Violences hospitalières, quelles pistes ?

Le titre apparaîtrait presque comme une oxymore, s’il ne s’agissait pas de désigner les atteintes aux biens et aux personnes commises au sein des établissements de santé publics et privés. Le thème de la violence en milieu sanitaire est récurrent tant elle est exercée également à l’encontre des médecins de ville, en particulier dans les bassins de populations précaires. Les résultats de l’Observatoire de la sécurité des médecins, mis en place par l’Ordre national des médecins ont montré une hausse importante du nombre de violences à leur égard (920 en 2010 contre 512 en 2009). Les lecteurs pourront utilement se reporter à la lecture du rapport 2010 dudit observatoire.

L’Observatoire national des violences hospitalières (ONVH) a reçu, de son côté, 4.742 signalements de violence au cours de l’année 2009, et 5.090 faits pour l’année 2010. 85% des violences déclarées sont des atteintes aux personnes, dont 21% concernent des insultes, injures, 18% des menaces, 45% des coups et 1% des faits qualifiés de crimes.

15% sont des atteintes aux biens, dont 13% concernent des vols simples et dégradations, 1% des vols par effraction, 1% des incendies ou dégradations graves. Les trois services les plus touchés demeurent la psychiatrie (40%), les urgences (15%), et la médecine générale (13%).

Le rapport 2010 de l’ONVH est consultable ici.

Des pistes peuvent être explorées, observation étant faite qu’il n’existe pas de solutions préconçues. Chaque établissement présente ses propres particularités (implantation géographique, typologie de la population, données architecturales, contraintes institutionnelles, etc.).

Au plan structurel, il conviendrait d’actionner les leviers suivants : le savoir-être du personnel et les conditions matérielles d’accueil, l’information et la communication aux patients, l’organisation de la gestion des flux.

Concernant, le savoir-être du personnel, on pourra méditer sur les réflexions suivantes :

« A-t-on parfois peur des malades ? Sont-ils dangereux ? Je crois vraiment que non. Cependant, ils ne sont jamais que le miroir de notre propre attitude. Le respect, le professionnalisme, un sourire viendront à bout des agressivités les plus coriaces. La première attitude à adopter est la politesse, puis le respect, respect de leur angoisse, de leur attente souvent mal formulée et qu’il faut s’attacher à comprendre. Au début, cette angoisse se manifeste souvent par une forme d’agressivité, surtout venant de leurs proches qui traduisent ainsi leur propre angoisse et leur impuissance par un comportement actif. Ils veulent le changer d’hôpital, le changer de docteur ! Ils parlent de procès, évoquent leurs relations dans le monde médical. C’est là qu’ils brandissent cet épouvantail : le Pouvoir Médical. Le patient, lui, plus concerné, est souvent beaucoup moins agressif. Je l’ai souvent vécu. » ((L. Seidel, Chirurgien au bord de la crise de nerfs, Albin Michel, sept. 2008.))

Propreté des lieux, éclairage et signalétique achèveront d’apaiser l’esprit des patients, comme celui de leurs accompagnateurs.

On n’insistera jamais assez sur l’importance de la communication, dont le défaut est inexorablement source de tensions et d’incompréhension. Au service des urgences, l’office de l’infirmière d’accueil et d’organisation (il paraît qu’on ne dit plus : orientation, terme réservé aux médecins) est primordial.

Enfin, les patients et leurs proches ne doivent pas avoir le sentiment que l’hôpital est un moulin, certaines parties devant être strictement réglementées (maternité, réanimation, etc.).

Au plan organisationnel, il importe de se focaliser sur les délais d’attente, les équipes de sécurité et l’équipement des personnels.

Suivant l’analyse qualitative et quantitative des actes de violence commis sur une période donnée, il conviendra de faire intervenir les équipes de sécurité, formées et entraînées, au cours des plages horaires jugées pertinentes (c’est-à-dire exposées au risque de violence). Les circuits d’alerte doivent nécessairement faire l’objet d’une réflexion approfondie.

Au plan institutionnel, l’intervention rapide des services de police est requise et peut se révéler déterminante dans certaines situations. Signé le 12 août 2005, le protocole Hôpital-Police-Justice, signé entre les ministères de l’Intérieur et de la Santé, a fait l’objet d’une modification puisque ce protocole est devenu tripartite, grâce à la Chancellerie, le 10 juin 2010.

On ne peut faire l’économie d’une formation des personnels à la prévention et à la gestion des manifestations de violence. Sans qu’il soit besoin de transformer les personnels soignants en Bruce Lee ou en Chuck Norris, la circulaire DHOS du 15 juillet 2009 relative aux axes et actions de formation prioritaires pour le personnel de santé a intégré ces besoins (approche comportementale et psychologique des auteurs de violence, etc.).

La signature d’une convention entre un établissement de santé, un commissariat de police et, pourquoi pas, un tribunal correctionnel (on peut toujours espérer), ne suffira bien évidemment pas. Pour faire vivre cette convention, il faut l’éprouver à chaque situation délicate. Ce n’est que dans la durée et en actionnant tous les leviers que les résultats deviendront probants.

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