Introduction

Although post-stroke apraxia is a common and disabling higher-order neurological deficit, there is no standardized evaluation method or treatment for this condition [1,2]. The existence of limb-kinetic apraxia has been questioned in the past [3,4]. Hemiparesis, impairment of elementary motor and sensory innervations in the brain, is the most common symptom of stroke.

On the other hand, in apraxia, patients lose learned and skilled movements due to higher-order motor deficits, despite preserved elemental motor and sensory innervation; [2]. herefore, the effective rehabilitation approach for patients with apraxia can be different. We report a case of bilateral limb-kinetic apraxia that occurred after a left postcentral gyrus hemorrhage, extending subcortically and anteriorly. The impaired motor control in this case was distinctly different from hemiparesis and manifested bilaterally from the left hemisphere lesion.

According to published work, psychiatric patients waited 10 minutes longer for physician assessment compared to other patients [4,5] in rural settings and ER wait time for psychiatric patients awaiting an inpatient bed is over three times longer than non-psychiatric patients [5,6]. In addition, rural ERs have limited ER staff available with mental health training [7,8].

Administrative data from the ESHC revealed that patients requiring psychiatric assessment and transfer to acute psychiatric facilities experience an increasing wait times during the pandemic and post-pandemic era. For example, the average wait times for patients seeking psychiatric assessment at ESHC-ER increased from 5.4 hours in 2017 to 9 hours in 2022. The internal data also revealed that at least 3 out of 509 patients waited over 12 hours at the ESHC-ER in 2022. This rural small hospital has rapidly and consistently experienced an increase in patient volumes and acuity since pandemic most likely due to expanded catchment area by 65,000, a 15% increase in migrant population, and closure of a local Urgent Care Center, Emergency Medical Service (EMS) diversion agreement in partnership with Essex Windsor EMS (EWEMS) and Windsor Regional Hospital (WRH), and lastly a lack of access to primary care during the COVID pandemic (ESHC, 2022).

The usual trend of ER in rural hospitals was a relatively busy influenza season and a quiet Winter before the pandemic hit Canada [9]. Unfortunately, ER operated at peak occupancy for weeks at a time during the COVID pandemic [10] offering little recovery time for care providers. The dominos effect led to staff burnout, increased sick calls and staff shortage leading to much longer ER wait times [11,12]. Longer ER wait times have been plaguing Canada’s health care system and may continue to exhaust Canadian emergency services and providers for years to come [13].

The overwhelming feeling of isolation and lack of resources is much more pronounced among the psychiatric patients in rural than in urban areas [14]. ER visits often offers ready access and outpatient monitoring to care for unexpected situations related to mental health such as drug overdose, mental health flare-ups, or crisis episodes [15]. Frequent ER visits by psychiatric patients are often due to, 1) poor self-care and lack of social support accompanied with lack of access to the continuum of care; 2) trust in urgent care provision; and 3) satisfaction with the urgent care received in terms of getting a priority care in areas separated from the other patients and genuine interest of the professional who attends them [15]. Psychiatric patients and their caregivers often do not seek direct and exclusive access to a psychiatrist, rather to a healthcare provider who can guide them access available resources in the community to facilitate their continuity of care in Mental Health [16].

No published qualitative enquiry on factors affecting psychiatric patient wait times in rural Canadian ER setting currently exists to the best of our knowledge. The aim of this enquiry is to explore the ESHC staff (informant) perspectives on 1) the factors that contribute to a longer wait time and 2) possible solutions replicable in similar settings.

Materials and Methods

A series of semi-structured interviews were conducted as the method for this study based on the authors’ paradigm position (constructivism) using an Interpretive Description approach [17]. The inquiry was conducted as an element of operational research and did not collect any patient information warranting ethical approval from the local Research Ethics Board (REB). However, the organization’s Office of Research approved the study following ESHC Academic Research Committee approval. The subsequent sections delve into the justification for the chosen study design.

In the 1960s and 1970s, the qualitative inquiry reformist movement challenged the idea of a single truth and introduced the idea of multiple realities in the philosophical approach to knowledge [18]. Unlike quantitative research, qualitative research provides distinctive facets of experiences, thoughts, and feelings of the individuals being investigated [19]. However, qualitative methods do not always meet the demand of pragmatic research of health sciences despite an intellectual agreement of subjective realities [20]. While social science capitalizes on health phenomena to answer elemental questions related to the core nature of human experience, health science focuses on solving everyday problems of patients or understanding the effect of a particular health intervention [21]. Interpretive Description [17,22,23] is suitable for health science as it can address realworld utility in health science, while adopting theoretical integrity in social science. We will refer the individuals interviewed for the enquiry as “informants” from this point onward. The interpretation of the informants’ observations and experiences was subjective and was open to interpretation, co-constructed by the authors and informants. Considering the process of knowledge generation (a logical relationship and accommodation from multiple perspectives of individuals all appertaining to a phenomenon), we incline towards labelling the inquiry as phenomenological constructivism in congruent with Mach (1959) [24]. However, unlike Merleau-Ponty’s phenomenology [25], the authors did not bracket their thoughts and perceptions, rather participated actively to co-construct knowledge. The constructivist paradigm takes a more naturalistic and relativist stance by recognizing multiple meanings and subjective realities [26].

The informants’ perspectives were based on their observations, experiences, and perceptions shaped by their relationship with psychiatric patients awaiting care at ER, their professional stance, and their subjective values. The enquiry aimed to explore (1) an actual real-world question (what are the factors contributing to longer wait times?), (2) possible solutions to overcome this challenge at the ESHC (how can we overcome this challenge?), and (3) replicability of the solution in similar context (can other rural hospitals replicate this solution?). Therefore, the methodology is closer to be hermeneutical and dialectical in congruent with applied health research.

Informants

Thorne (2016) [17] pointed out that individual interviews involving multiple people under multiple circumstances are useful in gaining insight into clinical issues. The ESHC staff members (nurses and administrators) had opportunity to observe typical days at the ER when psychiatric patients come for their care and to provide them care based on their symptoms, their state of mind, and to transfer them to the appropriate department/facility. Since the ESHC staff (clinicians and administrators) are positioned to provide a direct account of their observations/experiences with the phenomenon, we invited them to participate as informants for this study. Discerning the importance and diversity in terms of the knowledge each informant possesses, requires deliberate considerations [27]. In a qualitative inquiry, therefore, it is prudent to presume every voice provides a distinct perspective, and none has full comprehension of the topic of interest [17].

Recruitment

We approached the Director of Inter-professional Practice & Research at the ESHC to identify possible informants. The criteria used to identify possible informants were: 1) staff attending the psychiatric patients at ED; 2) staff ordering transfer of those patients; and 3) staff keeping record of wait time and reasons for any delay. We conducted one-on-one interviews with the staff (N=5) agreed to participate, an acceptable sample size to conduct interpretive description [17].

Interviews

The informants were interviewed during the month of March in 2023. We acknowledge our bias towards staff being incompetent ensuring timely management of psychiatric patients. Therefore, we consciously avoided leading the informants for sharing any perceived staff incompetency in managing such patients. The interviews extended an hour in a quiet room, away from the patient care area to allow the informants to relax. The informants spoke without any interruption with larger gaps to continue speaking following Green and Thorogood’s (2018) recommendations. At the end of the interview, we verbally summarized the informant’s account and sought his/her confirmation of the interpretation to avoid any discrepancy. Two interviewers were involved in the process to minimize subjective interpretation and to improve data validity. The interview data was saved in a laptop with a unique code and was shared in an encrypted Google drive folder with the informants to allow for verification of the data.

Quality of data

According to Thorne (2016) [17], the evaluative criteria for data quality typical in interpretive description are 1) epistemological integrity, 2) representative credibility, 3) analytic logic, and 4) interpretive authority.

To achieve epistemological integrity, the research question needs to be consistent with the stated epistemological standpoint and the interpretation of data sources need to follow that question [17]. Our research question invited multiple co-constructed truths and the data interpretation was rooted in the constructivist stance, hence achieved epistemological integrity. Representative credibility refers to involving individuals positioned to observe/experience a phenomenon from multiple angles of vision [17] in line with the concept of triangulation [28]. Our informants were frontline caregivers and administrators, rightly positioned to comment on the phenomenon. In addition, we verified the interpretation of the interviews with the informants to reach representative credibility.

According to Thorne (2016) [17], analytic logic refers to sufficiently visible inductive reasoning throughout the work so that the reader can either confirm or reject the credibility of the evidence. Based on the relevant literature [29-32], we performed an intellectual audit trail and provided a thick description of our work to achieve analytic logic.

The interpretive authority is often achieved by reflexive accounts of the author revealing his/her own bias or experience to help the reader to separate the subjective truth from the shared truth [28,33,34]. We were conscious of our own biases and declared our epistemic position to aid the reader distinguish our constructs from the informant’s constructs with sufficient clarity.

Data Analysis

The potential hazard in qualitative data analysis is to create patterns out of pieces of information (e.g. words, gestures) already hardwired in our minds as being meaningful [17]. What we consider meaningful is based on our own personality/experience/ disciplinary orientation/biases/curiosities. Therefore, two authors (FV, MRJ) analyzed the data independently. They discussed their own interpretations with each other to ensure all constructs were considered and understood proficiently.

According to Bailey (2008) [35], relying entirely on transcript data is a potential risk of losing insight arising from the nuances, pauses, tone and deliverance of informants’ discourse. We used the interview transcripts, and interviewers’ own observations when analyzing the data to avoid this potential pitfall. We used NVivo^© software [36] to help organize the data.

A thematic content analysis approach defined as “a method for identifying, analyzing and reporting patterns within data” [37] was used. Our explicit epistemological position aided consistency and cohesion in thematic analysis following the recommendation of [38]. We followed four basic steps: 1) preparation and organization of the data, 2) reduction of the data, 3) data interpretation, and 4) data representation during data analysis following [39].

Results

According to the informants, five themes emerged describing the possible factors contributing to a longer wait time at ESHC-ER: 1) admission process, 2) transfer process, 3) patient factors, 4) staff factors, and 5) available resources (Figure 1).

Figure 1: Emerged themes describing the contributing factors to increasing wait times at Erie Shores Health Care.

Admission process: Since ESHC does not have in-house psychiatrists, the diagnosis and admission decision for psychiatric patients rely on WRH’s on-call psychiatrist’s tele-health assessment [40]. The process gets even complicated when the on-call psychiatrist is hard to reach. The WRH on-call psychiatrist is often overwhelmed by their own patient population and often cannot respond to ESHC staff’s enquiry in a timely fashion. Figure 2 describes in detail the current patient admission and transfer process at the facility.

Figure 2: Current patient admission and transfer process at Erie Shores Health Care.