Going postal.

Wendy L. Bonifazi, RN, is a contributing writer to Contemporary Long Term Care.

IT MAY START WITH SILENT VIOLENCE. AN EMPLOYEE IS angry because a day off was denied. Another takes offense at suggestions. Others are infuriated when they don't get the raise, bonus, or holiday they thought they deserved.

As a manager, you bear the brunt. Nuisance calls. Parked cars "keyed" with disfiguring scratches. Theft. Absenteeism. Sabotage. Property damage.

Sometimes there's a murmur. Snide remarks. Not-so-funny "jokes." Foul language. Complaints. Muttered threats, quickly retracted.

Or not. But whether it's your 12-year maintenance man bellowing, for the umpteenth time, "Next time I'll knock your block off," or a new CNA sneering, "You'll regret that," how can you tell which behaviors are dangerous, which employees pose a real threat?

You can't. Nobody can predict which employee will erupt in a physical assault. Acknowledging the possibilities and developing a thorough, consistent approach to violence is your best safeguard.

The problem

Each year, more than two million American workers are victims of workplace violence. About 1,000 are killed. Nearly 40 percent of these assaults occur in health care settings. According to the National Institute of Occupational Safety and Health, the majority of nonfatal assaults on workers occur in service industries, with nursing home violence topping the list at 27 percent compared to 6 percent for hospitals and 13 percent for social service agencies.

Owners, administrators, and managers may prefer to believe they are immune, but violence is not limited to domestic spats that spill into the workplace or fistfights between feuding frontline employees. In fact, managers and supervisors at all levels have both added responsibilities for facility safety and added risk when they're targeted by disgruntled subordinates.

It happened mid-afternoon outside a Florida nursing home in 1997. A nurse on break was shot in the chest three times at close range. She survived. Prosecutors charged a nursing assistant, who was discharged hours earlier after failing to report to work for 10 days.

"Threats may come with the territory," says John Luken, president of Luken Associates, a workplace counseling and training company in LaGrange, Kentucky. At workshops for long term care administrators, Luken asks how many have been threatened or attacked on the job. "All their hands go up," he says.

During her career, administrator Michele Brousek has seen disgruntled employees throw everything at their managers. One heaved a ripe watermelon through a car window; a discharged nurse, seeking reemployment, slapped the nurse who fired her. Brousek herself has had to call police to remove terminated managers who refused to leave. "It's not just the front line staff," she says. "It can be anyone."

Brousek has implemented violence codes, response teams, strong relationships with local law enforcement, and mandatory violence training on hire and quarterly.

That puts her facility way ahead of most. Experts estimate that 80 percent of health care organizations have not established formal workplace violence programs.

Security consultants, who do a healthy business with hospitals, say they're baffled by long term care providers' disinterest. Some facilities curtail consultant use because of costs. And for administrators and managers used to surmounting major obstacles with minimal resources, superhuman self-reliance may foster an "I can do it" mindset to workplace violence and problem employees. They may also be reluctant to see problem employees as threats, viewing them not with fear but with the compassion common to the helping professions. "Even if you don't convince employees you're one big happy family, you want to believe it," says one administrator. "You do your best for them, and when they strike out, you take it personally. It's like admitting your husband beats you."

Acknowledging the problem

Who hasn't had an employee who parks in the wrong spot, argues with co-workers, or has on-the-job problems? Who hasn't gone the extra yard for a new employee?

Jefferson Place, a personal; intermediate, and skilled care facility near Louisville, Kentucky, is located in an upscale, residential neighborhood, two white dogwoods standing guard at its front door. It has been deficiency-free for seven of its eight years.

Executive director Deborah Bell, a former social worker and 21year company employee, was once named Kentucky Health Care Association's Administrator of the Year. Patricia Eitel became DON after extensive geriatric nursing experience.

When a 23-year-old CNA, "K," had problems, Bell and Eitel didn't ignore her. Instead, they offered support, attention, time, books, even chocolate.

"Debbie tried to take her under her wing," says Luken, who was a consultant to the company. "She crossed the line from employer to trying to be a friend The job was this girl's life ... Patty and Debbie became two of [K's] most significant people."

"Employee violence is an organizational issue," says Lynn McClure, a Mesa, Arizona, consultant and author of Risky Business. Managing Employee Violence in the Workplace (The Haworth Press, 1996). Managers are uncomfortable addressing problem behaviors, but their failure to do so allows the problem to escalate. McClure has identified eight types of people with problematic behaviors--and common managerial responses that let these behaviors continue unchecked. They include:

* Actors, who pound desks, slam doors, or pout, thinking bosses penalize or prohibit honest discussion.

* Fragmenters, who fail to complete tasks. They are often excused for this failure because they're high-ranking "specialists," such as hard-to-hire doctors, therapists, and others who resist completing their documentation.

* Shockers, good employees with dramatic behavioral declines. If the problem is domestic violence, trouble at home can carry over physically to the workplace. Yet managers often excuse the good old employee who suddenly comes in late or not at all, or exhibits a poor appearance or poor performance.

* Strangers, who exhibit antisocial behaviors and fixations such as being either remote or outspoken and who often condemn concepts or individuals. They may claim other employees are "getting inside their heads," "stealing ideas," or "making me do things." Their managers are often afraid to spark confrontations by addressing the problem.

* Me firsts. These people count on protection because of who they know. From the assistant manager who dumps her work on other departments to the CNA who takes breaks whenever she pleases, they know they're safe because they're pals with the boss, or hard to replace.

* Wooden sticks, who are rigid and inflexible, from the housekeeper who refuses to follow new infection control precautions to the manager who hires only able-bodied whites. Frustrated managers excuse or overlook their behavior, even when the need for change is obvious (equipment or practices are outdated) or required (by a new supervisor, acquiring company, or regulator).

* Mixed messengers. They say the right things ("Sure, I'll orient the new employee/switch shifts/cover more patients"), but do what they please-resentfully, and with excuses when their failures come to light.

* Escape artists, who avoid harsh realities and stress by lying and addictions to substances, gambling, danger, or even work. They're at high risk for theft and drug-induced violence.

Fearful managers try to protect themselves by refusing to acknowledge, discuss, document, or discipline threatening behaviors, McClure says. But silence reduces your credibility-and it could increase your liability in court, if violence eventually erupts.

Don't ignore, excuse, or interpret bad behavior; counsel employees; or gossip about them. Instead, says McClure, "managers should document these behaviors and suggest outside counseling where appropriate."

Taking action

"You've got to take any direct or veiled threat seriously," cautions Luken. But threats are not always verbalized. Other warning signs include intimidating behavior; carrying, discussing or showing weapons; inability to take suggestions or criticism; holding grudges; being obsessed with the job or with a romantic interest; having a rivalry with a group or person, and having a history of violence.

There's a catch-22 to employee violence: You ignore it at your own risk, yet reprimands, evaluations, and disciplinary actions may trigger retaliatory behavior. You must respond with an iron fist-clothed in a velvet glove.

Gerald Nilsson-Weskott, senior consultant at Organizational Horizons in Columbus Ohio, teaches a workplace violence program for long term care administrators at Ohio State University. To keep behavioral problems from escalating, he recommends a system he calls "Green light, yellow light, red light." Here's how you can handle different degrees of potential violence:

* Green light. At the first sign of belligerence and problem behaviors (including passive-aggressive absenteeism and uncooperativeness), hold a private meeting with the employee. Ask if the employee is okay. Specify the behavior you object to. Point out that it's out of character and unacceptable, discuss what is reasonable and acceptable, and explain your hope that this is an isolated event, not a pattern.

* Yellow light. If the problem behaviors continue after your meeting, document the ongoing issues and meet with the employee. Tell the employee what he did wrong. Then say: "We're seeing a pattern. We trusted you to change and you didn't, so we're giving you probation. We value and want you. We recommend counseling (provide referrals). We will terminate you after another incident. We will follow up every two weeks for several months."

Take notes on the meeting, and share them with administration. (Administrators disciplining top-level managers may want to copy human resources, a company executive, or the owner.) Gather supporting data from other supervisors and managers, but avoid questioning co-workers directly.

At follow-up meetings, ask the employee how he is doing. What does he think has improved, and what must stop? Tell him what you see, and set up your next meeting.

* Red light. Employees who don't change their behavior by the end of a probation period or who commit an act of violence must be terminated immediately. Notify your designated crisis intervention team (which may include security, human resources, external legal and counseling advisers, and law enforcement). Use tact to extricate the employee from the situation by saying it's clear he or she is bothered by something, and suggesting a cup of coffee. Go to a safe office (in human resources or administration). Acknowledge that the situation is difficult for both of you, but since his actions are not acceptable, he is terminated and must leave immediately. Be prepared to deal with paperwork and property on the spot, or, if the employee needs to cool off, at a later time. Explain how you will handle pay, paperwork (such as benefits), and property. If the employee was terminated for assault, fraud or theft, have security supervise as he gathers his personal possessions or gather them for him.

Ready, aim, fire

When K discussed bringing guns to the facility, she was terminated, said Bell and Eitel. They filed complaints with police and requested increased patrols, alleging that K harassed them with calls and threatened facility employees. One complaint says K trespassed at Eitel's home and kidnapped her dog.

Handling terminations may be your greatest challenge. Avoid confrontations in which the employee could lose face in front of peers. Think twice about asking someone to resign in order to avoid paying worker's compensation or unemployment benefits. Employees will he much angrier," says Nilsson-Weskott.

Security specialist Patrick Donaldson, president of Forbes & Associates in Portland, Oregon, avoids on-the-spot terminations, particularly for actual or threatened violence. "They go absolutely ballistic, and you become the target," he says, citing an Arizona housekeeper who, during termination, reached across the administrator's desk, grabbed her hair, and smashed her face onto the desk.

To avoid such situations, Donaldson recommends immediate suspension pending an internal investigation, the rules for which should be specified in your employee and violence policies. Even a one-day suspension gets a potentially violent employee off the premises. It protects the facility from employee overreactions and from a manager's mistaken interpretation while maintaining a clear rule: one physical strike, and you're out.

Donaldson suggests that you terminate in a lawyer's office or other safe location. Another option is to have a lawyer, human resources consultant, or behavioral counselor conduct the termination over the phone. If you choose that route, be sure the employee is told when to expect his final check and any personal effects.

You may also require a medical leave and psychological treatment as a condition of return, but if you do, discuss specifics with your lawyer first. Doctors and psychologists may recommend a premature return to work in hopes it will benefit the patient, regardless of the consequences to you.

If you terminate the employee onsite, Luken suggests using neutral, "official" locations. Remove dangerous objects, such as letter openers and vases. Avoid desks or tables that trap you and hide the employee's hands from view. If possible, direct the employee to a low, soft seat that slows movements, and sit on a high, firm chair with armrests. Maintain unrestricted access to an exit. Keep doors open for safety, speaking quietly for privacy. Include a second manager who can support the employee and witness the interaction.

The aftermath

April is a nice time to visit Jefferson Place, particularly during Derby Week, with its day and night festivities. That's when K decided to visit her former colleagues.

Terminations should include a clear statement that the employee is no longer welcome on the premises and that a return will be considered trespassing and lead to arrest. When terminating by phone, include this information and reiterate it in a written letter to follow.

Donaldson recommends alerting other employees. In addition to managers. receptionists and security staff, this may include general employees. "Tell them the individual is no longer employed and has been informed that if seen on the property, managers will be notified, and police will be called for trespassing," he says.

If you or other employees are specifically threatened, employment policies should include the option of a leave of absence, suggests John Lyncheski, chair of the labor and employment practice group at Cohen & Grigsby, a Pittsburgh law firm that represents many long term care companies. (While there are no guarantees. McClure says one study found that violent acts typically occur within a week after an employee has been fired and threatened to retaliate.) But he says that many will feel safer at work, with its limited entrances and security precautions, than they'd feel alone at home.

You or your company could also hire a guard or request a court order of protection (ask your local police which court in your area issues restraining, stalking, or "protection from abuse" orders.) Even without a court order, you can call police to arrest trespassing exemployees. But restraining orders and increased patrols are imperfect. "People who kill don't care about restraining orders," says Luken.

So what's the best protection? "Don't ignore any offense," says a Jefferson Place official. "It's a crazy world out there."

Deborah Bell and Patricia Eitel left work at Jefferson Place on April 29, 1997. Just outside the facility's front door, they were shot and killed Every April blossoms from the dogwoods trees planted in their memory will drop on the lawn.

Kimberly Harris (K) has been charged with their deaths.

A MATTER OF POLICY

Safety starts with the hiring process (for details, see "Lock out crime" in the July 1998 issue). Your next line of defense is an anti-violence training program.

According to Brenda Conway, president of Galloway Consulting Services in Raymore, Missouri, training for all employees should include explanations of policies, procedures, reports, and records; risk factors; employees' responsibilities; and how to assess and avoid volatile situations.

Supervisors and security staff need additional training in how to reduce both external and internal jeopardy (such as handling cash and checks, or working in isolated areas such as laundry or dietary), handle aggression, correct hazardons situations, document problem behaviors, notify law enforcement agencies, form crisis intervention teams, do crisis planning, and develop appropriate policies.

You also need systems designed to prevent or abate recognized hazards. OSHA's Workplace Violence Prevention Program recommends that employers institute the following:

* A strong, specific, zero-tolerance policy for violence, stating that any employee who commits or threatens to commit a violent act is subject to disciplinary action and/or criminal or civil prosecution. The policy should specify that anyone making substantial threats, behaving in a threatening manner, or engaging in violence will be removed as quickly as possible, pending the outcome of an investigation.

* Ongoing analyses of potentially hazardous employees, situations, and practices by designated teams including managers, employee representatives, and outside consultants from legal, security, human resources, and/or behavioral intervention companies.

* Policies and practices for screening, training, supervising, disciplining, and terminating employees

* Clear employee conduct rules

* Employee assistance and stress management programs

* Policies and procedures for reporting threats and violence immediately

* Policies to protect employees who report threats and violence

* Prompt action against employees who commit or threaten violence

* Initial and annual education for all employees on recognizing and preventing violent behaviors, company procedures, and survival strategies

* Relationships with local law enforcement

* Access to emergency legal and counseling resources

* Conflict resolution procedures for employee disputes

* Trained response teams, including internal staff and security and counseling consultants

* A checklist of things to do at termination

* Security programs and devices.