The Esquirol Hospital.
I : THE ENVIRONMENT.
a/ History of the hospital.
1) The creation of la Maison de Charenton.
Documents concerning the origins of la Maison de Charenton show that its creation and opening date back to 1641/1645. It was created under the name of "Home of Charenton Saint Maurice " and was run by Brothers who were members of the charitable order of Saint Jean de Dieu. On September 13th 1641, Sébastien Leblanc who was a councellor and war controller of Louis XIII donated some houses and land situated on the parish of Charenton Saint Maurice to the Brothers who had to settle there and to cater for poor people with a illness in a home comprising five beds and named Charité Notre Dame de la Paix.
The opening of the home of Charenton thus took place in the general context of what Michel Foucault (1) called the " great withdrawal " of the classical age, a policy of police streamlining whose institutional shape led to the creation of the general hospital.
Successive donations increased the capacity of the first home and a deed dated May 4th, 1662 aimed , for the first time, at increasing the boarding capacity of the hospital to " seven in the name of the Virgin's seven anxieties and the seven works of spiritual and corporal mercy " .
The Brothers who were members of the charitable order and had been called to France by Mary of Médicis settled in the hospital on May 16th 1645. This date is in fact the beginning of the religious occupation of Charenton. It was to last until the French Revolution.
It does not seem that at the beginning Charenton had been aimed at catering for local people. Thus the home belonged to what can be considered as the general background of Paris.
In September 1660, a Paris parliament ruling stated that insane people had to be catered for at the Hotel Dieu hospital, to be treated in specialized departments. Among the insane people who were sent there the most privileged ones were quickly transfered to the small homes of rue de Sèvres and to Charenton. This parliament ruling was the first legal step taken to send mentally ill people to specialized hospitals.
So Charenton did not cater for poor people but for patients who were better off.
During the second half of the 17th century more and more madmen were to be locked up there.At the end of the century a special building was erected. It was separated from the original buildings and devoted to the locking up of men suffering from mental disorders.
Throughout the 18th century the activity of the hospital increased, so that in 1768 the Brothers of the Charity bought up the seigneury of Charenton-Saint Maurice and the territories of la " Rivière " and la " Chaussée " (2)
2)The home of Charenton during the Ancien Regime.
" What is obvious is that the commital of lunatics did not follow any specific rule and that committing someone despite its seriousness escaped any legal investigation. The lunatics were catered for without any special authorisation and nothing guarenteed that admitting the patient was necessary. Arbitrariness governed the way someone was deprived of individual freedom " (3).
The coexistence of lunatics and convicts seems to be the major feature of the purpose of the Home of Charenton until the French Revolution. Even so, it is difficult to determine precisely the exact date when people started to be sent to the home by lettre de cachet. A capitular dated 1720 mentions the presence of convicts. Gaussens estimates that it became common at the beginning of the 18th century, it then developed progressively to decrease again at the time of Louis XVI.
In the 18th century the home was run by 10 members :
The Prior summoned and presided over the meetings of the Chapter. During these meetings the Brothers would " discuss the running of the hospital and of the community, what had to be improved for the patients and the convicts, what had to be restaured or built up. All the decisions were voted and a majority was required. A vote also took place any time the community received donations or sent money to other homes belonging to the same order which were situated in other French towns or cities " .(4)
It is mentioned, for the first time, in a 1701 capitular that a separate chapel had been built for the lunatics. The chapel was blessed the same year.
A 1720 capitular mentions the number of convicts : apart from the poor patients there were usually 120 convicts, most of whom were detained by order of the King, and often coming from the Bastille prison or other places.
A capitular dated February 2nd, 1722 mentions that the Prior was required to visit all the residents at least once a week " to comfort them as well as to know their situation, their needs and to make sure they were properly treated " . The same capitular stated that the apothicar had to be provided with the simple and composed drugs necessary for the Brothers, the patients either poor or mentally ill.
The Brothers, members of the order of Saint Jean followed the general rules of their order. " During their noviciate the Brothers studied medecine, surgery, pharmacy and administration then they specialized in one of these fields… The patients were separated in several groups according to the nature and seriousness of their disease ; seriousness, semi-freedom or freedom corresponded to each group. "
According to Doctor Lehalle(), the mentally ill were treated with drugs, bloodletting, comforting and medical care. The recalcitrant patients were condemned to isolation and locked up.
3)The period of the Revolution
The hospital did not avoid the stormy period but the transition was soft. A report established by the Begging Commission finishes with these words : "This hospital deserves more than the others". One could then believe that the hospital would not end up like the others.
An act of parliament passed on April 18th ,1792 required to suppress religious orders and led to the closing down of the hospital. The Public Salvation Committee ordered by decree on July 30th , 1795 that the hospital be totally evacuated : the patients were dispersed, the house was looted before being transformed into a state prison which was an annex of Vincennes.
On Frimaire 19th year VII, it was stated that insane people had to be sent to Charenton instead of being catered for at the Hotel Dieu in Paris. On June 15th ,1797 (Prairial year V) the Directoire ( French regime from 1795 to 1799) decided to reopen the hospital.
The hospital then benefited from a new lay and administrative status. It was placed under the administrative supervision of the Ministry of the Interior (Home office).
The person holding the concession to run the hospital was Father de Coulmier who had previously been Father superior of the Prémontés. In 1810, the home of Charenton catered for 328 residents.
Roulhac du Maupas, a former barrister, took after Father de Coulmier. Helped by the senior consultant, Roulhac du Maupas inaugurated a decade of changes heralding the reforms concerning insane people which were to be introduced by law on June 30th,1838.
4) The reconstruction.
The arrival of Jean-Etienne Esquirol in 1825 as senior consultant opened a period of intense activitites which contributed to the international reputation of the hospital. The hospital was to welcome the most famous psychiatrists : Moreau de Tours, Archambault, Ritti …
Esquirol, who was born in Toulouse, was Pinel's favourite disciple ; he believed in the necessity to improve lunatic asylums for the patients and wanted psychiatric homes to become a " recovery instrument " and not only a place in which to lock up people.
In June 1883 he launched a program to build a new home aimed at boarding 300 patients. He intended to have a symetrical and regular building erected on the plateau.The lines of the building were to be parallel and its stoutness was to have an effect on the patients and encourage the "moral treatment " of their illness.
For seven months, the architect Emile Gilbert worked on two variants of the reconstruction project. One of them roughly remained the definitive plan of the new hospital. The first stone of the new building was planted on October 30th ,1838.
The works lasted for six years, then they were stopped because of a lack of credit. They started again in 1865 and were finally finished in 1886.
The building was described by Pierre Pinon (an architect) as being either "a temple of reason " or " a madness of archeology ".
5) The maternity hospital.
In the aftermath of the first world war, in 1920, at a time when demography was shattered and when birth increase had become a national watchword a law was passed. It intended to transform the hospital into a national maternity hospital. The project only partially succeeded and did not undermine the psychiatric purpose of the hospital. It finally led to an original and sometimes complementary structure. In 1958, a cantonal maternity hospital was fitted out. It was to become a gynaecological and obstetric department.
6) The beginning of nurses'trade unionism in Saint Maurice.
" It is only at the beginning of the XXth century that private life and professional life started to be separated …As social laws evolved the gap existing between the asylum staff and the employees had become unbearable. In large hospitals nurses started to signal their desire to get organized along specific goals : the first registered claim by nurses working in the old asylum of Charenton dates back to 1888 and concerned wages and perks.
Yet it is only on April 18th ,1906, that the Association of the employees of the national hospital of Saint Maurice was created. The following year it joined the trade union of low ranking personnel working in national asylums. The members of the association numbered 140 people (80 men and 60 women) i.e 3/5 of the so called low ranking staff. The administration spoke of a " nurses'trade union " and worried that a list of union demands was written in 1908. "
7) The Esquirol hospital.
In 1970, the national hospital was turned into an autonomous public hospital of the department of Paris.
In 1991, the hospital became a public hospital.
The buildings are registered as ancient monuments ; any project concerning the buildings or the open spaces of the hospital must be approved by the Ministry of Culture, as the hospital comes under the regime of ancient monuments and under the regional organization responsible for urban development and equipment whose task is to maintain the country's architectural heritage as well as the open spaces of conservation areas.
a/The geographic sectors.
The psychiatric departments for adults and for children and adolescents depending on the Esquirol hospital cover at the same time some Paris arrondissements and some towns situated in the department of Val de Marne, corresponding roughly to the south east of Paris.
Psychiatric department for adults.
Paris 1st and 2nd arrondissements.
Paris 11th arrondissement.
Paris 12th arrondissement.
Charenton le Pont, Saint Maurice, Alforville.
Psychiatric department for children and adolescents.
Paris 1st, 2nd, 3rd, and 4th arrondissements.
Paris 11th arrondissement.
Saint Mandé, Vincennes, Fontenay sous Bois, Joinville, Saint Maur des Fossés.
Charenton le pont, Saint Maurice, Maisons Alfort, Alforville.
Vitry sur Seine, Thiais, Choisy le Roi, Orly.
The patients attending the hospital are city dwellers. Depending on where they live they attend such or such a hospital. The latest census (1990) stated that the adult population concerned by the psychiatric deparments was :
As a whole, the adult population for these sectors numbers : 341,368 heads.
c/ Partnership and competition.
Partners receiving patients from any sector in their psychiatric departments for adults :
5 Impasse du Bon Secours, PARIS XI
184 rue du Faubourg Saint Antoine, PARIS XII
33 Boulevard de Picpus, PARIS XII.
Both hospitals situated in the 12th arrondissement of Paris deal with emergencies 24 hours a day, propose hospitalization if necessary and admit out patients.
Other partners dealing with psychiatry in Paris :
d / social and economic background.
II : RULES AND REGULATIONS.
a/ Legal status.
The hospital being state run it is regulated by law (act of parliament n° 91 748 July 31st ,1991, dealing with hospital reform).
" Each state run hospital concerned with fighting against mental illness is responsible for fighting against it in each psychiatric department it is attached to. In its psychiatric sector the hospital offers the population services such as prevention, diagnosis and reajustment treatment as well as social integration. These services are offered inside and outside the hospital " .
b/ Financial status.
The financial organisation of the hospital is regulated by an act of parliament dated January 19th , 1983.
An overall budget replaces individual tariffs. A global allocation for running costs is fixed yearly and covers most of the spendings. The allocation is calculated on the basis of the previous year attendance figures to the hospital. The increase in the allocation is linked to a base rate which is the sole instrument to contain hospital costs.
State run hospitals are submitted to a budget, financial and accounting scheme defined by law:
The budget is composed of expenses and receipts concerning numerous entries which are gathered along two axes, on the one hand the running of the hospital (working expenses) and on the other hand its development (capitul expenditure)
- Investment receipts have two origins : internal funding or loans. As regards internal funding the hospital possesses the funds necessary for its projects or may get them by selling for example some of its estate. Otherwise it can ask for a loan by following a specifique procedure.1()
c/ The status of the staff.
The civil service is based on the notion of career development which allows to ensure its permanence. So someone working for the civil service in a hospital has a statutory position. His/her career development develops according to a procedure which is codified by the status. The status of permanent staff members is defined by law :
To be recruited the applicant must :
To join the civil service the applicant must take a competitive entrance examination, based on his/her diplomas, or on his/her diplomas together with the success in a competitive exam or on the success in a competitive exam alone.
Staff in Esquirol on 31st.12.1995.
Non medical staff on 31st.12.1995.(distribution in %)
The real staff figure for the non medical staff on 31.12.1995 was 1303,26.
Nurses represented 498,40 and nurses working in the psychiatric departments 438,50.
Medical staff (real staff figures) on 31.12.1995.
d/ Hospital project.
Hospital projects are ruled by act of parliament n°94-630 (July 25th, 1994) article 16.
The hospital project, based on the medical project, defines the general goals of the hospital concerning medical, care and treatment fields, biomedical research, social policies, training schemes, management and information systems.
This project which must correspond to the goals of sanitory organization determines the number of beds, people and equipment that the hospital needs to implement its project. Act of parliament n° 91-748 (July 31st,1991). The hospital project is a five year project. It can be revised before the end of the five year period.
III : ORGANIZATION.
a/ Organization chart.
b/ Authorities and committees.
1°) The hospital medical committee.
Legal reference texts :
Composition of the committee :
Ordinance n° 90-956 (October 26th, 1990) and circular DH/AFA/44/92 (September 29th, 1992) set up the composition of hospital medical committees making a distinction between ordinary hospitals, teaching hospitals, non teaching hospitals, local hospitals and non local hospitals.
Members of the hospital medical committee are elected (majority vote, two round ballot) by an electoral college representing the different categories and status of hospital consultants.
Competence of the committee :
The hospital medical committee sets its own rules and regulations as long as they do not contravene legal texts and regulations.
It elects its president and vice president among the senior consultants, who are members of the committee. The president fixes the agenda and signs the convocations. He is the administration councellor.
The committee meets at least four times a year. An extraordinary meeting can be called at any time by :
The meetings are private and minutes of the meetings are written by the hospital.
2°) The hospital technical committee.
Legal reference texts :
Competence of the committee:
The committee acts as an advisor for any collective question concerning the staff and must be consulted in any case.
The competences of the committee are divided between the Director and the Board of Directors.
Sphere of competence of the Board:
Sphere of competence of the Director ( the Director is obliged to consult the committee in the following cases) :
Composition of the committee:
The Director is the President of the committee. There are 16 members on the committee (plus the President). The members are elected on a list system and they belong to the hospital staff. (4 CRC, 4 CGT)
In Esquirol the Director surrounds himself with his executive team and sometimes calls on experts.
Functioning of the committee:
The committee meets at least once per quarter. It organizes the various committees (eg. adult continuing education committee.). The recommendations of the committee are transmitted to the Board of Directors and to the staff.
The chairman of the Board of Directors is the President of the committee. The president has no casting vote. He calls the meeting of the committee, and sets the agenda.
The members of the committee must have the documents concerning the meeting at least a fortnight beforehand.
To deliberate half the members of the committee, who have voting powers, must be present when the meeting starts. If there is no quorum a new meeting is summoned eight days later. No quorum is needed then.
3°) The administrative joint committees.
Legal reference texts :
The civil servants belonging to category A and B come under two distinct administrative joint committees. Civil servants from category C and D come under one committee.
There are local and departmental administrative joint committees. Only the latter are taken into consideration for the representation of unions at a national level.
The administrative joint committees are composed of representatives of the administration and of the staff in equal numbers. They are composed of permanent and replacement members. ( College A : 2 CRC, college B/C : 4 CRC,1 CGT, 1 CFDT.)
The Departmental Director of the sanitory and social affairs or his representative is a member by right and is the President of the departmental administrative joint committees.
The members of the local and departmental administrative joint committees are appointed for a three year period. Their term of office can be renewed.
The meeting of the local and departmental administrative joint committees is called by the President :
A Prefect can also call the meeting of a departmental administrative joint committee.
The administrative joint committees usually meet twice a year : in spring and in autumn.
The agenda is determined by the President on proposals of the Director in the case of local administrative joint committee, or of the hospital Directors in the case of departmental administrative joint committees.
Votes are held by show of hands or by secret ballot if it is asked by at least a third of the members who are present.
Competence of the committee :
The administrative joint committees mainly deal with individual questions concerning permanent staff members, sometimes with questions concerning trainees (to be confirmed in a post) or with questions concerning non permanent staff members (training).
Their opinion is collected either in plenary assembly or only by few people.
In plenary assembly, the administrative joint committees examine :
Only a few people are needed to examine :
4°) The committee for the fight of hospital infections.
Legal reference texts :
Ordinance n° 88-657 (May 6th, 1988)
The committee must :
In Esquirol, the committee made a survey on prevailing hospital infections from June 3rd to June 7th, 1996. It was the first step in a national programme of supervision of infections in hospitals, conducted by the national technical committee to fight hospital infections. (Comité technique national de lutte contre les infections nosocomiales).
The objective of the survey is to federate all the French hospitals. The results of the survey and their analysis will be conducted by the Centre of coordination of actions to fight hospital infections ( Centre de Coordination de lutte contre les infections nosocomiales).
Legal reference texts concerning the national technical committee to fight hospital infections and the Centre of coordination of actions to fight hospital infections :
Decrees dated August 3rd, 1992, April 19th, 1995, October 19th, 1995.
5°) The hygiene, safety and working conditions committee.
Legal reference texts :
Act of parliament December 23rd, 1982
Ordinance August 16th, 1985
Each hospital employing more than 50 people has a hygiene, safety and working conditions committee. Meetings are called by the hospital technical committee with the agreement of the hospital Director depending on the nature of the risks or on the problems encountered in the field of action of the hygiene, safety and working conditions committee.
Composition of the committee :
The Director of the hospital is a member by right of the committee. In Esquirol he surrounds himself with a company medical officer, a consultant, an engineer, the bursar, the head nurse and six representatives of the unions (5 CRC, 1 CGT).
Functioning of the committee :
The committee meets at least once per quarter on the initiative of the Director. An extaordinary meeting is called any time an accident has caused or may have caused dramatic consequences.
The agenda is set by the President and the committee secretary. It must be sent to the members of the committee, the government inspector (concerned with health, safety and the respect of labour laws), and to the civil servants of the Prevention department of the National Health Service (Sécurité Sociale) at least two weeks before the meeting.
The hygiene, safety and working conditions committee takes decisions and resolutions if a majority of its members are present. All the minutes are kept in the hospital and the Government Inspector (concerned with health, safety and the respect of labour laws), and the civil servants of the Prevention Department of the National Health Service can access them.
Competence of the committee :
It has a consultative power ; yet the actions proposed can only be rejected by the Director if he motivates his decision. Some decisions can be enforced after appealing to arbitration by inspectors and experts.
The committee must also contribute to protect the health and safety of the staff of the hospital and to improve working conditions.
It analyses professional risks and contributes to promote their prevention.
6°) The nursing unit committee.
Legal reference text :
Ordinance n° 92-272 (March 26th, 1992).
Mission of the committee :
The committee must be consulted on :
The committee is presided by the Director of the nursing care unit assisted by second grade nurses.
In each college, (executives, nurses, nursing auxiliaries) people volonteer to belong to the committee. The members of the committee are drawn among the candidates (32 members maximum).
The term of office is three years and can be renewed.
The nursing unit committee meets at least three times a year, the meeting are called by the
President or by the Director any time he requires it from the President.
As in any other committee experts can be associated on a temporary basis.
Some people can be present in an advisory capacity :
The committee elects two members to be represented on :
In Esquirol, the nursing unit committee was created in December 1992. It is composed of 16 members.
are present in an advisory capacity.
From 1992 to 1995 several working themes were discussed,
7°)The department council.
Legal reference texts :
Act of parliament article L 714-22, article 8 (July 31st, 1991) concerning hospital reforms
Ordinance n° 92-272 (March 26th, 1992).
Composition of the council :
The council is presided by the senior consultant of the department.
It is composed of members who are members by right :
It is also composed of permanent and temporary members who represent the medical and non medical staff of each unit. These members are drawn among candidates as in the nursing unit committee.
The term of office for members is : three years and can be renewed.
Mission of the council.
The council must :
8°) The medical data processing department.
Legal reference text :
Circular March 14th, 1990 concerning mental health policies
DECISION MAKING BODIES.
There are two decision making bodies :
1°) The Board of Directors.
Legal reference texts :
Act of parliament dated July 31st, 1991 article 714-2
Ruling n° 96-346 (April 24th, 1996) article 42.
The President and the Vice President of the hospital medical committee are members by right of the Board of Directors.
The presidency of the Board of Directors is in the hands of the President of the General Council.(Conseil Général)
The Board of Directors sets the general policy of the hospital and discusses :
2°)The Director .
The act of parliament dated December 21st, 1941, article 13, defined the role of the Director : " He is a civil servant appointed by the hospital whose duty is to execute the decisions taken by the Administrative Committee ( former name of the Board of Directors) and ensure the direction of the service ". Since this law was voted the Director's duties have kept increasing.
Act of parliament n°91-748 (July 31st, 1991), article 8.
The Director represents the hospital in case of legal proceedings and in all actions taken in civil life.
- He prepares the works of the Board of Directors and submits the hospital project to the Board.
Act of parliament n° 94-43 (January 18th, 1994) article 41-III.
The Director is entitled to order payment and can transfer credits between different accounts of a functional group, during the fiscal year. The Accountant, the State Representative and the Board of Directors must be informed of these transfers.
c/ Local practices.
Since 1994 the Esquirol hospital has been involved in total quality control in all its departments (written formalization in the 1996-2000 hospital project). Total quality control aims at reaching an optimum satisfaction of the patients by improving constantly the quality of the service . Total quality control implies that strict answers be provided and that professional practices which underlie total quality control be evaluated.
THE QUALITY DEPARTMENT
The quality top executive is appointed by the Director to deal with quality. The executive, who is in charge of the relations with the patients, and of the finances and data processing and who is a member of the management team, guarantees that quality control is implemented. He is in relation with :
The nurse executive in charge of the coordination between the different elements of the quality department which participates to a set of missions.
It gathers representatives from all the professional groups of the hospital, ie 26 representatives.
Its members come from the quality committee and represent the four main professional categories involved in quality control (administrative, technical, nursing, and general staff).
He offers methodological help and has a role of technical assistance.
The objective of these pluri-professional groups is to allow the improvement of service or of the process at an institutional level.
Nowadays there are ten groups responsible for the improvement of quality.
Each of them concentrates on a work theme and has a different coordinator responsible for improving :
- Department groups or functional groups :
They allow a department to implement one or several quality controls in the specific services they offer.
- Twinning :
The Esquirol hospital is twinned with a British regional hospital complex :
- The patients' living conditions committee :
It is composed of nurses, doctors, management executives. According to the file experts can join the committee. Its mission is to allow patients to express their desires and to provide answers corresponding to the conception of state controlled hospitals. In the long term patients will sit on this committe.
- Dealing with emergencies :
- Communication :
A hospital journal "Panoramiques " is published four or five times a year. It informs all the professionals who participate to the life of the hospital of the present and future projects going on in the hospital and of the initiatives taken by the hospital staff in the professional as well as in the cultural fields.
- Events and conferences.
Every year the hospital complex organizes events whose aim is to promote the actions and the know-how of the hospital.
It is the case for the numerous medical and para-medical seminars, open house days and events organized by the hospital, as for instance the 35Oth anniversary to celebrate the creation of the hospital.
- Video in Esquirol.
d)Typology of the departments
THE MATERNITY DEPARTMENT()
The maternity department which was set up in the psychiatric hospital as a maternity hospital in 1920, opened a unit for premature babies in 1961 and has been taking important actions in the field of gynaecological surgery over the last few years.
The hospital project () 1996-2000 for the maternity department proposes three new activities :
Its aim is to favour proximity between mothers and their children when they are in patients in a unit for premature babies.
Creation of an ultrasound scan and mammographic unit with the possibility to diagnose from echo guided sampling.
It should allow to cater for pregnant women who also have a psychiatric pathology.
It should allow to take prevention measures as soon as the relationship between mother and baby deteriorates.
It could participate in the creation of a child-mother unit to provide mothers with a short intensive hospitalisation ; this would concern mothers suffering from mental illness after delivering their babies, or young mothers who are fragile, single, or are dropouts .
IV°DOCTOR M. WINDISH'S DEPARTMENT.
The act of parliament dated July 31st, 1991 stated in article L 714- 20 that " to fulfill their missions public health hospitals, other than local hospitals, have to be organized in departments… created by the Board of Directors on the basis of the hospital project… ".
Sector 14 for adult psychiatry in Paris was attached to the Esquirol hospital on December 20th, 1972. This sector (75 G 14) serves a part of the 12th arrondissement of Paris, the arrondissement population represents 73.269 heads and 946 patients coming from this arrondissement registered in the hospital in 1995, their number was slightly decreasing (0.08%).
(entries : 1021, hospitalization days :24.730).
Doctor Marc WINDICH was appointed senior consultant of the 14th sector on August 27th, 1992. He replaced Professor Léon DREYFUSS.
In the document " situation of the staff " dated October 1996 and published by the Department of human ressources, there was a total of 90 nurses in the department headed by Dr Windich.
The department is composed of three hospitalization units located in Esquirol, and offers 54 hospital beds.
It is also composed of
1°) Full time hospitalization units ()
Full time hospitalization units are places for 24 hours per day careand treatment, prevention and medical diagnosis ; they are opened to answer mental health requirements of the adult population.
Contrary to classical hospitalization units they alone are allowed to admit mentally ill people and hospitalize them. (cf : act of parliament June 27th,1990).
Moreover, they must provide personnalized careand treatment to agitated patients or to patients who need to be protected or watched over.
2° The mediko-psychological centre :
It is " an open environment unit of coordination and reception which takes actions in prevention, diagnosis, out patient care and home medical care ". It is also a place of advice.
The mediko-psychological centre is "the first place of reference and settlement of the polyvalent sector team in the town, village or canton ". ()
It is the first place of contact for the population and must be known by everybody. It is the place where care requests are made either by the patient or by the patient's relatives or colleagues. It is in this place that all out patient care actions, in concordance with hospitalization, take shape. It is also there that all the projects of alternative structures, to avoid hospitalization, shorten it and allow the reintegration of patients, are elaborated.
The nurse who is on duty catters for the patient, his family and/or circle of friends. In collaboration with the multidisciplinary team, the nurse analyses the request and adjusts the answer to the situation.
Following the established project, the nurse participates to individual or group therapies and to organized and leisure activities. The nurse can also participate by organizing individual or family interviews. The nurse helps the patient deal with officialdom or professional procedure. The nurse sees to the relations with the institutions, outpatient care and home visits.()
3°) The short term therapy centre.
The short term therapy centre was opened in December 1995 and is regulated by a decree dated March 14th, 1986. It deals with the equipments and units to fight mental illness, which have or do not have boarding capacities.
The short term therapy centre is a reception and crisis centre. It is a permanent centre which offers seven beds permitting to cater for patients in an intensive and short term, and to answer emergency situations and acute distress. Its functioning is flexible so as to avoid a severe decompensation.
As it is very close to the population which is concerned, the short term therapy centre answers first intention emergencies. It allows to care for transitory decompensations of young adults. Clinical assessments, which require to observe the patient for a few days before the patient is directed to the proper structure, are undertaken in the centre.
This type of action allows :
In the reception centres the nurse :
4°) The part time therapy reception centre.
The part time therapy reception centre was opened in1992. Its aim is to maintain or favour autonomy in life thanks to active support and group therapy.
It is aimed at people who have difficulties to fit in the social fabric (psychotic and social distress) or at patients who need or do not need to be hospitalized.
The reception of patients and the use of adapted activities both aim at avoiding the isolation and the loss of cognitive, affective and relational capacities.
The part time therapy reception centre is the continuation of the activities of the mediko-psychological centre, the short term therapy reception centre and the outpatient clinic.
What is done in the part time therapy reception centre is essentially oriented towards relations of the patient to other people and towards the reshaping of the patient's autonomy thanks to every day gestures and different ways of expression.
The way the nurse takes part in the process is exclusively influenced by the state of the patient and by the care procedure. In the centre as in the outpatient clinic it is extremely important that the nurse vouch for the contents (prescribed care activities), the frame (place, space,day, and time) and for the care and treatment contract entered into with the patient.
5°) The studio flats .
The studio flats were opened in 1993. They are rented by the sector association (ACRL, Association for Creativity, Reintegration, Leisures). They are located in the 12th arrondissement of Paris. There are 7 studio flats available for patients for a limited period of time. They are different from therapeutic flats in so far as the medical staff is less present.
Every patient lives normally their every day life while being treated at the mediko-psychological centre, the short term therapy reception centre or the outpatient clinic. Some of the patients work. Every patient living in a studio flat pays a rent, prepares their meals and looks after the flat.
As for the nurse, he or she works at maintaining links with the outside world by helping the patient in his/her everyday life inside and outside the flat.
6°) The outpatient clinic.
The outpatient clinic " Saint-Eloi " was opened in 1997. It is located in the Saint-Eloi district situated in the 12th arrondissement of Paris. It provides individualized polyvalent and intensive care in the day time. It is a transitory care unit. The length of time the patient attends the outpatient clinic is determined by taking into consideration the story of each patient and his/her capacity to be situated in time.
This division of time aims at " colouring not only time but times and at opening up spaces to initiate the movement between inside and outside ".()
The aim is to offer the patient the opportunity to " play, replay and avoid his fundamental intra-mental difficulties such as divide and division ".()
Apart from this psychotherapeutic aspect, the outpatient clinic aims at optimizing the integration of patients in their families and professional environments.
The nurse participates in psycho-socio-therapeutic and educative actions, helps the patient deal with integration initiatives and supervises the taking of drugs.
Translate M H. Advielle.
1 FOUCAULT (M), Histoire de la folie à l'âge classique, coll. TEL Gallimard, Paris, 1972.
2 GAUSSENS (JP) " Histoire institutionnelle de la maison de Charenton ", Mémoire de fin d'assistanat, Ecole Nationale de la santé publique, Rennes, 1978.
3 STRAUSS ©, La maison nationale de Charenton, Imprimerie Nationale, Paris, 1900.
4 ESQUIROL (J.M), Des maladies mentales, édition J.B Baillière, Paris, 1838, tome 2 p. 359.
5 LEHALLE (A) " Contribution à l'histoire de la médecine " La maison de Charenton " , thèse pour le doctorat en médecine, Paris VI, 1972.
6 " Hôpital ESQUIROL 350 ans d'histoire " , Plaquette parue pour les 350 ans d'Esquirol, 1991.
1 J.P.DEBERT, "Le budget des hôpitaux", l'infirmière magazine,janvier 1994, n°79.