Beneficence and maltreatment in healthcare facilities: a major societal issue

The issue of beneficence and mistreatment within healthcare hospitals has become a major societal issue in France. Despite the numerous quality initiatives put in place, a significant portion of the population expresses concerns about the risk of mistreatment for themselves or their loved ones. This HAS (Haute Autorité de Santé) guide to improving practices, validated on October 3, 2024, aims to encourage the dissemination of good professional practices in the health, medico-social and social sectors, by proposing common benchmarks to better understand these complex and subjective notions.

It is intended for all professionals working in these hospitals, recognizing that promoting well-being and combating mistreatment is everyone's business.

Understand the fundamental concepts: beneficence and maltreatment.

The distinction between beneficence and maltreatment is crucial for guiding practices and policies within hospitals.

Maltreatment, legally defined in Article L. 119-1 of the Code de l'action sociale et des familles (CASF) since 2022, targets any person in a vulnerable situation when an action, word, gesture, or lack of action compromises or harms their development, rights, fundamental needs, or health, within a relationship of trust, dependence, care, or support. It is important to note that the situation of maltreatment can be occasional or lasting, intentional or not, and of individual, collective, or institutional origin.

Violence and neglect can manifest in multiple and associated forms. There are seven types of mistreatment:

• Physics
• Sexual
• Psychological
• Material and financial
• Neglect, abandonment, or deprivation
• Discrimination
• Exposure to a violent environment

It is essential to differentiate between mistreatment and violence. Mistreatment involves a relationship of assistance between the person and the perpetrator, while violence occurs in the absence of this relationship of assistance (for example, between two people being cared for or between professionals themselves).

Beneficence, on the other hand, is a positive and global notion. It corresponds to care for the person and their entourage that meets their expectations and needs, while respecting their rights and freedoms. Beneficence is a culture that inspires individual actions and collective relationships within a hospital, aiming to promote the well-being of the user while keeping in mind the risk of mistreatment.

It involves:

• To personalize support
• Inform the person of their rights
• Assess their communication needs
• To ensure that the action corresponds to their expectations
• To support autonomy
• To do "with" and not "instead of" the person
• To regularly question their practices
• To respect fundamental rights
• To maintain a social, cultural, and family life
• To form alliances with informal caregivers and user representatives

Quality human interaction is at the heart of trust and satisfaction for all stakeholders.

The issues of mistreatment and the fundamental importance of benevolent care

Preventing mistreatment within healthcare facilities raises numerous issues, affecting individuals, institutions, and society alike.

Societal challenges

• Aging population and increase in vulnerable people
• Strong public concerns regarding the risks of mistreatment

Quality and safety challenges

• Risk prevention and signal management
• Healthcare hospital certification and assessment of social and medico-social establishments (ESSMS)

Public health challenges

• Harmful consequences of mistreatment (depression, cognitive decline, premature death)
• Need to train professionals to better identify and prevent these situations

Ethical challenges

• Reflecting on the autonomy and self-determination of our guests

Legal challenges

• Respecting the fundamental rights of vulnerable people
• Legal obligations of establishments

Political challenges

• National strategy to combat abuse
• Policy on aging well and autonomy

Well-treatment is not limited to the absence of mistreatment; it constitutes a global and proactive approach aimed at promoting respect for the rights and freedoms of users from the moment they are welcomed.

Identify and prevent situations of mistreatment: a collective commitment

Identifying and preventing situations of mistreatment involves the mobilization of all staff at all hierarchical levels.

Risk factors

• Related to the people being cared for
• Related to professionals (lack of training, excessive workload, degraded conditions)
• Related to the hospital and the environment

Weak warning signals

• Sudden changes in behavior and mood
• Sudden deterioration of health status
• Complaints from the person being cared for or their relatives

All signals must be taken seriously, passed on to line management and recorded in the person's file.

Implementing benevolent care: principles translated into concrete actions

Guaranteeing freedom of choice and the power to act for the people we support

• Involve the person in decisions
• Promote autonomy and self-determination
• Ensure understanding of one's rights upon arrival.

Helping professionals to take a step back from their practices

• Continuing education
• Feedback sessions (RETEX)
• Discussion spaces for teams

Engage the entire hospital

• Formalize commitment to the hospital project
• Identify persons of reference for benevolent care
• Promoting a reporting culture

The Key Role of Reporting and Handling Signs of Mistreatment

Reporting any situation of mistreatment or warning signs is a crucial step.

Legal obligations

• Professional secrecy lifted in cases of proven abuse
• Obligation to report to the competent authorities

Internal procedure

• Alert to hierarchy
• Securing the victim
• Analysis of facts and implementation of corrective actions

Feedback: a tool for learning and continuous improvement

RETEX (Return on Experience) allows us to take a step back and identify the root causes of situations of mistreatment.

Analysis methods

• ALARM Method
• Feedback meetings

Objectives

• Identify potential areas for improvement
• Implement prevention measures

Institutional commitment: evaluation and perspectives for a sustainable culture of benevolent care

Hospitals must ensure:

• Rigorous management of alerts
• Follow-up on action plans
• Ongoing assessment of practices
• Regular training for professionals

Continuous improvement of practices and investment in training are essential levers to guarantee quality and respectful support for all.

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Source : HAS

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