Workplace Violence Prevention: Impacting Providers and Patients, with Kathy Griffis

Organizations and resources mentioned in this episode:

• Hutchinson Regional Medical
• Titus Regional Medical Center
• Leadership Fellows: 10 Years of Grassroots Advocacy for Texas Hospitals, Texas Hospital Association
• Texas Child Mental Health Care Consortium (TCMHCC), University of Texas System
  • Child Psychiatry Access Network (CPAN)
  • Perinatal Psychiatry Access Network (PeriPAN)
• Telepsychiatry Initiative, Texas Tech University Health Sciences Center
• Workplace Violence Against Nurses Reports, Texas Center for Nursing Workforce Studies

Transcript

Andrew Nelson: Welcome to Exploring Rural Health, a podcast from the Rural Health Information Hub. My name is Andrew Nelson. In this podcast, we'll be talking with a variety of experts about providing rural healthcare, problems they've encountered, and ways in which those problems can be solved.

In December, I traveled to the Health Innovation Potluck in Hutchinson, KS, hosted by Hutchinson Regional Healthcare System. While there, I was able to record interviews with several rural workforce experts. In this episode, I'll be speaking with Kathy Griffis, Chief Operating Officer of Titus Regional Medical Center in Mount Pleasant, Texas. We discussed her recent efforts at Titus Medical Center to reduce and eliminate workplace violence.

Can you tell me a little bit about the Mount Pleasant area and what it's like to operate a hospital there?

Kathy Griffis: Mount Pleasant is a rural community. 16,000, I think, is the population. We are on I-30 between Dallas and Texarkana, closer to Texarkana, about two hours from Dallas, about an hour from Texarkana, Texas, 60 minutes away from any tertiary hospital. We are the last independent rural hospital in Northeast Texas.

Andrew Nelson: There are a lot of challenges that I'm sure you've had to face and overcome operating this hospital. I'd like to ask you specifically about what Titus Medical Center has done to implement workplace violence prevention policies, and what changes have you seen that have made the biggest impact so far?

Kathy Griffis: I've been at the hospital for 20 years doing a variety of jobs. I started out as a director of the Behavioral Health Unit. I'm an ICU nurse by trade. So, I really was able to see the need in taking good care of these patients and how their problems are as real as a heart attack or a car accident, a trauma victim. And I think a lot of people don't really understand that, and it's so widespread in our community, like it is throughout the United States. And there's a huge health disparity. We spent a lot of time at Titus Regional, where we have a ton of accolades. We're a primary stroke center. We're an AHA-awarded Gold Plus hospital for eight years. We're Target: Stroke Honor Roll Elite Plus, top 16% of the nation. We have Gold Awards from AHA in heart attack and STEMI, big heart attack, congestive heart failure. Our EMS is Gold.

So, we've done all of these wonderful quality programs, which are very important to the community. What we didn't really do well early on, and I was looking at that from afar — I became the Chief Nursing Officer in 2020, and we weren't really putting in place preventative programs within our emergency department to keep our nurses safe from violent psychiatric patients that were in acute psychosis. Our call to action was — or my call to action was — my emergency department director, Suzanne McGee, telling me this emergency room, this emergency department, is not safe. The nurses do not feel safe. And then we watched a video of our trauma coordinator being thrown against the wall by a mental health patient, and literally kind of falling down the wall like a ragdoll. And to me, that was really a call to action. I didn't know exactly what to do, it's not a problem that you can solve immediately, like Bewitched, twitching your nose or whatever, or snapping your finger. It's multifactorial and it takes a multifactorial approach to try to combat that problem.

Andrew Nelson: Can you tell me how you started to formulate a plan for reducing workplace violence?

Kathy Griffis: Fortuitously, I was offered a spot in the fellowship program for Texas Hospital Association. And we were given workplace violence as a project. We were all given various different workforce issues in the state of Texas. Our team was given workplace violence. Interestingly, I was with Kyle Armstrong, the president of Baylor University Medical Center, and also Anil Sinha, a surgeon CMO from Lake Jackson. And when we first started kind of scratching our heads and thinking, "In this amount of time, do we solve such a huge problem?" What we said was, "Let's figure out where the majority of this violence is happening." So, we did some research and we found that the majority of the violence, and you could probably talk to any hospital administrator in the United States of America, they'd tell you the same, happens in the emergency department because this is where patients in acute psychosis with psychiatric disturbances come for treatment, for help. So, they're coming in here. And in the interim of that, what is going on is, they're displaying acts of violence against healthcare workers. Is it all unconsciously done? Is some of it by design and consciously done? I'm certain that it is, but many times these patients, if you can imagine, they are in this acute psychotic state, they don't even know what's going on. They don't even know that they're lashing out, and that these things are happening to them. And here is this healthcare worker that is not a police officer, a security officer, is really untrained to be able to combat the violence that they see. We have patients that literally will break through plexiglass walls. I mean, barge through doors, take them off the hinges, so it is a huge problem, and it's a huge problem nationwide.

So, what we said we would do is, "How can we help to reduce this violence?" We didn't have a broad landscape to paint this portrait of how we would work through this. What is one thing we could do? One of the problems that I was seeing at Titus Regional Medical Center is, we had a lack of mental health beds in the state of Texas. So, the mental health beds were overcrowded, and sometimes we would have boarders in our emergency department that would wait up to three weeks. Many times, they're waiting for five, ten days, two weeks, waiting for inpatient placement. In the interim of that time for those mental health patients, they're still in acute psychosis. So, they're getting emergency behavioral medications.

And then we have physicians that if you look at some studies, their boards are very light. Less than 5% of their boarded questions are on mental health. So, they really did not feel prepared to take care of those patients. So here they are being boarded, they're not getting proper care because they don't have a psychiatrist. And rural communities — number one, there's not enough psychiatrists. We only cover one third of the state of Texas in psychiatrists; one third of the mental health patients for psychiatrists. Some counties in Texas don't even have one psychiatrist. So, our idea was, we already had a standing program in the state of Texas called CPAN, Children's [Psychiatry] Access Network, where every child in the state of Texas could see a psychiatrist. And also newly implemented at that time was PeriPAN, where if you are a new mother in postpartum depression, you could see a psychiatrist.

Our thought was, how about "EDPAN?" So why can't our borders have access to that expert that can help them with their medications, see them daily? And what we found was with that approach, I pitched it to my CEO, told him what I was doing. He was kind of baffled at first with it, but then he said, "Wow, you know, maybe you're right about this." He took it to John Henderson at TORCH [Texas Organization of Community and Rural Hospitals]. They sent it through legislature, and they funded it for $7.4 million. So now we have telepsychiatry in our hospital at Titus Regional Medical Center. We felt like that this is what would happen. The outcome metric of this would be, is that we would offload mental health beds in the state of Texas. And we did by over 50% because we were able to control the psychosis, control the violence, get them on the right medications, and they were able to be safely discharged to outpatient services, psychiatric services.

With that, we invested in security coverage. We had a couple of guys that were also working in our maintenance department that also served as our security guards. So, we have a very robust security team now. We have at least two to three security officers on shift at any time. We put together a behavioral emergency response team. And what that meant was, no nurse could approach one of these patients by themselves, because they would get hurt. We saw this over and over, they would get hit, they would get hurt, they were in danger. So now our security responds, and if a security officer does not respond, we call PD. So, we call the police department to help us. We also invested in de-escalation training, taught our staff how to de-escalate these through conversation [with] these patients. And that really helped. So, we have a behavioral emergency response team, and we added a robust security surveillance camera program throughout our hospital.

So, seeing her sliding down that wall like a ragdoll, was really a call to action. And this became a multifactorial approach to the problem.

Andrew Nelson: How do you balance maintaining a welcoming patient-centered environment while you're also enforcing strong safety protocols?

Kathy Griffis: I told you these patients many times in acute psychosis. It's a very sad thing to look at, but then you've got this nurse and you don't want your nurse hurt, quite frankly. So, it's an "imagine if" statement. Imagine if we were able to build a program where we helped a patient, we cared about them, we wanted to help them with their psychiatric illness, and we still maintained a safe environment. And we believe that that's what we have done with Texas Tech. And I did not mention that Texas Tech is the university with psychiatrists that provide our telepsychiatry network with TORCH. And it has been just an absolute game-changer. And we've had patients, interestingly, that came in prior to what we call TORCH, our physician access network, you can call it EDPAN, ED Rural PAN.

We had patients that came in before we had it, and we have patients that have come in since, and we had a parent of a patient that was just in the hospital, a young child in the hospital, over and over and over, with outbursts and psychiatric problems, outbursts of anger, and all these things. And this parent is just like, "It is like night and day, having these psychiatrists come in through a telemonitor and be able to talk to our kid; just start[ing] the right medications and start[ing] these programs has really been a game changer."

We've got good people in the emergency department; our culture, we've worked really hard on the culture. We have compassion for these patients. And if we find someone that doesn't, we have to have a discussion about that because, like I said, this mental illness is important, is as serious as anything else we take care of in the hospital. So, I believe we have a very welcoming environment for these patients where we want to help them. And now we have the means to help them.

Andrew Nelson: Obviously, workplace violence can impact staff not only in the moment, but afterwards. What kind of support systems or mental health resources do you have in place to provide support for employees after an incident?

Kathy Griffis: Well, you bring up a very good question, and it's a very challenging question. I was an ICU nurse. I didn't attend any type of support groups that were offered to me. Nurses have a tendency to internalize these issues. In fact, the state of Texas is doing, they did it in 2018… I think they just published their second study on workplace violence against nurses. And what they found was, a lot of nurses didn't even come forward. And a lot of nurses, and especially RNs, feel that it's just part of the job. Suzanne McGee, our ED director, and I have talked about that. And Brandon Nance, our ED charge nurse who is here presenting with us at this conference, they just feel like, "Hey, it goes with the job." You'd be on an oil rig, and you're in a dangerous situation out in West Texas. You know, this thing just goes with the job.

It doesn't have to just go with the job. You know, we have a standing committee with our behavioral health leader who sets up in a classroom on a certain date, and she is there, and we will continue to do that. Is our attendance good? No, I wish it were good. So that is one of the puzzles that we are really trying to solve, is how can we get the nurses to talk about this? Now, I will tell you, if you poll the nurses that were there prior to what we implemented and what we have implemented since, they feel a whole lot safer than they did during that time.

But nurses in Texas, according to the survey, do not feel safe. Only 50% of them feel safe in their work environment. They feel unsafe. So, it's a problem, and we've got to continue to try to find solutions like this to help them feel safe. And yes, we want them to come forward, yes, we want them to talk about this. We want to eliminate some of this stress on them. Getting them to do that is a mite harder than just saying, "We've got this, please come." But we continue to set up shop down in that classroom. We'd love to see them and continue to encourage them to come. We do a lot of incident stress debriefing and things like that.

Andrew Nelson: Do you generally kind of rely on the nurses or the care providers to reach out if they feel like they're struggling? You mentioned a debriefing. Is that part of the standardized process after an incident?

Kathy Griffis: We have debriefings all through the hospital. Our labor and delivery department especially really does an excellent job. We really like to take what they're doing and move that out actually through other departments and really hardwire that. You've got to have participants, but also leaders can help, leaders that say, "We're going to do this, guys, and we're all going to feel better after we do this, after we're able to talk about it." So, you bring up a very good point, and I think that those debriefings after the event happens is probably what we need to do more of in hospitals.

Andrew Nelson: Looking forward, as we're all trying to improve both the care that we are providing to our patients, and also the safety and well-being of our staff and providers, are there changes that you think need to be made in the future, or cultural shifts to further that end?

Kathy Griffis: We have the data to show that through early access to an expert, a psychiatrist who is an expert in their field and can help these patients, we can control violence and we can help patients. So, we know this, and we have data to show that we are offloading patients in inpatient acute psychiatric beds. So instead of building more inpatient psychiatric beds, let's continue to work on programs in Texas or throughout the United States, and especially in rural communities that can help us with that. This is the second legislative session that this program has been funded for $7.4 million to get psychiatrists to rural areas, to emergency departments, to try to offload that.

And I think that needs to continue, and we probably need to expand that, because I can tell you, when you're worried about every dollar in a rural hospital and you're trying to keep your doors open, the last thing that you're thinking about is, "Do I pay for a psychiatrist to see these patients? And if I did, where would I find them? Where would I find the psychiatrist that we only cover one third of the state of Texas for mental health patients in their care?" So, we need to continue to find solutions like this solution, which was just a bright idea that turned out to be something very grand, in my opinion. And we need to continue, and we need to expand that. Early prevention for mental health patients is really where we need to be focusing.

We have a little local mental health authority, and I do not want to take away from them. They're very important to our community. They provide our outpatient services, and they also see our patients within the hospital, and they are the gatekeepers to the state mental health facilities. So, they come and assess those patients prior to the psychiatrist. These folks are not trained psychiatrists. So, to say that a patient could go home from our emergency department that was in acute psychosis, number one, we weren't handling their medications right. So over 90% of those patients went to inpatient beds. And our local mental health authority qualified mental health professional is who suggested that they go, and no physician is going to discharge those patients back out into the community on a safety plan to follow up outpatient. But now that we have telepsychiatry, we're able to do that. So, this only makes sense.

The other thing that I think is important, and this is a long road to get back to your question, but is that we've got to partner with our community, our jails. Okay? A lot of these patients are violent patients. And the jails, they cannot handle these patients if they don't have psychiatric help. So, we had a session with them. We introduced them to Texas Tech, and Texas Tech is now in our local jail. They're providing service. They were waiting for up to 48 hours before they could ever talk to a doctor for some of these inmates. And they need that help. That in turn keeps those patients out of the emergency department. Those patients don't need to be in the emergency department.

Of course, we want to help them, but these are patients that have committed crimes. Our nurses are not jailers; they're not trained to be. But we still want to help them, we also want to partner with our jails and in communities to help them get mental health to those patients early as well. They've seen remarkable differences. We're going to start trying to help them find some grants for that and start partnering and letting them use our grant writing resources.

Andrew Nelson: Is there a single core takeaway that you'd want people to understand about your experiences with preventing workplace violence?

Kathy Griffis: Prior to 2020, when I became the chief nursing officer, I watched this from afar and it seemed like a huge problem. And it was a huge problem. And it was a dangerous problem. When this nurse was thrown against the wall and this ED director came in and said, "We've got to do something. This place is unsafe," you tend to react and say, you know, your conscience says, "What in the world do we do, and what can I do?" Don't ever feel helpless or hopeless or just ignore a problem because it's a problem that you don't think that you could find a solution for. I had no idea. I was blown away that the Texas legislature would fund this for $7.4 million. But this bright idea was passed [to] my CEO, he had connections with John Henderson at the state level, and then, what do you know? We end up with it.

So, no idea is stupid. You've got to try to do something; you can't do nothing. That is one thing that you can't do. And furthering that, also, just the compassion for mental health patients. These patients are sitting in a room without any electronic devices in most cases, because those have to be taken out because they trigger these patients, and bad things can happen. They're sitting there in our ED, they were without a TV, we found solutions there. And we put in TVs that you can't break. So, they have that, they don't go outside, they don't get nature. One of my next projects is, I really want to put nature up in the ceiling where they can't get at that or hurt themselves.

So, your conversation about, "how do you find compassion?" You must find compassion for these patients. Exercise, you could bring in an exercise therapist. We've done it. She can be from afar, they can be in another area, and they can do stretches if you're waiting for a mental health bed, because we're still waiting for a mental health bed in some cases. No going outside, no electronic devices, having very limited interaction with family. They're interacting with staff. What do we think most of us would do in this technological age that we live in? That would be enough to cause psychosis. So always be mindful of that, and find ways to help these patients. So, we keep our staff safe, we help these patients. It's a win-win in the long run. And that's what I would leave with, is your compassion statement. Think about the patient. At the end of the day, that's what we're here for.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. In this episode, we spoke with Kathy Griffis, Chief Operating Officer of Titus Regional Medical Center during the Health Innovation Potluck in Hutchinson, KS. Look in our show notes for more information about their work and visit ruralhealthinfo.org for all things pertaining to rural health.