rehabinkmag Commentary, Issue 12

Five Reasons Why People Should Consider Wearing Home Clothes and Moving More Often During Hospital Admission

Illustration by Nadine Tan & Anais Lupu for rehabINK

Topical Commentary

By Gurech James Wai 

End PJ Paralysis is probably no longer a new phenomenon to many people in healthcare. For those unfamiliar with the phrase, this pragmatic movement calls upon healthcare providers and caregivers to routinely enable hospitalized patients to get up, dress in their personal clothes and move as much as possible instead of staying in bed wearing hospital gowns (pyjamas or PJ) for a prolonged period (1-3). This article shares personal perspectives explicating and rationalizing why people should consider this simple intervention and the benefits it embodies: preserving patient dignity, improving patient experience, reducing the length of hospitalization, reducing healthcare cost and preserving functioning (4).

End PJ Paralysis was started in 2018 by Professor Brian Dolan of the Exford University and initially applied in clinical settings by the National Health Services in the United Kingdom (UK) (1, 2). It instantly became a social media phenomenon and a global movement. It has since spread to the rest of the world including Canada. Several Canadian hospitals, including more than ten of the major health centres of Alberta Health Services, are implementing the initiative (1). The name, End PJ Paralysis, denotes the vision of the movement to end physiological deconditioning (paralysis) associated with prolonged bed rest, an epidemic being perpetuated in part by the healthcare culture of putting patients in hospital pyjamas (PJ) (5, 6).

Most of the participating health centres include all patients at risk of functional decline or pressure ulcers, most of whom happen to be older adults at least 65 years old (7, 8). The existing evidence indicates that they are more vulnerable to deconditioning and benefit the most from routine mobilization to preserve their muscle strength (9, 10). Dressing in personal clothes during hospitalization is arguably a unique dimension that the initiative adds to existing efforts to maintain functions and improve experiences during the hospital stay (1, 11). However, the significance of encouraging patients to wear home clothes and move more during admission is not a well-established public discourse. This awareness limitation may be more prominent among older adults, due in part to the novelty of the initiative (1). This article contributes to the effort to improve awareness.

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Kampus Production (Pexels)

It is important to note that only a small subset of medical procedures, devices, medical examinations, or care require the patient to be in a hospital gown or wear no bottoms (12-14); the uniforms are not clinically necessary for most admitted patients (15). Some healthcare researchers argue that the practice is being sustained, not necessarily by the medical benefits it affords to the patient, but largely by a deep-rooted healthcare culture and the convenience the pyjamas provided to the caregiver and patient (5, 16, 17). This is not to discount other intended functions of hospital pyjamas, such as patient safety and ease of access to sterile linens. However, harm to patients, including infections, associated with personal clothes have not been substantiated (18, 19). Moreover, logistical concerns about laundry services can be mitigated with family support to harness potential benefits (20).

Below is a personal perspective describing and rationalizing why people should consider the End PJ Paralysis simple intervention and the benefits it embodies.

Dressing in personal clothes preserves dignity,  which is often left at the hospital entrance

Prevent pyjamas paralysis

Enabling mobility prevents hospitalization-associated disability (10, 21). However, this fundamental practice to preserve function during and after hospitalization is sometimes overlooked (21). It is not uncommon for seniors who were able to function independently pre-admission, such as walking and using the toilet, to lose that ability by the time they get discharged (22, 23). At least a third of older adults aged 70 and older are discharged with a new disability that was developed during hospitalization (15). This loss of function is often associated with immobility during the hospital stay, not necessarily because of the medical reason that preceded the admission (24, 25). Many health scholars describe this condition as hospital-acquired disability (HAD), pyjamas paralysis or physiological deconditioning (the loss of bone and muscle mass and strength) associated with prolonged bed rest (24-27). This condition refers to new or additional disability in activities of daily living (ADL), such as walking and using the toilet, at hospital discharge, compared to the pre-admission baseline (22, 28).

Intentional and routine ambulation of hospitalized patients can prevent hospitalization-associated disability (21, 29), and patients in all care settings are encouraged to participate (21). However, the extent of mobilization and ability to dress in personal clothes may depend on the health condition and care needs of each patient (1, 2). Nonetheless, educating and enabling patients to get up from the bed and dress in personal clothes to break the resting time, get out of bed, move about and do self-care are simple strategies providers can use to motivate those at risk (2, 30). These activities help to exercise muscles to maintain strength and functional ability (4, 21, 30). Unlike exercise through movement, there is limited empirical research into the statistical significance and mechanism through which dressing in personal clothes maintains functions independent of other care elements and mobility. However, there is emerging evidence that its contribution is positive and there is minimal risk for wearing personal clothes (21, 30, 31).

Preserve personal dignity

Dressing in personal clothes preserves dignity (14, 32),  which is often left at the hospital entrance (16). Putting patients in the traditional hospital gowns that barely cover intimate parts of their bodies has been part of healthcare well-intended practice for centuries (33). The humiliating tales and sense of vulnerability associated with the practice are not new either (14, 16, 32). However, these have recently been elevated by End PJ Paralysis and similar movements. Some scholars on the subject share the opinion that the inherent use of pyjamas as part of care has been perpetuated partly by the convenience the attire provides to the care provider and not necessarily for patient-centred reasons (16, 17, 33). A recent study in Ontario showed that the majority of hospitalized patients wore hospital pyjamas with no bottoms unnecessarily. This is in spite of surveys indicating that most patients are interested in wearing personal clothes (13, 14).

Patient-centred initiatives that enable patients to wear their personal clothes during the hospital stay preserve patient dignity and promote health (13, 32, 34). Most people are self-conscious and dressing up provides the sense of personal dignity and privacy they need to participate in social and personal wellness activities (5, 13, 20). It enhances their self-image and the confidence they need to get up, socialize and move about more often (3, 35). Besides its potential contribution to health outcomes, preserving human dignity during hospital admission is not just a means to an end; it is a conceivably integral part of overall personal well-being (5). Therefore, educating and supporting patients to access and wear home clothes or other dignifying garments, as advocated by End PJ Paralysis (1, 2), may be a beneficial practice.

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Annie Spratt (Unsplash)

Shift mindset from sick role to recovery

Creating some sense of normalcy promotes a recovery mindset (35). Mindset plays a significant role in the pace of personal recovery and even health outcomes (35, 36).

Some End PJ Paralysis advocates argue that staying in bed in pyjamas when it is not indicated, reinforces the sense of powerlessness, sick role, and incapacity (34, 37). These psychological factors and mindset may subconsciously mediate the desire to stay in bed longer and gradually decondition as a result (25).

Giving patients the choice to wear their home clothes and creating a care environment that enables personal grooming, are not only about practicing activities of daily living and functioning independently, they also mediate activities such as walking, socializing, and developing a positive self-image (1, 5, 30). Dressing in personal clothes is associated with healthy routines and normalcy and is believed to shift perception from sick role to recovery mindset (36, 38). Encouraging patients to believe in themselves, have confidence in their recovery process and practice self-care, as advocated by End PJ Paralysis, is one way to empower them physiologically and psychologically in their recovery process (39).

Go home sooner

Preserving physical and cognitive functioning and preventing health complications can enable patients to recover and go home in time (40, 41). Evidence of the effectiveness of patient mobilization initiatives in reducing the length of hospitalization is growing, however limited (21, 42). Mobilizing patients routinely during hospital admission minimizes the risk of cognitive decline and several hospitalization-associated complications (1, 4, 21, 25, 30, 43). The commonly cited complications include pressure ulcers, blood clots, and pneumonia; leading to a longer treatment regimen and therefore longer hospitalization (21, 30, 43). Furthermore, research indicates that hospitalized older adults, 70 years and older, with low mobility are five times more likely to be institutionalized after hospitalization (44, 45). This disability leading to placement in long-term care is avoidable. Patient-centred and routine patient mobilization interventions embodied by End PJ Paralysis are promising interventions that contribute to preventing risks of prolonged hospitalization and enable patients, especially older adults, to go home sooner and not get institutionalized (46, 47).

Reduce healthcare cost

Promoting health for hospitalized patients also minimizes high utilization and cost burdens on healthcare systems (48, 49). Some of the recent publications indicated that inpatient mobilization initiatives have the potential to reduce the length of hospital stay for one to several days during an admission event (1, 49). Comprising over 20% of healthcare costs, it is well established that hospital stay is one of the costliest healthcare components (50). A reduction in length of stay, no matter how minimal, can translate into significant healthcare system cost savings. Most hospitals can achieve these savings with modest investments and patient-centred and function-focused care (1).

Cost benefits realization depends largely on everyone playing their parts. This includes healthcare providers and informal caregivers collaborating with patients to prevent avoidable hospital-associated health complications (44, 49). These collaborative efforts in turn minimize the need for more intensive, extensive, and expensive treatment regimens (49). Therefore, reducing healthcare cost is an important dimension for healthcare systems to embrace End PJ Paralysis.

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Matthew Henry (Burst)

Conclusion

End PJ Paralysis promotes a supportive and compassionate care environment; a place where patients feel valued, informed and enabled to get up, dress and move more often. For hospitalized older adults, these practices contribute to preserving dignity, preserving functions, improving patient experience, reducing the length of hospital stay, and healthcare costs. End PJ Paralysis is worth spreading to all health facilities to benefit more people. It is important to note that there is a paucity of scholarly research done on End PJ Paralysis due to its novelty. However, the emerging anecdotal data is promising and may continue to drive adoption and more research on its effectiveness as a multicomponent and patient-centred initiative.

Acknowledgements

Featured illustration by Nadine Tan & Anais Lupu for rehabINK.

To refer to this article, it can be cited as:

Wai JG. Five Reasons Why People Should Consider Wearing Home Clothes and Moving More Often During Hospital Admission. rehabINK. 2022:Issue12. Available from: https://rehabinkmag.com

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