Ending PJ paralysis for hospitalised patients: a quality improvement initiative

Abstract

Introduction

PJ paralysis refers to the negative effects experienced by hospitalised patients who remain inactive and dressed in hospital clothing, and is a serious problem, affecting one-third of hospitalised older adults. This study evaluated the impact of a multicomponent hospital-based intervention to get patients out of bed, dressed in non-hospital attire, and moving around/mobilised.

Methods

A 3-month quality improvement initiative was conducted at one hospital unit in Western Canada, which aimed for 50% of all patients to be dressed in their own clothing by midday, sitting up in a chair for all meals and mobilising to activities. Healthcare providers, patients and family members received PJ paralysis education, and a new patient dress code care standard and physician patient care order were implemented. Measures included: daily percentage of patients dressed and up for meals, weekly mobilisation rates, patient and provider satisfaction, and complication rates. Descriptive statistics were completed.

Results

From July to October 2019, 70 patients participated. Approximately 14.3% of patients were dressed in their own clothing daily, 6.4% were sitting for all three meals, and the weekly mean number of patients mobilising to activities was 0.9 (SD 0.7) and mobilising for other reasons was 4.5 (SD 1.3). Five physician care orders were written. A trend was observed towards decreased falls, with minimal change in the number of staff, nursing assessment time and complication rates. Patient feedback revealed improvement in their self-identity.

Conclusion

Alleviating PJ paralysis in hospitalised older patients requires a complex multifactorial approach. Despite not achieving the project aim, the intervention demonstrated positive impacts without complications or additional workload, and ease of implementation suggests feasibility and (potential) long-term sustainability. Further research is needed to explore the experiences and perceptions of patients and healthcare providers to identify facilitators and barriers, which may aid in enhancing and implementing future interventions.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• PJ paralysis refers to ‘the negative physical and psychological effects experienced by patients who spend lengthy periods of time inactive and in their pyjamas (PJs) while in hospital’, and is a prevalent and preventable issue among hospitalised adults, which results in multiple complications for the patient (eg, decreased mobility and functional capacity, cognitive changes, increased risk of infections) and for the healthcare system (increased hospital length of stay). Addressing this problem is crucial to reducing or avoiding adverse outcomes; however, the specific intervention(s) for achieving this remains unclear.

WHAT THIS STUDY ADDS

• This quality improvement initiative used a multicomponent intervention combining education with the use of a new patient dress code care standard and physician patient care order, to raise awareness about PJ paralysis and its significance. This multifaceted intervention, aimed to educate patients, healthcare providers and the general public, was determined to be feasible, simple and low-cost, with no negative impact on hospital processes or nursing workload.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• The feasibility and adaptability of the intervention eased uptake and use across diverse settings and populations, highlighting the potential benefits to the global health community, justifying a need for health organisations to reassess and update hospital policies, processes and patient care dress/attire standards. Further research is recommended to better understand the barriers and facilitators of behavioural change with a focus on patient and staff perspective and experience with this intervention.

Problem description

PJ paralysis refers to ‘the negative physical and psychological effects experienced by patients who spend lengthy periods of time inactive and in their pyjamas (PJs) while in hospital’.¹ The prevalence and significance of PJ paralysis led to the formation of an international campaign (called #EndPJparalysis) targeting this problem. Getting patients out of bed and mobilising for any purpose can significantly impact patient outcomes, such as patient satisfaction, mobility, functional status and complications, for example, falls.²

Alberta Health Services (AHS) is the provincial health organisation for Alberta, Canada. Following recognition of this problem locally, AHS joined the national #EndPJparalysis movement, with campaigns initially forming at several locations in Alberta, and subsequently spreading province wide. Previous campaign results have shown behavioural change, with patients willingly getting out of bed and into non-hospital clothing.³ Furthermore, to support implementation efforts, AHS established a provincial PJ paralysis Community of Practice, which has over 100 members province wide.

However, this campaign was not occurring at all hospitals in the province, which included the focus of this initiative, an 885-bed acute care University Teaching Hospital located in Edmonton, Alberta, Canada. This hospital has an Acute Care of the Elderly (ACE) unit, a 20-bed inpatient unit comprising geriatric and neurology stroke patients, which uses paper-based charting.

Baseline data identified the majority (n=15–18) of patients had no medical reason for not changing out of hospital clothing; however, only zero to three patients dressed in their own clothing, with access to non-hospital clothing identified as a significant barrier. 6 out of 18 patients (33%) were sitting up for all meals and mobilising (defined here as the process of physical movement with the use of mobility aids (like a cane or walker), as needed). Based on these findings, this study aimed for 50% of patients to be dressed, out of bed and mobilising, a target thought feasible for this patient population, given the low number of patients changing their clothing preintervention.

Available knowledge

Deconditioning is a complex process involving physiological changes across multiple organ systems due to prolonged immobility, such as bed rest.² Hospitalisation promotes deconditioning by keeping patients in bed and in hospital clothing, leading to the term ‘PJ paralysis’, referring to ‘the negative physical and psychological effects experienced by patients who spend lengthy periods of time inactive, and in their pyjamas while in hospital’.¹

Despite mounting research on the complications of deconditioning, PJ paralysis remains a frequent problem among hospitalised patients, especially older adults who are most vulnerable to adverse outcomes. Some of the most recognised complications from deconditioning include loss of muscle strength (1%–5% a day¹) and a decline in mobility and function; 34% of older patients may lose independence in one basic activity of daily living following their hospital stay.^{4 5} Unfortunately, these losses are difficult to regain and contribute to adverse patient outcomes, including a perceived need for an alternative level of care at hospital discharge,⁶ predisposition to infections,⁷ cognitive changes⁸ and increased length of stay,⁹ to name a few.

Recognition of PJ paralysis began in the UK, where a national 70-day campaign was launched to generate awareness of this problem,¹⁰ which quickly spread internationally to Australia and Canada, who subsequently launched their own campaigns. In Alberta, AHS has also recognised the importance of addressing PJ paralysis at local hospitals and joined the global movement.¹

Conquering PJ paralysis requires people to get out of bed and start moving¹¹ to preserve mobility, reduce complications, shorten hospital stays^{3 12} and potentially lower healthcare costs. The use of early mobilisation programmes to reduce hospital-associated complications has been well documented,13,16 with one study showing that a 50% increase in physical activity (walking) resulted in a 6% reduction in hospital length of stay.¹⁷ Following the launch of an #EndPJparalysis campaign at one Nottingham Hospital in the UK, reductions in falls, pressure injuries, patient complaints, and a 1.5-day shorter length of stay were identified.¹²

Although getting patients out of bed and moving has numerous clinical benefits, the best singular or multicomponent intervention(s) to achieve this is unknown. Given the success of previous campaigns, each of which used different interventions, it is reasonable to conclude that the most critical driver of success may be in raising awareness and public engagement with the issue rather than the intervention itself.

Rationale

The Model for Improvement¹⁸ guided this quality improvement (QI) initiative and facilitated the use of iterative Plan-Do-Study-Act (PDSA) cycles. This framework enabled the trial of an innovative modified intervention and, through successive iterations,¹⁹ allowed for continuous modification and reimplementation of the intervention, making this approach an excellent fit for our QI initiative.

Specific aim

By 30 September 2019, 50% of patients on the ACE unit shall get up and dressed in their own clothing by noon daily, sit up in a chair for all three meals, and mobilise to activities, using any available aid (eg, a walker) as necessary.

Context

Our project team, which included a geriatric physician, unit manager, patient engagement consultant, four registered nurses, patient care manager, nurse educator, QI consultant and occupational therapist, developed a multicomponent intervention by adapting elements from past #EndPJparalysis campaigns and frontline worker feedback. Each component was tailored to fit the local hospital unit context, ensuring simplicity, ease of integration and sustainability in routine care for nursing staff. The study was implemented from July to October 2019 at a large University Teaching Hospital in Edmonton, Alberta, Canada.

Intervention

Intervention components

The multicomponent intervention incorporated a promotional campaign to generate public awareness about PJ paralysis, targeted education for patients, family members and healthcare staff, and implementation of a new patient dress code care standard and physician patient care order. A detailed description of each intervention component is provided in the following sections.

Promotional campaigns

The study began in July 2019 with a hospital-wide campaign (EndPJparalysis) aimed at raising awareness about PJ paralysis among the public, patients and staff. This coincided with the conclusion of the National End PJ Paralysis Day and included a unit-based campaign on the ACE unit. Campaign strategies included AHS-approved promotional materials (posters, leaflets), electronic communication via emails, in-person presentations and a new unit-based PJ paralysis display which featured photographs of the study team in PJs, and participating patients (online supplemental material: study group photo).

Targeted education

Targeted education about PJ paralysis and this initiative was provided to patients, family members, unit staff (which included nursing staff and interdisciplinary team members) and physicians, using various strategies. Unit staff and physicians received formal education via a PowerPoint presentation focused on PJ paralysis, patient complications and the QI initiative, with ongoing education provided by the research team as needed.

Physician-specific education was provided in one formal presentation about PJ paralysis and this initiative at the geriatric medicine divisional meeting, though efforts to reach neurology-stroke physicians were unsuccessful. Education about PJ paralysis and this initiative was also provided at other relevant physician meetings, where possible.

Patients and family members were informally educated about PJ paralysis and the initiative at different stages, starting with brief information from the admitting physician team in the emergency room (ER). Once transferred to the ACE unit, nursing staff or the unit manager provided detailed one-on-one verbal education, which was supported by two specifically designed patient information brochures—one developed by AHS on PJ paralysis and another about the QI initiative—as well as a poster displayed above the patient’s hospital bed during their stay for additional reminders (online supplemental material: PJ paralysis poster). Patients already residing in the unit and their family members received the same one-on-one verbal education by nursing staff or the unit manager at the beginning of the implementation period, as well as written information, including the poster.

Patient dress code care standard

A new patient dress code care standard was created for this study, which outlined three unit specific patient care unit expectations: (1) patients were to get dressed in their own personal clothing by midday, (2) up and out of bed for all meals and (3) mobilising to activities (with mobilising defined as the process of successfully encouraging patients to move with the use of mobility aids (like a cane or walker), as needed). Due to unit workload constraints regarding nursing staff levels and patient care needs, midday was chosen as the most feasible time for having all unit patients dressed.

The standard was integrated into the daily nursing assessment process. Patients unable to meet this standard were encouraged to participate as much as possible. Ongoing communication and daily reminders about the new care standard were provided through daily written reminders within the unit’s communication book and verbal reminders during interdisciplinary rapid rounds and unit huddles to help encourage and sustain this intervention.

Physician patient care order

Physicians were encouraged to write a specific admission ‘PJ paralysis’ patient care order, which instructed staff about the patient dress code care standard. This physician order was either integrated into the patients’ admission orders for those admitted from the ER or included within the daily patient orders for patients already residing in the unit. The purpose of this order was to support the unit’s new patient dress code care standard. Weekly reminder emails were also sent to physicians rotating on the ACE unit by the study team.

Participants

All patients admitted to or residing in the ACE unit from July to October 2019 were eligible for participation, regardless of age or medical problems. No absolute exclusion criteria were set, allowing as many patients as possible to benefit from the intervention, given physiotherapist staffing restrictions which limited all patients from being seen daily.

For patients unable to fully participate in the intervention (eg, patients who were bedbound or required med-lift for transfers, were comatose, had severe behavioural disturbances (eg, physical aggression) that could endanger themselves or staff, or had no family (with family defined by who the patient chooses as family and not by blood or marriage), partial participation was encouraged, varying by patient. For example, patients unable to sit in a chair for meals may still be propped up, and those not wishing to change clothes could still wear a house coat or their own shoes. This flexible approach ensured that most patients could participate in the study.

Study of the intervention

Baseline assessment

After establishing the study team, baseline data was collected from the authors’ local institution (AHS) to benchmark against national and local PJ paralysis campaigns. Key stakeholders and frontline staff were identified, and meetings were held to explore the issue and determine improvement strategies. Discussions highlighted areas for improvement in nursing assessments, daily workflow and patient admission. Existing drivers and barriers were identified, leading to the development of relevant measures. Feedback from patients, family members and front-line staff about their awareness of PJ paralysis and hospital experience was incorporated into the proposed intervention and study design.

Implementation process

The new care standard and physician order were implemented for the duration of the study. When full implementation was not possible, patients were encouraged to participate as much as they could. Everyone—patients, families, unit staff and the healthcare team—was encouraged to help patients get dressed and out of bed, supporting the intervention’s delivery and sustainability.

Measurement and assessment

Daily monitoring was conducted using standardised data collection paper sheets attached to the patients’ whiteboards, which could be completed by nursing staff, rehabilitation staff, patients and family members throughout the day. These sheets were collected weekly by a study team member and entered into an electronic database (REDCap).

Preintervention and postintervention data were collected to measure outcome, process and balancing measures. Preintervention and postintervention individual interviews with patients and family members were conducted by the study team using specially designed questionnaires reviewed by the AHS patient engagement community to evaluate the intervention’s impact. Similar interviews with nursing staff assessed the feasibility and impact of the intervention, while additional feedback was sought from participating physicians. The unit manager also gathered patient and family feedback during weekly leadership rounds.

Measures

The multicomponent initiative used a variety of measures to evaluate implementation and impact (table 1).

Table 1. Table of measures.

Measures	Variable collected	Instrument/measurement strategy
Outcome	1. Daily percentage of patients dressed in their own clothing by midday (12:00, noon)	Calculated as the daily average (mean) number of patients dressed in their own clothing by midday during the study period
	2. Daily percentage of patients sat up for all three meals	Calculated as the daily average (mean) number of patients sat up for three meals during the study period
	3. Average number of patients mobilised to activities per week	Calculated as the average (mean) number of patients mobilised to activities per week during the study period
	4. Total percentage of patients up for two out of three meals	Calculated as the percentage of all patients who were up for two out of three meals at some point during the study period
	5. Total percentage of patients dressed in their own clothing	Calculated as the percentage of all patients who were dressed in their own clothing at some point during the study period
	6. Change in PJ paralysis awareness in (a) staff and (b) patients	Qualitatively calculated from staff and patient feedback collected postintervention, from the questionnaire results
Process	1. Total percentage of patient-days with mobilisation	Calculated by dividing the total number of hospital days patients were mobilising to activities during the study intervention period, as a percentage of all patient hospital days
	2. Total percentage of patient-days in their own clothes	Calculated by dividing the total number of patient hospital-days patients were dressed in their own clothing during the study intervention period as a percentage of all patient hospital-days
	3. Number of education sessions held with attendance by (a) physicians, (b) nursing staff, (c) multi-disciplinary team members and (d) unit staff	Calculated as the total number of education sessions held and the number of attendees at each session recorded. Type of attendee recorded as being either physicians, nursing staff, multi-disciplinary staff or unit staff
	4. Number of physician patient care orders written	Calculated as the total number of physician’s orders written due
Balancing	1. Change in nursing assessment time (minutes)	Calculated qualitatively from nursing staff feedback, comparing assessment time preintervention versus postintervention
	2. Change in nursing staff morale	Calculated qualitatively from nursing staff feedback from staff questionnaires
	3. Average number of nursing staff required for patient care assessments	Calculated qualitatively from nursing staff feedback, staffing schedule and feedback from staff questionnaires
	4. Need for additional nursing staff	Calculated qualitatively from nursing staff feedback from staff questionnaires and staffing schedule
	5. Patient satisfaction	Calculated qualitatively from patient questionnaire responses
	6. Number of patient complaints	Calculated from number of patient complaints received during the study period
	7. Number of adverse events	Calculated from the number of adverse events reported during the study period
	8. Total number of falls	Calculated as the total number of falls of unit patients during the study period
	9. Number of patients requiring restraints	Calculated as the number of patients requiring the use of any form of restraint during the study period
	10. Average length of stay (days)	Calculated as the mean length of stay for all patients. The length of stay in days was measured for each patient, from which the mean was then calculated from
	11. Number of patients with a change in mobility	Calculated by comparing the patients preintervention level of mobility to that postintervention/discharge
	12. Number of patients with a change in their disposition status	Calculated for patients discharged during the study duration by comparing their discharge location to their residence at admission
	13. Incidence of pressure ulcer	Calculated as the total number of new cases of pressure ulcer documented during the intervention period

Outcome measures

Outcome measures included the daily percentage of patients dressed in their own clothing by midday (12:00, noon), the daily percentage of patients sat up for all three meals, the weekly average number of patients mobilised to activities, the proportion of patients who received the intervention, total percentage of patients up for two of three meals and dressed, and change in PJ Paralysis awareness. The daily percentage of patients dressed and up for all three meals, weekly average number of patients mobilised, and percentages of patients up for two of three meals and dressed were calculated from individual patient data sheets. Intervention participation was based on the proportion of patients receiving the intervention out of all enrolled. Change in awareness of PJ paralysis was evaluated from postintervention patient survey feedback.

Process measures

Process measures included the total percentage of patient-days with mobilisation, total percentage of patient-days in their own clothes, number of education sessions held with attendance by physicians, nursing staff and multi-disciplinary staff, and number of physician’s orders written. Patient-days with mobilisation were calculated as a percentage of the total number of patient days for mobilisation, while the patient-days in own clothes were calculated in a similar manner using the total number of patient days wearing own clothing. Attendance at the education sessions was recorded and analysed according to the type of attendee. Number of physician orders was extracted from patient charts.

Balancing measures

The intervention’s impact on nursing staff was evaluated by changes in assessment time and nursing staff morale (from survey feedback), the average number of nursing staff required for patient care assessments and the need for additional staff. Patient-focused measures included patient satisfaction, complaints, adverse events and complication rates (eg, number of falls, restraint use, length of stay, mobility status, change in disposition status and incidence of pressure).

Nursing assessment duration and morale were compared preintervention versus postintervention, alongside the average number of nursing staff required, and the need for additional nursing staff. Patient satisfaction and complaints were evaluated from patient survey responses, while adverse events were collected from the AHS reporting and learning system. Complications were tracked using patient records, unit data and AHS databases.

Analysis

StataBE²⁰ was used for quantitative data analysis. After an initial data review, a descriptive summary was performed. Discrete data was rounded up to the highest integer, and continuous data to one decimal place. Averages were calculated using the mean and SD. Categorical data were displayed in tables, while continuous data were shown in line charts (run charts) to visualise changes over time.

Qualitative (textual) data from patient and staff feedback/quotes was collected by one team member (PM), and analysed by grouping quotes into themes by another (FC), with both reaching consensus and making minor edits to finalise themes and quotes.²¹

Results

70 patients participated over 4 months (July to October 2019), 69 completed the study (99%). Over half (57%, n=39) were female with a mean age of 80.2 years (SD 8.8). See table 2 for results.

Table 2. Demographics of study population.

Demographics	Study population (n=70)
Of participants enrolled
Participated in some degree with the intervention	69
Did not participate	1
Gender—no. female (%)	39 (57)
Age in years (mean, SD)	80.2 (8.8)
Medical specialty
Geriatric	30
Neurology	38
General Internal Medicine	1

Outcome measures

Almost all patients (99%) enrolled participated in the initiative. The daily average per cent of study patients dressed by midday was 14.3% (figure 1), while 6.4% of patients were sat up for all three meals daily (figure 2) and 0.9 people were mobilising to activities each week. The total percentage of patients dressed in their own clothing by midday was 54% (n=38), while 69% (n=48) of patients were up for two out of three meals was 69% (n=48).

Figure 1. This run chart shows the daily percentage of patients who were dressed in their own clothing by midday (12:00) on the unit during the study period.

Figure 2. This run chart shows the daily percentage of patients sat up for three meals.

Although not quantitatively assessed, improvement was reported in patients/family members and unit staff’s awareness about PJ paralysis from the questionnaire feedback.

Process measures

Three education sessions were held (two for unit staff and one for physicians), which had 24 attendees (6 physicians, 10 nursing staff and 8 interdisciplinary team/unit staff). 43 study brochures were handed out to patients and family members. Five physician orders were written during the 4 months, and the average number of patient-provider conversations held was 0.9. The total percentage of patient-days with mobilisation was 41.8%, while the total percentage of patient-days in own clothes was 9.4%.

Balancing measures

No additional nursing staff were needed for the intervention. There were no changes in weekly restraint use, pressure ulcer incidence or discharge status, though a trend towards fewer falls was noted (see figure 3). Data collection challenges prevented accurate assessment of patient mobility. The median length of stay was 33.5 days (IQR 1–148). No patient complaints or adverse events occurred.

Figure 3. This run chart shows the average weekly number of falls starting 1-week intervention implementation (week 1).

Qualitative feedback from nine nursing staff members (see online supplemental material: staff questionnaire feedback) showed that most (n=7) believed that PJ paralysis was solvable with teamwork. Despite challenges, the majority noted positive changes in patient attitudes, with patients being more willing to get out of bed when dressed in their own clothing.

Due to challenges with patient turnover and feedback availability, responses were collected from nine patients (see online supplemental material: patient questionnaire feedback). Nearly half (n=4) reported that the intervention shifted their mindset from ‘I am sick’ to ‘I am getting better’ and helped them establish a routine. Three patients (33%) reported improved self-identity and perspective changes. Only one patient had difficulty in obtaining clothing, and none reported issues with lost or damaged clothing.

Summary

The aim of our QI study was to have 50% of hospitalised patients on the ACE unit dressed by midday, out of bed and mobilising/walking to activities, to prevent deconditioning and its associated complications. Despite not meeting the project aim, the study had an overall positive impact on patients by improving self-identity and empowering patients to get out of bed and dressed. This, together with an observed trend towards decreased falls, an absence of complications or impact on nursing staff workload, and minimal financial burden, supports the potential feasibility and sustainability of this intervention and the need for further study. Strengths of this study include the evaluation of a diverse set of measures, which includes clinical and patient-focused measures, which, although highly relevant for the hospital setting, are often not evaluated, and the alignment with the provincial health organisations goals (AHS), resulting in subsequent uptake and spread of this project following completion.

Interpretation

This QI initiative did not meet its goals due to factors such as the omission of key steps in nursing assessments, lack of physician orders, poor communication between staff and patients, high nursing turnover, heavy workloads and inconsistent data tracking, similar to other studies.²² A short timeframe and reliance on a single cycle also limited progress. However, several unexpected (but significant) findings emerged, including a trend towards decreased falls, ease of intervention application and improvements in patient self-worth among both patients and nursing staff.

Challenges, including the complexity of patient care and staff constraints, impacted the ability to assess the intervention’s full impact. While similar interventions showed improvements, differences in approach and environment may explain the conflicting results.^{3 10} While intervention ineffectiveness or incorrect intervention application may be a factor, the results and challenges encountered, and evidence-based strategies used, do not support this.^{3 10}

Nurses faced difficulties with getting patients out of bed, conflicting with other studies.¹⁰ One explanation includes time constraints for patient care standards: our midday target differs from studies with later deadlines, which reported more positive findings.¹⁰ Variations in mobility measurement and data collection methods are another possibility.^{10 23} Despite unchanged staff requirements, these challenges are significant and warrant further exploration.

Promoting a team approach to addressing PJ paralysis and enhancing staff attitudes are important for improving accountability²¹ and patient engagement. Indeed, our results revealed that when nursing staff persisted, they observed positive changes in patients, aligning with previous research.¹⁰ As patients reported no difficulties, this discrepancy could be from staff-patient miscommunication, unclear roles or responsibilities (previously recognised in older adult (but not PJ paralysis) literature),²⁴ or QI initiative issues. This discrepancy requires further exploration, as it may hinder patient participation and assessment. Additionally, the complexity of patient care led to intervention adjustments, highlighting the need to understand the implementation context and target population for future cycles.

However, key observations emerged, which deserve highlighting. Some patients reported improved self-identity, which could positively impact both patient and clinical outcomes. Nursing staff also indicated a positive shift in their perception of patients, likely influencing their interactions and expectations. Although comprehensive clinical data, like pressure ulcers, was not gathered, our fall data aligns with previous studies.¹⁰ A longer implementation period may reveal more improvements.

The intervention’s simplicity, cost-free nature and integration into routine care led to its adoption by AHS despite not fully reaching its goals. Though the initiative’s short duration limited observable changes, patient benefits, adaptability and acceptance highlight the potential for future cycles. Future cycles should consider context, population and barriers to implementation for greater effectiveness, and focus on timing, ensuring proper data tracking, and gathering more consistent feedback from patients and staff to improve effectiveness.

Limitations

The study has several limitations. Conducted on a single mixed medical specialty unit (geriatrics and neurology-stroke) at a large teaching hospital, the findings may not be widely applicable due to the unique patient population of older adults post-stroke. The diversity of patients and dual specialties likely contributed to variations in care requirements and implementation challenges. Modifying the intervention to accommodate patient abilities was encouraged to address these issues. The mixed physician specialty on the unit also influenced results. While geriatric physicians were engaged, participation from neurology physicians was minimal, with only one strong supporter identified, whose involvement will be crucial for future cycles.

The study coincided with the pre-implementation phase of a new provincial electronic medical system, which diverted frontline staff’s focus. A concurrent research project on the same unit also added to staff fatigue, and project restrictions prevented rescheduling. Additionally, a high reliance on locum nursing staff due to shortages in permanent staff led to inadequate briefings about the study, affecting intervention uptake and communication. Despite efforts to improve awareness through various channels (verbally, via the communication book, and during rapid rounds), the effectiveness of these measures is uncertain.

Finally, the lack of standardisation in how nursing staff documented patient care in paper charts posed challenges. Although a thorough chart review was conducted, significant variations in documentation made it difficult to find consistent data. Transitioning to an electronic medical system should alleviate these issues in the future.

Conclusion

As part of one cycle of change, this QI initiative aimed to reduce the rate of PJ paralysis among hospitalised adults by implementing a multifaceted intervention that included public awareness, targeted education for patients, family members and healthcare staff, along with the implementation of a new standard of care for patients and physician order to prevent deconditioning and its complications. Despite not meeting our aim, our simple intervention positively impacted other areas, including patient self-identity, consistent mobilisation rates and a trend towards decreased falls, which justifies the importance of our findings. This intervention’s simplicity, adaptability, lack of complications and lack of impact on nursing staff workload all support long-term sustainability, which has already been maintained after the study and a second PDSA cycle initiated in the following years. AHS plans to scale and spread this intervention to other units within the facility, emphasising the research’s impact.

Future initiatives should evaluate patient (and clinical) specific outcomes to explore the intervention’s impact from the patient (and healthcare providers) perspective. An in-depth exploration of all enabling factors and barriers to implementation, guided by an appropriate established knowledge translation framework (eg, the Promoting Action on Research Implementation in Health Services Framework²⁵), is recommended prior to future initiatives, to ensure acquisition of the necessary contextual information required for implementation planning and tailoring of the intervention accordingly, to maximise the chances of success. Other considerations include clear delineation of roles and responsibilities for all involved and ensuring a clear and consistent communication process throughout.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.