The government has launched a major consultation to respond to the problem of attacks suffered by nursing staff.
It was one evening in 2015, at the start of shifts, in the psychiatric emergency room of a Parisian hospital. Camille Boutouyrie, a child psychiatrist then in her second year of internship, was called in to help around 7 p.m. The alarm is ringing to channel a patient in crisis, “very excited, [et] who couldn’t bear to be locked up”, remembers the young woman. “It went up very quickly in the towers.“The mobilized caregivers do not seek to contain the patient. Free to move, he swoops down on the young woman.”He smashed my skull against a wall in the hallway. I was operated on for a triple fracture of the displaced face”, breathes the doctor, her voice trembling.
From 2005, the National Observatory of Violence in the Health Environment (ONVS) collects reports of attacks, such as that experienced by Camille Boutouyrie. In 2021, this entity received 19,328 reports on a dedicated platform, of which 84% of declared victims are caregivers (PDF document). With 22.2% of reports filed that year, psychiatry is the area most affected. These figures are based on statements by caregivers and do not reflect ongoing complaints and investigations. In order to better protect caregivers, a consultation was launched on Thursday February 16 by the Minister Delegate to the Minister of Health and Prevention, Agnès Firmin Le Bodo, with the objective of arriving at a plan of action before the summer.
Rare physical damage, but with significant psychological impact
Paula* is a nursing assistant in a closed child psychiatry unit in Paris. The young woman, recently graduated, supervises meals, hygiene and patient safety alongside the nurses. Often confronted with crisis situations, she is accustomed to threats, spitting and other scratches aimed at the members of her unit. “It would be better have a hard head to do my job”, blows the 25-year-old caregiver. “We can take chairs, it throws furniture in the bedrooms…“
In psychiatry, physical violence represents 38% of reports made in 2021. “Whether the majority of patients are not dangerous, some are at increased risk of violence,” states the latest report. The High Authority for Health, based on an international study, estimated in November 2016 (PDF document) that 2% of patients repeatedly went through moments of violence. If the physical damage is fortunately most often benign, “the psychological impact of these episodes are significant“, emphasizes the public authority. Attacks of brutality often concern patients hospitalized without their consent, admitted at the request of a representative of the State or a director of an establishment: these profiles are likely to become “hetero-aggressive”that is to attack another patient or a member of the hospital staff.
Few tools are given to caregivers during their studies, which last only one year. On the question of violence, although omnipresent in psychiatry, Paula feels that he was too unprepared. Katia Lupanof, trainer at the Institute for the Training of Caregivers (Ifas), admits that the basic course constitutes a base that must be reinforced once in an institution. “If we really wanted to train caregivers well, they would have to spend a full year in Ifas”, Katia Lupanof gauge. The trainer believes that the issue of violence must work both in an institution and within a team. “There is an obligation to increase one’s skills through experience“, she assures. Within her department, Paula has only received two days of continuing education in two years. “We are fighting for sheets and garbage bags… In the face of this, training is falling by the wayside”, castigates the young woman.
“A drastically reduced workforce”
In 1992, the nursing diploma in psychiatric care disappeared to merge with the more general state nursing diploma. A decision that Camille Boutouyrie deplores. “Being a psychiatric nurse cannot be invented. It’s crazy that we don’t train [ces personnels] more specifically“, is surprised the child psychiatrist.
A clinical nurse specialist and member of the board of the National Union of Nursing Professionals (SNPI), François Martineau considers himself lucky to have learned in the field frompsychiatric nurses. They taught him “methods of de-escalation of violence.” Convinced that this type of tutoring persists during internships in certain establishments, he nevertheless regrets a “Insufficient initial contribution in psychiatry“, and an “transmission between peers which no longer takes place correctly, with staff reduced to a trickle.”
Several psychiatric unions mobilized in November 2022 in Paris to alert on the shortage of doctors and nurses, which would affect according to their count “five establishments out of six”. In this context, thworking in a unit where there are around thirty caregivers for twenty patients is a “exception to the rule” believes Sandra Mandez, who benefits from such conditions in her job as a nurse in a unit for difficult patients. Such a ratio of caregivers to patients allows to anticipate the passage to the act: “Violence is present in the unit for difficult patients, but it is very well channeled. The patients are constantly busy, we calm them down before the crisis explodes.”
A billvoted by the Senate on February 1, aims to introduce a minimum ratio of caregivers per patient and per specialty in public health establishments. “Psychiatry will be concerned”assures Senator Bernard Jomier (PS), author of the bill. Right now, these ratios exist in departments like resuscitation and critical care,”but not in psychiatry“, deplores the senator. But even if the text is adopted by the National Assembly, it would be necessary to wait another four years before these quotas come into force. “The text gives the Haute Autorité de Santé two years to establish a range by specialty, and two more years to specify the quotas. adds Bernard Jomier.
“I was alone with the complaint”
Samuel Lepastier, psychiatrist in the Paris region, emphasizes that he “there is no miracle cure for violence”. To limit it, the practitioner advocates human support, because “the more we listen to patients, the less they take action.” But when the assault takes place, health professionals rarely seek redress. In 2021, 78% of reports were not followed by legal action, according to the ONVS. The Observatory nevertheless puts this rate into perspective, explaining that health establishments are not necessarily notified of the filing of complaints, as well as of the legal consequences which would result therefrom.
The silence around issues of brutality is partly explained by the difficulty of being both caregiver and victim. “Talking about violence is taboo, says Camille Boutouyrie. It’s as if we had to put up with everything.“Four days after her attack in 2015, on leaving the hospital, the child psychiatrist went to the police station to file a complaint. The judicial police officer demanded the patient’s name. Does she have the right to disclose it? “My management couldn’t tell me“, she recalls. “I was completely unaware of my rights and the procedures to follow. I was alone in the complaint”, sighs the young woman.
As an intern, Camille Boutouyrie could have benefited from functional protection, a measure that compels the administration to “protect the agent, provide him with legal assistance and repair the damage he has suffered”, specifies the ONVS. The child psychiatrist did not know of the existence of the device. “She was badly advised at the time”, believes Me Caroline Benhaim, lawyer specializing in health law, for whom these problems are less frequent in the private sector, “where information on procedures circulate better“.
“I might not be able to work anymore”
After changing institutions, Camille Boutouyrie ended up persevering with her complaint, later supported by her lawyer sister who agreed to represent her. In February 2019, four years after his assault, the patient was found criminally responsible and sentenced for “violence against a person charged with a public service mission”. The psychiatrist has consequences: a victim of post-traumatic stress, she has never been able to work again in adult or adolescent psychiatry and fears a new attack. “I might not be able to work anymore. It is my great fear, she confides in a flat voice.
Contacted by franceinfo, the office of Minister Agnès Firmin-Le Bodo, who has just launched a consultation on the subject, affirms that “the accompaniment of caregivers in their legal procedures will be one of the points of attention of the work”. Sector-by-sector solutions are not envisaged, however, because “all caregivers are concerned by the issue of violence in the healthcare environment, regardless of their profession”. Conclusions are expected by mid-May. The president of the Syndicate of French psychiatrists, Maurice Bensoussan, hopes for additional means: “We need leads to break the silence and deal with each incident. This is how we will get out of the violence“.
*Name has been changed.