missed nursing care in the critical care unit, before and during the COVID-19 pandemic: A comparative cross-sectional study.

OBJECTIVES: Todescribe and evaluate reported missed nursing care in the critical care context during different phases of the COVID-19 pandemic in Sweden. RESEARCH METHODOLOGY: A comparative cross-sectional design was used, comparing missed nursing care in three samples: before the COVID-19 pandemic in 2019, during the second wave of the pandemic in spring 2020, and during the third wave of the pandemic in fall 2021. SETTING: The study was conducted at critical care units at a university hospital, Sweden. MAIN OUTCOME MEASURES: The MISSCARE Survey-Swedish version was used to collect data along with two study-specific questions concerning perception of patient safety and quality of care. RESULTS: Significantly more overtime hours and number of days absent due to illness were reported during the pandemic. The nurse/patient ratio was above the recommended level at all data collection time points. Most missed nursing care was reported in items concerning basic care. The most reported reasons for missed nursing care in all samples concerned inadequate staffing, urgent situations, and a rise in patient volume. Most nurses in all samples perceived the level of patient safety and quality of care as good, and the majority had no intention to leave their current position. CONCLUSION: The pandemic had a great impact on the critical care workforce but few elements of missed nursing care were affected. To measure and use missed nursing care as a quality indicator could be valuable for nursing managers, to inform them and improve their ability to meet changes in patient needs with different workforce approaches in critical care settings.

Patient safety, quality of care and missed nursing care at a cardiology department during the COVID-19 outbreak.

AIM: To evaluate missed nursing care and patient safety during the first wave of the COVID-19 pandemic at in-patient cardiology wards. DESIGN: A cross-sectional design with a comparative approach. METHOD: Registered nurses and nurse assistants at a cardiology department were invited to answer the MISSCARE Survey-Swedish version, and questions on patient safety and quality of care during the COVID-19 pandemic. The data were compared with a reference sample. RESULTS: A total of 43 registered nurses and nurse assistants in the COVID-19 sample and 59 in the reference sample participated. The COVID-19 sample reported significantly more overtime hours and more absence from work due to illness in comparison with the reference sample. The patient safety and quality of care were perceived significantly worse, 76.7% (N = 33) versus 94.7% (N = 54), and 85.7% (N = 36) versus 98.3% (N = 58, respectively. The COVID-19 sample reported more missed nursing care in wound care and in basic nursing.

Missed nursing care during the COVID-19 pandemic: A comparative observational study.

AIM: To evaluate frequencies, types of and reasons for missed nursing care during the COVID-19 pandemic at inpatient wards in a highly specialized university hospital. BACKGROUND: Registered nurse/patient ratio and nursing competence are known to affect patient outcomes. The first wave of the COVID-19 pandemic entailed novel ways for staffing to meet the expected increased acute care demand, which potentially could impact on quality of care. METHODS: A comparative cross-sectional study was conducted, using the MISSCARE Survey. A sample of nursing staff during the first wave of the COVID-19 pandemic (n = 130) was compared with a reference sample (n = 157). RESULTS: Few differences between samples concerning elements of missed care and no significant differences concerning reasons for missed care were found. Most participants perceived the quality of care and the patient safety to be good. CONCLUSION: The results may be explained by three factors: maintained registered nurse/patient ratio, patients' dependency levels and that nursing managers could maintain the staffing needs with a sufficient skill mix. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing managers impact on the occurrence of MNC; to provide a sufficient registered nurse/patient ratio and skill mix when staffing. They play an important role in anticipatory planning and during infectious disease outbreaks.

Registered nurses' experiences of working in the intensive care unit during the COVID-19 pandemic.

BACKGROUND: During the pandemic, increased numbers of patients requiring intensive care unit (ICU) admission required an increase in ICU capacity, including ICU staffing with competence to care for critically ill patients. Consequently, nurses from acute care areas were called in to staff the ICU along with experienced intensive care nurses. AIMS AND OBJECTIVES: To describe Swedish registered nurses' experiences of caring for patients with COVID-19 in ICUs during the pandemic. DESIGN: Mixed method survey design. METHODS: An online questionnaire was distributed through social media to registered nurses who had been working in the ICU during the COVID-19 outbreak. Data were collected for 1 week (May 2020) and analysed using content analysis and descriptive statistics. RESULTS: Of the 282 nurses who participated, the majority were ICU nurses (n = 151; 54%). Half of the nurses specialized in ICU reported that they were responsible for the ICU care of three or more patients during the pandemic (n = 75; 50%). Among non-intensive care nurses, only 19% received introduction to the COVID-19 ICU (n = 26). The analysis of data regarding nurses' experiences resulted in three categories: tumbling into chaos, diminished nursing care, and transition into pandemic ICU care. Participants described how patient safety and care quality were compromised, and that nursing care was severely deprioritized during the pandemic. The situation of not being able to provide nursing care resulted in ethical stress. Furthermore, an increased workload and worsened work environment affected nurses' health and well-being. CONCLUSIONS: The findings from the present study indicate that nurses perceived that patient safety and quality of care were compromised during the pandemic. This resulted in ethical stress among nurses, which may have affected their physical and psychosocial well-being. RELEVANCE TO CLINICAL PRACTICE: The COVID-19 pandemic had a severe impact on nurses' work environment, which could result in burnout and staff turnover.

Digitalizing a Brief Intervention to Reduce Intrusive Memories of Psychological Trauma for Health Care Staff Working During COVID-19: Exploratory Pilot Study With Nurses.

BACKGROUND: The COVID-19 pandemic has accelerated the worldwide need for simple remotely delivered (digital) scalable interventions that can also be used preventatively to protect the mental health of health care staff exposed to psychologically traumatic events during their COVID-19-related work. We have developed a brief behavioral intervention that aims to reduce the number of intrusive memories of traumatic events but has only been delivered face-to-face so far. After digitalizing the intervention materials, the intervention was delivered digitally to target users (health care staff) for the first time. The adaption for staff's working context in a hospital setting used a co-design approach. OBJECTIVE: The aims of this mixed method exploratory pilot study with health care staff who experienced working in the pandemic were to pilot the intervention that we have digitalized (for remote delivery and with remote support) and adapted for this target population (health care staff working clinically during a pandemic) to explore its ability to reduce the number of intrusive memories of traumatic events and improve related symptoms (eg, posttraumatic stress) and participant's perception of their functioning, and to explore the feasibility and acceptability of both the digitalized intervention and digitalized data collection. METHODS: We worked closely with target users with lived experience of working clinically during the COVID-19 pandemic in a hospital context (registered nurses who experienced intrusive memories from traumatic events at work; N=3). We used a mixed method design and exploratory quantitative and qualitative analysis. RESULTS: After completing the digitalized intervention once with remote researcher support (approximately 25 minutes) and a brief follow-up check-in, participants learned to use the intervention independently. All 3 participants reported zero intrusive memories during week 5 (primary outcome: 100% digital data capture). Prior to study inclusion, two or more intrusions in the week were reported preintervention (assessed retrospectively). There was a general pattern of symptom reduction and improvement in perceived functioning (eg, concentration) at follow-up. The digitalized intervention and data collection were perceived as feasible and rated as acceptable (eg, all 3 participants would recommend it to a colleague). Participants were positive toward the digital intervention as a useful tool that could readily be incorporated into work life and repeated in the face of ongoing or repeated trauma exposure. CONCLUSIONS: The intervention when delivered remotely and adapted for this population during the pandemic was well received by participants. Since it could be tailored around work and daily life and used preventatively, the intervention may hold promise for health care staff pending future evaluations of efficacy. Limitations include the small sample size, lack of daily intrusion frequency data in the week before the intervention, and lack of a control condition. Following this co-design process in adapting and improving intervention delivery and evaluation, the next step is to investigate the efficacy of the digitalized intervention in a randomized controlled trial.

Translation, culture adaption and psychometric testing of the MISSCARE Survey-Swedish version.

AIM: To translate the MISSCARE Survey into Swedish and establish its validity and reliability by evaluating its psychometric properties. BACKGROUND: Missed nursing care is defined as any aspect of required nursing care that is omitted or delayed. The consequence of missed nursing care is a threat to patient safety. The MISSCARE Survey is an American instrument measuring missed nursing care activities (part A) and its reasons (part B). METHODS: The translation was accomplished according to World Health Organization guidelines, focusing on a culture adaptation. Acceptability, construct validity, test-retest reliability and internal consistency were analysed. The Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) was used as reporting checklist. RESULTS: The translation and culture adaptation needed several revisions. A total of 126 nurses answered the test and retest which showed acceptability of missing data. The factor analysis revealed a lack of fit to data for the original factorial structure in part B, while further analysis provided results suggesting a modification based on omitting six items. The internal consistency for part B and its subscales showed good results. CONCLUSIONS: The MISSCARE Survey-Swedish version is a reliable and valid instrument, with good psychometric properties. RELEVANCE TO CLINICAL PRACTICE: More reliable language versions of the instrument enable national and international comparisons that could be valuable for nursing managers and/or directors of nursing who are responsible for quality of care and patient safety in the strategic care planning process.

Patient experiences of initial trauma care.

BACKGROUND: Correct initial treatment of trauma patients reduces mortality and morbidity. However, the initial examination may be perceived as traumatic because of the stressful situation, the unfamiliar setting and the shock of being seriously injured. To date, little is known about patient's experiences of initial trauma management. The aim of this study was to explore trauma patients' experiences of being exposed to initial full trauma team assessment at a Level 1 trauma centre. METHODS: Interviews with 16 patients who had been exposed to initial trauma care were conducted at a Level 1 trauma centre, at a Swedish University Hospital. The interviews were transcribed verbatim and analysed with qualitative content analysis. RESULTS: Patients' experiences of initial trauma care can be summarized as: feeling safe in a frightening situation. The trauma team members were mostly perceived as professional, well-organised, and efficient. Yet, the patients described an emotional response to the trauma, physical discomfort during the examination, and feeling prioritised or being ignored in the encounter with the trauma team members. CONCLUSION: The initial trauma care may be improved if the trauma team members keep the patient's physical and emotional wellbeing in focus and maintain an informative dialogue with the patient during the whole process.

Prehospital emergency care nurses' strategies while caring for patients with limited Swedish-English proficiency.

AIMS AND OBJECTIVES: To explore the strategies of nurses working in the ambulance service while caring for patients with limited Swedish-English proficiency. BACKGROUND: Communication difficulties due to lack of mutual language is a challenge in healthcare systems around the world. Little is known about nurses' strategies while caring for patients with whom they do not share a mutual language in an unstructured, unplanned prehospital emergency environment, the ambulance service. DESIGN AND METHOD: A qualitative study design based on interviews was used, and a purposeful sample and snowball technique were used to identify nurses with prehospital emergency experience of caring for patients with limited Swedish-English proficiency. RESULTS: Eleven nurses were interviewed, and the main strategy they used was adapting to the patients' need and the caring situation. The nurses used their own body, and tone of voice for creating a sense of trust and security. The nurses also used structured assessment in accordance with medical guidelines. Translation devices and relatives/bystanders were used as interpreters when possible. Another strategy was to transport the patient directly to the emergency department as they had not found a secure way of assessing and caring for the patients in the ambulance. CONCLUSION: The nurses used a palette of strategies while assessing and caring for patients when there was no mutual language between the caregiver and care seeker. RELEVANCE TO CLINICAL PRACTICE: The nurses need to be prepared for how to assess and care for patients when there is a lack of mutual language; otherwise, there is a risk of increased unequal care in the ambulance service. To further explore and learn about this field of research, studies exploring the patients' perspective are needed.

Registered nurses' own experience of using a nurse-initiated pain protocol based on their working experience.

AIMS AND OBJECTIVES: To explore registered nurses' (RNs) own experience of using the nurse-initiated pain protocol (NIPP) in the emergency department (ED) based on their working experience. BACKGROUND: Pain is known to be one of the most common symptoms among adult patients seeking care at the ED. Several strategies aiming to improve pain management have been developed. Despite some improvements in pain management using NIPP, a large number of patients continue to have inadequate pain treatment when cared for in EDs. DESIGN AND METHOD: A cross-sectional study design based on a questionnaire was used. The variable working experience was based on a theory that experience will make a change in RNs' knowledge. Descriptive statistics and Pearson's chi-square tests were used for analysing quantative data. Qualitative data were analysed by summative content analysis. RESULTS: Seventy RNs answered the questionnaire (response rate 42%) and 61% considered the NIPP adequate to relieve patients' acute pain at the ED. No significant difference was found on how the RNs used the NIPP. However, qualitative data showed that more experienced RNs adapt the NIPP according to the patients' needs in a higher extent. CONCLUSION: A majority of the RNs consider the NIPP to be adequate to relieve patients' acute pain in the ED. An increase in working experience showed an impact on how the NIPP was used, with an increase in pain management that is personalised depending on individual patients' needs. The RNs used several alternatives to both dosage and type of medication when the ED becomes crowded. RELEVANCE TO CLINICAL PRACTICE: Registered nurses' working experience should be considered when planning nursing schedules to be better able to meet patients' needs. Guidelines should be developed and evaluated by both healthcare professionals and patients.

Ambulance personnel's management of pain for patients with hip fractures; based on ambulance personnel's gender and years of experience.

According to the World Health Organization (WHO) the goal of health care is for the entire general population to have good health and receive care on equal terms. Little is known about gender differences in the management of patients in the ambulance service. There is also a lack of studies investigating how the characteristics of health care personnel, such as gender and work experience, impact on patient care Therefore, the aim of this study was to describe ambulance personnel's assessments and the pain relief they provide for patients with hip fractures, based on the ambulance personnel's gender and years of experience. METHOD: A retrospective study of patients (>65 years) with hip fracture who, during 2011, were transported by ambulance to hospital. RESULT: Seven hundred and twenty two patients were included. Most patients reported experiencing pain and 50% received pain medication. Ambulance personnel with working experience of <10 years administered more pain medication compared to those with experience of >10 years. There was a tendency for male ambulance personnel to give pain medication more often compared to female personnel, but this tendency showed no significance. CONCLUSION: The main finding of our study is that personnel with working experience of less than 10 years administer more pain relief, even though only half of the patients received pain medication during ambulance transportation.

Patient participation in the intensive care unit.

OBJECTIVE: Patient participation in healthcare is important for optimizing treatment outcomes and for ensuring satisfaction with care. The purpose of the study wasto explore critical care nurses' perceptions of patient participation for critically ill patients. DESIGN AND SETTINGS: Qualitative data were collected in four separate focus group interviews with 17 nurses from two hospitals. The interviews were analyzed using qualitative content analysis. FINDINGS: Initially, the nurses stated that patient participation in the intensive care unit (ICU) was dependent on the patient's health condition and consciousness. However, during the interviews three descriptive categories emerged from their experience, that is: passive patient participation, one-way communication and nurse/patient interaction. CONCLUSION: In the ICU, the possibilities for patient participation in nursing care are not only dependent on the patient's health condition but also on the nurse's ability to include patients in various care actions despite physical and/or mental limitations. When the patient is not able to participate, nurses strive to achieve participation through relatives' knowledge and/or other external sources of information.

Mandatory documentation of pain in the emergency department increases analgesic administration but does not improve patients' satisfaction of pain management.

BACKGROUND: Pain is one of the most common symptoms treated in emergency department (ED). Pain may cause suffering and disability for the patient. Inadequate pain management may be associated with increased risk of complications such as sleep disturbance, delirium and depression. Previous studies conclude that pain management in ED is insufficient and inadequate. Yet, little is known about patients' own experience regarding pain management in ED. OBJECTIVE: The aim of this study was to explore the satisfaction of pain management in patients having acute musculoskeletal injuries before and after implementation of mandatory documentation regarding pain assessment in the ED. METHOD: An observational pre-post intervention study design was used. The study was conducted on patients having acute musculoskeletal injuries such as soft tissue injury, back pain or wrist/arm/leg/foot fractures in a 24-h adult (>15 years) ED at a public urban teaching hospital in Stockholm, Sweden. Data was collected by an interview based on a questionnaire. RESULTS: A total of 160 patients answered the questionnaire. In the pre- (n=80) and post-intervention (n=80) groups, 91/95% experienced pain in the ED. A significant difference (p<0.003) was found during the post-intervention period, with more patients receiving analgesics compared to the pre-intervention group. A significant decline (p<0.03) in patients' own reported pain intensity at discharge was found between the groups. Patients' reported satisfaction on pain management in the ED increased in the post-intervention group, but the difference was not statistically significantly. CONCLUSION: Patients' satisfaction with pain management increased, but not statistically significantly. However, both percentages of patients receiving analgesic drugs increased and pain intensity decrease at discharge were statistically significant after the intervention that made nurses obliged to register pain. IMPLICATION: According to the findings of this study, mandatory pain documentation facilitates pain management in the ED, but there is still room for improvement. Additional actions are needed to improve patients' satisfaction on pain management in the ED. Mandatory pain documentation in combination with person-centred care could be a way of improving patients' satisfaction on pain management. Effective pain management is an important quality measure, and should be focused on in acute care in the ED. By routinely asking patients to report the pain intensity at discharge, the ED personnel can have direct feedback about the factual pain management. RNs may also be encouraged to use intravenous analgesics in higher extent when the patients have very severe pain.