Yann Laurans
email: yann.laurans@iddri.org

Xavier Leflaive

Aleksandar Rankovic

Decision-making, now in 3D: Exploring three dimensions of decision-making processes and their consequences for biodiversity research

Keywords: Decision-making, biodiversity, valuation, conventions, rationalism, Highlights

Science and knowledge are called to participate in the institutional, political and behavioral changes that are necessary to address biodiversity loss. Knowledge however does not possess direct performative powers, and the relationships between knowledge production and use are complex, as has been documented for multiple issues and by different fields of research. This paper proposes to unpack three dimensions of "decision-making". By taking the field of ecosystem service assessment and valuation as its main example, the paper discusses and illustrates how this unpacking can help researchers situate themselves in the diversity of decision-making contexts that can exist, and how this can influence the contributions they can make to try and solve biodiversity issues they are involved in. After describing some key characteristics of the "rationalist" vision of decision, it suggests that looking at the temporal continuity of decision-making processes (e.g., a one-time moment versus a continuous and diffuse process), the degree of conflict in a process, and the range of actors involved and their modes of interaction, widely expands the variety of ways that ecosystem service assessment and valuation can be involved in decision-making. The paper uses three case studies to illustrate this variety, and discusses some implications for researchers, both in terms of acknowledging their situatedness and of future research prospects.

Introduction

Addressing biodiversity loss requires involving economic and social activities in all sectors (Convention on Biological Diversity COP 13, 2016;[START_REF] Moran | Identifying species threat hotspots from global supply chains[END_REF][START_REF] Newbold | Has land use pushed biodiversity beyond the planetary boundary? A global assessment[END_REF]IPBES, 2019). Responses to this challenge therefore involve not only technical changes, but also, and perhaps most importantly, profound changes in institutions, policies and behaviors (Hassan and Scholes, 2005). Science and knowledge are called to participate in these institutional, political and behavioral changes. Knowledge however does not possess direct performative powers. For instance, decision to ban pesticides was not mainly taken because research documented impacts on biodiversity and health [START_REF] Dedieu | Governing by ignoring: The production and the function of under-reporting of farm-workers' pesticide poisoning in French and Californian regulations[END_REF]. This is true at the social level, since social shifts arise from political processes with conflicting values, actors who pursue divergent plans, competition of messages and priorities [START_REF] Kørnøv | Rationality in decision-and policy-making: implications for strategic environmental assessment[END_REF][START_REF] Majone | Evidence, Argument and Persuasion in the Policy Process[END_REF][START_REF] Walsh | The effect of scientific evidence on conservation practitioners' management decisions: Summarized Evidence Changes Management[END_REF]. It is also true at the individual level, since it has long been shown that individual behavior is not directly related to information on the risks or on costs and benefits [START_REF] Weber | Mindful Judgment and Decision-making[END_REF], and that individual capacities to process information are limited [START_REF] Kahneman | Prospect Theory: An Analysis of Decisions Under Risk[END_REF].

Nonetheless, as for other environmental issues, a "linear model" of expertise, where scientific works simply "speak truth to power" (e.g., [START_REF] Jasanoff | Science and decisionmaking. Human choice and climate change[END_REF][START_REF] Beck | Moving beyond the linear model of expertise? IPCC and the test of adaptation[END_REF] is still prevalent in debates around biodiversity and is seen, for example, in how global expertise is organized [START_REF] Stevance | The 2019 review of IPBES and future priorities: reaching beyond assessment to enhance policy impact[END_REF]. This is despite the wide body of work, coming from different disciplines and on a diversity of issues, that has established how non-trivial and nonlinear the relationships between knowledge production and utilization are (e.g., [START_REF] Weiss | The Many Meanings of Research Utilization[END_REF][START_REF] Jasanoff | Contested boundaries in policy-relevant science[END_REF][START_REF] Funtowicz | The emergence of post-normal science[END_REF]Sarewitz & Pielke Jr, 2007). This has also been documented for topics directly concerning biodiversity (e.g., [START_REF] Turnhout | The effectiveness of boundary objects: The case of ecological indicators[END_REF]Dunlop, 2014;[START_REF] Leith | Analysis of operating environments: A diagnostic model for linking science, society and policy for sustainability[END_REF].

Researchers' contribution to decision-and policy-making, in the field of biodiversity as in any field, is closely linked to how decision-making is envisaged by those who intend to contribute. It is indeed, at least in part, in response to how they view decision-making that researchers and experts can perceive the need for what they will consider as relevant research and choose the knowledge formats in which their results are to be conveyed. These choices are not only to be made "at the end of the research pipe" in order to ensure an efficient transmission of the results. If one considers that research is to play a role in decision-making, then researchers should design their epistemological and methodological orientations bearing in mind the social contexts in which they wish to have an impact [START_REF] De Bruijn | Scientific expertise in complex decision-making processes[END_REF]Fisher and Forester, 1993;[START_REF] Pielke | The Honest Broker: Making Sense of Science in Policy and Politics[END_REF][START_REF] Sutherland | Making predictive ecology more relevant to policy makers and practitioners[END_REF].

There is a vast diversity of research, data and information types that are useful -and usedfor biodiversity-related decision-and policy-making, such as ecological assessments and indicators, bio-physical modelling, impact evaluation, sociological surveys (see for instance the wide range of subjects and approaches Sutherland and colleagues have pointed out as ecological research relevant to current biodiversity policy-making challenges (2013)). As an illustration of our views on these subjects, this paper will however focus on the field of ecosystem services assessment and valuation and, among the many research communities involved in biodiversity policy-and decision-making, it will specifically concern ecologists and environmental economists, who are the most involved communities in this subfield.

Even if they had been practiced in different forms for (at least) decades, the last fifteen years have seen a strong development in economic approaches of ecosystem service valuations (ESV), mobilizing mostly certain strains of economics (welfare economics, especially) and ecology. These approaches have led to much research being produced, and found their way in numerous policy discourses, with much hope that such works could provide decisive information to improve the inclusion of biodiversity concerns into policy choices. The "linear model" is still very present in these approaches (see Laurans et al., 2013b), and they have arguably contributed to its further perpetuation.

It is only in the second half of the last decade that the question of how ecosystem service assessment and valuation are actually used in real-life decision-making has progressively been empirically studied, in various environmental contexts [START_REF] Guerry | Natural capital and ecosystem services informing decisions: From promise to practice[END_REF][START_REF] Kilham | Biggest bang for your buck": Conservation triage and priority-setting for species management in Australia and New Zealand[END_REF][START_REF] Lautenbach | Blind spots in ecosystem services research and implementation[END_REF][START_REF] Mckenzie | Understanding the Use of Ecosystem Service Knowledge in Decision-making: Lessons from International Experiences of Spatial Planning[END_REF][START_REF] Ruckelshaus | Notes from the field: Lessons learned from using ecosystem service approaches to inform real-world decisions[END_REF] or more specifically for tropical coastal management contexts (Laurans et al., 2013a;[START_REF] Marre | The use of ecosystem services valuation in Australian coastal zone management[END_REF][START_REF] Marre | Is economic valuation of ecosystem services useful to decision-makers? Lessons learned from Australian coastal and marine management[END_REF][START_REF] Waite | Use of coastal economic valuation in decision-making in the Caribbean: Enabling conditions and lessons learned[END_REF]. This -rather new -research field is congruent with mounting evidence that ecosystem services assessments and valuations are not commonly used as assumed by textbooks and mainstream theoretical frameworks (Laurans et al., 2013b).

It is also congruent with the diverse body of work mentioned above. It is also reflecting the results of diverse works rooted in sociology and economics, especially convention theory, that shows how groups use varied tests and proofs in their disputes, putting the question of modes of commensurability at the centre of their observation [START_REF] Boltanski | On justification. Economies of worth[END_REF][START_REF] Centemeri | Reframing Problems of Incommensurability in Environmental Conflicts Through Pragmatic Sociology: From Value Pluralism to the Plurality of Modes of Engagement with the Environment[END_REF][START_REF] Fourcade | Cents and Sensibility: Economic Valuation and the Nature of "Nature[END_REF][START_REF] Hertin | Rationalising the policy mess? The role of ex ante policy assessment and the utilization of knowledge in the policy process[END_REF].

On the one hand, this accumulation of research calls for frameworks that allow situating the different "utilization cases" relatively to one another, in order to compare them and draw general conclusions from their observation. On the other hand, adapting biodiversity valuation and assessment methods to their social contexts requires differentiating and specifying these contexts for that purpose. As a complement to these works from diverse disciplines, this paper proposes to focus on the diversity of ways that "decision-making" itself can be unpacked. It suggests ways to acknowledge this variety and to broaden the scope of envisaged contributions from ESV-type works, even if they stick to their usual economic and ecological analyses.

The paper first discusses how the "rationalist" model of decision-making limits the contribution of "ESV researchers" to one certain type. It then proposes three, rather simple, "dimensions" of decision-making, and proposes a combination of archetypical cases which, alone, constitute 27 different types of situations. This both complexifies the picture and broaden the range of possible contributions from ESV researchers to decision-making processes. The paper then illustrates the heuristic usefulness of the typology with three empirical cases, and concludes with reflections on how this formalized, "3D vision" of decision-making could be used and the questions it opens.

The "rationalist" vision of decision-making and its consequences on researchers' contribution

A "rationalist" conception of decision

Environmental economists and ecologists often appear to share the same view of what decision-making is and how it works -and probably share it with common representations of decision-making in contemporary Western democracies [START_REF] Hahn | The impacts of economy on environmental policy[END_REF][START_REF] Kahneman | Prospect Theory: An Analysis of Decisions Under Risk[END_REF][START_REF] Martinez-Harms | Making decisions for managing ecosystem services[END_REF][START_REF] Sagoff | The quantification and valuation of ecosystem services[END_REF][START_REF] Sutherland | Making predictive ecology more relevant to policy makers and practitioners[END_REF].

In this framework, also known as the "rationalist" model of decision, the problem of decision-making posed by biodiversity loss mainly comes from 1) a lack of information1 on which to base judgment and choice; and 2) lack of capacity to build a consensus, overcome conflict and steer implementation. This view is akin to rational decision-making as defined by methodological individualism: a decision is typically made at a given moment in time by an individual decision-makerusually a political or economic leader -who uses information to rationally compare alternative courses of actions. Implementation then unfolds; the more reliably, the better.

Conflicts and trade-offs are ignored, or overcome through better information.

Typical contributions from research in the "rationalist" decision-making model

In the rationalist approach, information is a means for optimising decisions, thus guaranteeing their efficiency and their consideration for the environment. A typical example would be a natural reserve manager seeking to define management choices using ecological and economic criteria [START_REF] Metrick | Conflicts and Choices in Biodiversity Preservation[END_REF]. The theory of conservation choices by "triage 2 " [START_REF] Bottrill | Is conservation triage just smart decision-making?[END_REF] emerges as well from this vision of decision-making (one can even consider "triage" as an archetype or as a caricature of the rationalist model). Indeed, it presupposes a decision unit (the manager), whose choices are based on an optimization calculation (prioritization), having to select means for alternative uses under budgetary constraint (the budget allowed for reserve management). The conflictual dimension is absent from such a framework (no opposition between decision-makers, or between points of view), or it is reduced in the notion of budget constraint (the budget allowance embodies the tradeoffs already made by higher level decision-makers and the priorities they gave to different objectives).

In a less characteristic or simplistic way, the contribution of economists or ecologists in such a configuration may be considered to be typically that of describing the future situations that would result from this or that choice in terms of ecosystem services [START_REF] Erb | Exploring the biophysical option space for feeding the world without deforestation[END_REF][START_REF] Pereira | Scenarios for Global Biodiversity in the 21st Century (review)[END_REF]. It consists in informing the choices to be made by exposing the risks and opportunities associated with the alternatives; some kind of "ecological what-if". In conjunction with this type of a priori ecological assessment, its economic equivalent (and often its monetary extension) is the cost-benefit analysis of environmental management options, for example management alternatives available to an environmental manager, a budget manager, or to a public authority responsible for the implementation of a policy [START_REF] Belli | Economic Analysis of Investment Operations[END_REF][START_REF] Jenkins | Valuing ecosystem services from wetlands restoration in the Mississippi Alluvial Valley[END_REF][START_REF] Smith | A conceptual overview of the foundation of Benefit-Cost Analysis[END_REF][START_REF] Loomis | Economic benefits of rare and endangered species: summary and meta-analysis[END_REF]OECD, 2002 and the "Cost Benefits and the Environment" series3 ). This is the context in which ecology's and economics' methodologies to "support decisionmaking" are the most often promoted, developed, discussed, and challenged. Indeed, it is the situation for which the concept of indicator on the one hand, and on the other, analysis and cost-benefit ratio are made: technical treatments designed to express a complex and multiple reality in terms that can be manipulated by non-experts [START_REF] Belli | Economic Analysis of Investment Operations[END_REF][START_REF] Nyborg | Project analysis as input to public debate: Environmental valuation versus physical unit indicators[END_REF]OECD, 2002).

It is now time to examine alternative theories of decision-making that put the rationalist view in perspective.

Acknowledging the complexities of decision-making

The rationalist vision of decision-making can be supplemented by approaches questioning the assumption that a decision is necessarily: (1) a distinctive and isolated moment in time, (2) responding to a need for coordination and (3) made by individuals. This section builds on research in decision theory and maps a variety of decision models. The subsequent section will consider how ecologists and environmental economists can contribute in these different models.

From a one-time to a diffuse process

As previously observed by Young and colleagues (2014), decision-making is predominantly conceived as a linear process, which starts with the identification of a problem to be solved (e.g., loss of biodiversity), the exploration and assessment of a range of possible responses, the moment of choice by the decision maker, then followed by implementation. New Public Management recommends to separate decision-making, which is strategic and political by nature, from implementation, which is considered a distinct, essentially technical and bureaucratic process. This so-called "linear" conception of decision-making was characterized and challenged in the early 1970s by a range of authors. Mintzberg and colleagues (1976) highlighted that decisions should at a minimum be conceptualised as working in circles, as implementation follows decision-making and can lead to a revision of the initial decision. [START_REF] Cohen | A Garbage Can Model of Organizational Choice[END_REF] portray decision-making as processes whereby problems, solutions, choices and decision makers randomly connect, a model that resonates with concrete situations they have observed in universities. In his book first published in 1973, [START_REF] Sfez | Critique de la décision, 4th ed, Références[END_REF] documents how large-scale infrastructures actually result from a sequence of illconceived and unrelated decisions, based on wrong assumptions yielding unintended consequences. The fact that the "linear" conception of decision-making remains prevalent today, despite this longstanding critique, is in itself an object of inquiry [START_REF] Leflaive | Repenser l'entreprise et la gestion[END_REF].

It therefore appears that all decisions are not stand-alone moments in time. Many decisionmaking processes would be better portrayed as sequences of successive moments, each revisiting previous decisions. Envisioning decision-making as a sequential process, with repeated and linked moments that together participate to the general decision-making process, somehow represent a first step away from the rationalist model, with respect to the characterisation of the continuity of decision-making. This is not to say that one-time decisions do not exist or that modelling decision-making as a unique and punctual process is erroneous. Rather that, in some situations, a sequential representation might prove more efficient to think of the decision-making context in which researchers are involved.

One additional step to move further away from the one-time conception lies in considering decision-making as a continuous and diffuse process with no identifiable chronological origin (i.e., each decision takes its source in a bundle of previous decisions and events). Rooted in modern systems theory, whose application to decision-making dates back to Walter [START_REF] Buckley | Sociology and modern systems theory[END_REF], this conception amounts to considering a decision as the product of a series of interactions between components of a system, the result of which is only identifiable ex-post, through a reconstruction process. A decision eventually emerges in retrospect, depending on how the process is characterised by the analyst, who is thus acting as an historian. In a different domain (migration policy in France), Sylvain [START_REF] Laurens | Une politisation feutrée. Les hauts fonctionnaires et l'immigration en France[END_REF] challenges the prevailing idea that a radical decision made in 1974 was a turning point: he shows how that apparent distinctive and decisive "moments" actually embody processes that had started years before.

It is thus proposed here to consider an axis on which the representations of decision can be ranked from a pole constituted by the one-time decision, followed by a second degree constituted by sequential decision-making, and then to the other extreme constituted by diffuse decision-making. We call this the "continuity" axis.

These conceptions may complement each other. They account for dimensions or gradients in the continuity of the decision-making process. According to the contexts and types of decision, one or the other may prevail, while the others still remain but are less salient. Note that the three "degrees" of this axis do not necessarily refer to discrete states, but to a continuum on which we arbitrarily select three archetypical positions.

Integrating conflict

In the rationalist model of decision, the decision-maker contemplates alternative choices in view of achieving an optimum, with respect to the choices made by other decision-makers.

The strategies followed by "other decision-makers" are implicitly regarded as independent and as a given (or a conjecture) with which the decision-maker must compose so that her own decision is as close as possible to the optimum. Decision-makers are not considered to be in conflict with each other, nor are they in conflict with the general interest, or more specifically here with the good condition of ecosystems or biodiversity. In other words, in the rationalist model, interactions between decision-makers are mostly seen as a search for coordination to reach a general optimum. In that respect, the rationalist model of decision-making resembles game theory's "pure coordination" games [START_REF] Shelling | The Strategy of Conflict[END_REF], where agents win or lose together, but are hindered in the search for the optimum by communication hurdles. Indeed, pure coordination games mean that the best combination of choices for a given agent is also the best combination for all other agents. They just do not know exactly where the collectively optimal choice lies, and their interaction is all about overcoming communication difficulties to find out which of the individual options will yield the maximum collective benefits. Since interests grow or fall together, there is no other difficulty than communication, for no one has an interest in deviating from the optimal choice. Environmental policy-making is however not always (and one might say it is generally not) a coordination game. Although biodiversity is most often presented as a common good, conflict arises when it comes to implement biodiversity protection policies, since they most often entail restricting the access of some agents to natural resources.

Where conflict and cooperation are intermingled is the reign of negotiation. Coordination issues are indeed present in all negotiations: they are situations where agents prefer reaching an agreement rather than avoiding or confronting others. Negotiators need some cooperation.

Conflictual dimensions are present as well, since some individual choices will result in more benefits for some than for others. In other words, in negotiations everyone needs to meet the others somewhere, but all prefer the meeting point to be as close as possible from where they stand originally [START_REF] Fisher | Getting to yes: Negotiating Agreement without Giving In[END_REF][START_REF] Raiffa | The Art and Science of Negotiation -How to resolve conflicts and get the best out of bargaining[END_REF]. Negotiation situations therefore represent a step away from the rationalist model with respect to the characterisation of the conflict inherent to decision-making.

One step further away, at the end of this axis, are situations of "pure conflict", in which the gains of an agent or a social group cause loss to one or more others, and which give rise to different forms of confrontation and struggle.

Therefore, just as we have been able to propose three discrete arbitrary states on the "continuity" axis, we can propose, in an equally conventional way, three discrete states on the "degree of conflict" axis: coordination, negotiation, and conflict.

From an individual to a social process

Lastly, decision-making is not always a matter of individuals, as it is represented by the rationalist decision-making model [START_REF] Laurans | Ecosystem services economic valuation, decision-support system or advocacy?[END_REF]. [START_REF] Allison | Essence of Decision: explaining the Cuban Missile Crisis[END_REF] have shown, through the example of the Cuban missiles crisis, that at least three variants of the decision-maker coexisted in such an extremely complex case: 1) the individual variant, referring to the two superpowers' confronting leaders; 2) the organizational variant, referring for example to the US navy or the Soviet army, the organizational logic of which is indispensable to explain certain decisions4 ; and 3) the political dimension, which is also indispensable for explaining part of the decisions taken during this period, and which refers to political groups, arguments and processes. Indeed, representing decision-making as the result of an individual reasoning tends to overlook the individuals' limited capacity to handle information, as amply demonstrated by Daniel Kahnemann in his analysis of cognitive biases (see for instance [START_REF] Kahneman | Prospect Theory: An Analysis of Decisions Under Risk[END_REF]. Alternative models see individual decision-making as embedded in and complemented by organisational processes, as was argued by March and Simon (1958). Indeed, organisations allow collecting and processing more information, as Willamson (1975) put it. "Organisational" models of decision-making therefore pay attention to the processual dimension of decision-making and the non-hierarchical systems that can coordinate action, such as the emergence of routines and of standard operation procedures. Political scientist Mark Considine argues that conventions and the routine practices of government agencies and civil servants frame the options available to policy makers and civil society [START_REF] Considine | Making Public Policy: Institutions, Actors, Strategies[END_REF]. Although they are seldom debated, these conventions and routines frame deliberations, limit the number of alternatives and how they are assessed. In this perspective, "expertise involves equipping actors to bring previously developed solutions and to apply them to each new decision problem" [START_REF] Considine | Making Public Policy: Institutions, Actors, Strategies[END_REF], p.59), including a routine to adjust pre-packaged solution to new situations [START_REF] Schon | Frame reflection: Toward the resolution of intractrable policy controversies[END_REF]. Likewise, a given instrument, like payments for ecosystem services, or like the code referred to by judges in environmental legal disputes, can be analysed as a socially constructed and accepted standard response to certain issues. They are seen as "responses looking for problems" [START_REF] Cohen | A Garbage Can Model of Organizational Choice[END_REF].

Going a step further away from the representation of the decision-maker as a sole individual, "political" models referred to by [START_REF] Allison | Essence of Decision: explaining the Cuban Missile Crisis[END_REF] are representations where decision-making emerges out of competition between social groups who strive for power over the policy-making processes, as Dahl depicted in his seminal representation of decisionmaking in a local government (2005). Rather than organisational routines, key concepts here are the interests of social groups as well as value systems, patterns of beliefs, control over information, etc., and how these resources are used by different types of leaders. This is well captured by Allison and Zellikow's metaphor on what makes pieces move in a chess game, "[…] the pattern of play [in the political model] might suggest to an observer [that] a number of distinct players, with distinct objectives but shared power over the pieces, could be determining the moves as the resultant of collegial bargaining." (Allison and Zelikow, 1999 p.

7).

Therefore, as in previous sections, we propose to identify three positions on an axis, called the "process and agent" axis, where assumptions regarding the nature of decision-makers are differentiated: the rationalist vision where decision-makers are individuals, the organisational model where they are organisations, the social and political model where they are groups.

Three dimensions of decision-making define a volume of possible situations

The three dimensions of decision identified above can be combined. On each of the three dimensions, three standard positions have been identified, thus producing an illustrative typology of 27 typical cases, representing different combinations in this "volume" of decision-making types. Of course, just as the three positions on each axis are conventions by which continuous variations are fixed, the resulting 27 combinations produced should be regarded as arbitrary and illustrative points of reference within a continuous volume.

The corresponding "volume" of decision situations is thus illustrated in Figure 1. On each axis, the "1" position corresponds to the "rationalist" model of the decision. Positions "2" and "3" move away from this archetype.

Figure 1. Three dimension "volume" of possible decision types when taking into account the "continuity", "degree of conflict", and "process and agent" dimensions of decisionmaking

The significance of these combinations will now be illustrated by examples taken in the field of biodiversity, before the next section proposes further reflection on the types of information best suited to these types and on the contributions of researchers in such decision-making configurations. The question to be addressed now is how this variety of decision-making configurations suggests a corresponding variety of contribution from scientists, and more specifically from ecologists and economists, in biodiversity dossiers.

Ecologists and economists facing a plurality of decision-making modalities

In individual, sequential, and conflictual contexts

In terms of practical tools and methodologies to be considered by actors willing to take part in environmental jurisdictional disputes, note that this type of decision-making context calls for "pleas", which are very specific and interesting forms of discourse when considered from a researcher point of view: they are rhetorical discourses developing a consistent line of argumentation and making use of available evidence, to compose a partial but credible message. The more undisputable and refutable the evidence, the better, but rhetorical discourse also appeals to emotions, values, and images. How should stakeholders willing to make the case of biodiversity protection be equipped for such exercises? They should for instance develop environmental observatories that focus on precise and measurable data indicating the status of environment in the most robust way. This suggest investing in defining those indicators and focusing on them, which in turn may entail a thorough analysis of existing jurisprudence. This greatly differs, for instance, from observatories whose mission is rather to raise a general awareness of an environmental issue, which conversely can and should display very general information valid for all types of audiences.

In organizational, sequential, and negotiation-based contexts

When the organisational dimension is factored in, issues related to alliances, or budget allocation, shape decision-making processes and their fragile outcomes. Here, environmental information (e.g., ecosystem service assessment) may be used by organizational units in a leadership position to frame the perceptions of other units so that they align with their organizational goals. Besides, organizations are continuously redefining their acceptability standards and mandates, which allows for many recurring opportunities to influence norms and perceptions. See for instance guidelines or reference documents produced in organizations such as The World Bank or in various national administrations on the importance of ecosystem services and the need to take them into account in the procedures of these organizations.

In situations of negotiation, information has both the status of a tactical resource and that of a means of coordination. As a tactical resource, its role can be justifying a position by pointing to alarming potential consequences of alternative choices, or conversely suggesting benefits expected from the supported position. As resources for coordination, ecological and economic scenarios can be used to explore the potential common benefits that would derive from a negotiated project, as [START_REF] Laurans | Les négociations pour la recréation de sites littoraux : quelles dimensions économiques ?[END_REF] showed with a case where a reserve manager negotiated the development of the site with representatives from economic activities, using ecological and economic scenarios to depict the collective benefits expected from the project he supported.

This type of situation may for instance involve negotiation of agreements between organizations, as in the case of a payment for ecosystem services involving a city, a water company and representatives of forest owners. These are situations in which the authors have personally participated, as producers of economic and environmental assessments. The first quantification of ecosystem services provided by wetlands in France [START_REF] Laurans | Les services rendus par les zones humides à la gestion des eaux : évaluations économiques pour le bassin Seine-Normandie[END_REF] was carried out to feed the discussions of the Board of Directors of a Water Agency (hence the organizational and recurring type), discussing how much of water users' money (levied by the Agency) would fund action in the field of "nature-based" 5 flood protection. This was a negotiation involving the department responsible for environmental action, allied with supportive Board members, and on the other side their colleagues (both in administration and in the Board) in charge of water engineering projects and reluctant to see funds diverted from the water infrastructure to support what they perceived as "paying for nature". In such a context, the need for knowledge (originating from the first party) was not about calculating an "optimal" decision or program; it was rather illustrating the "generic interest in investing in nature-based solutions for water management", thus comforting their negotiation position.

The illustration had then to be based on geographically situated examples, in which the ecological part of reasoning (the description of the functions and services produced by the wetlands) was at least as important as the associated monetary encryption [START_REF] Laurans | Economic valuation of the environment in the context of justification conflicts: development of concepts and methods through examples of water management in France[END_REF].

In terms of practical tools and methodologies, producing research for organisational decisionmaking suggests trying to influence the "norms of appropriateness" that prevail in the targeted organisation(s). This would mean, for instance, translating ecosystem services assessments and valuations into impacts on things that relate to social norms: what difference, for this or that social norm (e.g., effectiveness, or justice, or gender equality, or working conditions…) when this or that type of organisation invests in preserving ecosystem services? Besides, the effect of a negotiation context on information use and on organising the production of knowledge lies in the openness of the process. Although it is better to make research processes and choices as transparent as possible in consensual contexts, in negotiation contexts some confidentiality is of the essence. This should induce actors committed to improve the sake of biodiversity, when programming their knowledge production processes, to somehow resist the pressure for full openness and concertation, thus acknowledging the strategic essence of information. Actors in sequential or recurring negotiation contexts should also invest in enquiring about the preferences and the value systems of their negotiation counterparts, so as to shape their research in ways that may convince them. One might say that this is already the rationale of ecosystem services valuation (ESV) and explains its success: somehow ESV is an attempt to "speak for nature" in terms that may convince economic actors such as businesses, ministries of agriculture or industry, etc. But this suggests paying attention to other concerns than economic ones, since some negotiation partners may be sensitive to other types of benefits of ecosystem services preservation: social benefits (e.g. impact on the number and the nature of jobs and on qualifications), justice and equality (e.g. impact on the distribution of wealth), democracy (e.g. impact on access to nature's benefits), and so on.

In political, sequential, and conflictual processes

Conventions that frame a particular decision (or account of a decision) can be challenged from another perspective, which embodies a competing convention. There is no rational way competition or tensions across conventions can be addressed and mitigated [START_REF] Boltanski | The New Spirit of Capitalism[END_REF][START_REF] Boltanski | On justification. Economies of worth[END_REF]. In that context, knowledge and science can be used to fuel the critique of a prevailing convention. A requisite is to demonstrate the very possibility of a critique and alternative worldviews. In such contexts, information does not focus so much on facts, but on the assumptions that frame the narratives used to account for facts. Literary critique can be a resource.

Information is typically summoned to point out the interests of groups and categories in the influence struggle, and to indicate the nature of the potential gains and losses that would result from the implementation [START_REF] Dahl | Who Governs? Democracy and power in an American city[END_REF]. We can consider here, by way of illustration, the conflicting public relations around the environmental management of a natural area with strong presence of economic activities (agriculture, mining, hunting, etc.). Conflicts can include management modalities, such as disputes over a wetland water management, or wildlife management and crop damage (see in particular, for reflections on the status of knowledge in such contexts, [START_REF] Graham | Seals, salmon and stakeholders: integrating knowledge to reduce biodiversity conflict: Seals, salmon and stakeholders[END_REF][START_REF] White | Developing an integrated conceptual framework to understand biodiversity conflicts[END_REF][START_REF] Young | The emergence of biodiversity conflicts from biodiversity impacts: characteristics and management strategies[END_REF]. In that case, interactions between actors are relatively recurrent, for example during the meetings of a management committee. Actors involved in such contexts are politicized and grouped (e.g. hunters, farmers, local residents, etc.) but do not necessarily form stable institutionalized organisms (i.e. unions, etc.). This type of context is typically suitable to "deliberation" processes, where values foundations and value systems are subject of dispute and deliberation rather than derived from elsewhere and passively applied [START_REF] O'neill | Markets, Deliberation and Environment[END_REF]. Under these conditions, in our experience, the role of ecological and economic information should be understood as a strategic resource used by different groups for different purposes: (a) to broaden their mobilization base; (b) to discredit the content of arguments put forward by the opponents and (c) to justify their own propositions to the authorities liable to arbitrate (administration, justice…). In terms of tools and methodology, this speaks for example in favour of preparing ecological and economic arguments about the positive role of this or that profession or activity, for society (amenities generated), economy (jobs) or landscapes. Expertise can also be used to challenge or conversely to demonstrate the importance of certain ecological factors, such as when discussing how to exploit a forest to meet economic or environmental objectives, or when the evaluation concerns damages by wildlife (flamingos and rice crops, sharks and surfers, etc.).

Conclusion

How research is to contribute to decisions on environmental issues is still often considered through a "rationalist" representation of decision-making. This view implicitly assumes an individual, one-time and cooperative decision in search of an optimum; the role of information is therefore commonly seen as revealing concerns otherwise concealed, and consequently as a means to correct imperfect decision-making. Information leads to one solution (There Is No Alternative -TINA). All it takes then is political will for the right decision to be made. It will then be implemented by a value-neutral bureaucracy. This article proposes complements on three dimensions of decision-making, namely the degree of continuity of decision, the relative importance of conflict in the decision structure, and the social construction of problems, solutions and decision makers.

Even by unpacking only these three dimensions, and by chosing archetypical posiitons on each of them, it still shows how there are multiple modalities decision-making contexts, and how each can call for different knowledge contributions. The status of information changes according to the type of decision-making context, as well as its role, its potential use, the way it is captured, its quality requirements and its capacity for conviction (or persuasion). This calls for methodologies to be adapted to the different types of situation, on a case-by-case basis [START_REF] Berghöfer | Increasing the Policy Impact of Ecosystem Service Assessments and Valuations: Insights from Practice[END_REF][START_REF] Förster | Assessing ecosystem services for informing land-use decisions: a problem-oriented approach[END_REF][START_REF] Groot | Challenges in integrating the concept of ecosystem services and values in landscape planning, management and decision-making[END_REF][START_REF] Tonn | A Framework for Understanding and Improving Environmental Decision-making[END_REF].

However, some general trends emerge when considering what complements the rationalist variant of decision-making. When dealing with organizations or groups, participating in situations involving a dosage of conflict, and making diffuse decisions, information is much more relating to value systems than it is supposed to be in a rationalist context. In other contexts, which correspond to most actual situations, information is often used in an "argumentative" way, and may question values, hierarchy of reasons, different priorities and their corollaries in terms of renunciations. However, the characteristics of an argument differ from that of a technical information used to feed a calculation process. Arguments must convince or persuade; their form and the narrative they refer to are thus essential qualities. This should lead researchers to consider how to contribute to debates involving value systems, and to processes of argumentation. It the field of biodiversity, this concurs with authors pointing that acknowledging non-linear forms of decision-making should bring, inter alia, to "frame research and policy jointly" [START_REF] Young | Improving the science-policy dialogue to meet the challenges of biodiversity conservation: having conversations rather than talking at one-another[END_REF]. Moving in this direction will come with its own share of complex issues, notably on inclusivity (who is to participate to the framing of issues?) and associated questions of power asymmetries between actors [START_REF] Jasanoff | Technologies of humility: Citizen participation in governing science[END_REF]. It will also require to further develop the debate among researchers on how to acknowledge their own situatedness in debates, while being able to maintain scientific credibility, which is an important political resource for them [START_REF] Cash | Knowledge systems for sustainable development[END_REF]. This resonates with the broader challenge of recognizing that the strength and value of scientific work does not primarily stem from a mythicized detachment from values and concern, but rather from the richness and stringency of the actual work and inquiries that researchers perform (Latour, 1997;de Vrieze, 2017).

This article has merely outlined 3 cases out of 27 archetypical possibilities, and further research in this direction is needed, for instance by accumulating ex-post reviews on the use of information in biodiversity policy-making in various decision-making contexts. Particular attention should be paid to the social construction of issues, to the decision-making process itself and to the nature of the parties involved. It is by multiplying such empirical works, and discussing them collectively, that biodiversity researchers will be better equipped to orient themselves on how to best contribute to solving the continuous loss of biodiversity.

"Process and agent" axis "Degree of conflict" axis "Continuity" axis

  Table 1 indicates examples of decision-making situations for the 27 combinations. It shows that even if the points chosen on the axes are archetypical, the typology still applies to, and helps navigate in, different real-world contexts.

	3. Diffuse	3. Conflict
	2. Sequential
	1. One-time
			2. Negotiation
			1. Coordination
	1. Individual	2. Organisation	3. Social and
			political

Table 1 . Examples illustrating the variety of the 27 types of decision-making situations 337 for environmental and ecosystem services concerns 338

 1

	Continuity

Examples of such a vision are expressed in numerous economic articles and books with important authority, from the work of late David Pearce[START_REF] Pearce | Cost-Benefit Analysis and environmental policy[END_REF], to economic "Nobel Prize" Jean Tirole's last book(Tirole,

2017). Well designed and recent examples of different kinds can be found in[START_REF] Johnson | Resilience Thinking and a Decision-Analytic Approach to Conservation: Strange Bedfellows or Essential Partners[END_REF] or Bateman (2013).2 These are approaches that seek to express conservation priorities based on the metaphor of triage of patients in emergencies, classifying conservation issues (generally endangered species) in decreasing order of priority and assuming an arbitration process which would go down this list until saturation of the budget constraint.

www.oecd-ilibrary.org/fr/environment/cost-benefit-analysis-and-the-environment

And more generally referring to Simon's framework for understanding action and decision-making in organizations[START_REF] Simon | Administrative Behavior. A Study of Decision-Making Processes in Administrative Organization[END_REF].

At that time (mid-1990's) the vocabulary was different, but the ideas were similar to that of nature-based solutions as opposed to grey infrastructure solutions.

Acknowledgements

This article has received financial support from the French government in the framework of the programme "Investissements d'avenir", managed by ANR (the French National Research Agency) under the reference ANR-10-LABX-01. We are most grateful to two anonymous reviewers for their comments that helped improve the manuscript.

Consider first the situations characterized by individual decisions, on a sequential basis, in a situation dominated by conflict (position 1-2-3 in the volume defined by the three axes of Figure 1). What could be the potential contributions of ecologists and economists in such a context? In this case, the main difference with the "rationalist" model is most notably the contradictory nature of the conflict procedures when formally framed, as in the case of judicial procedures.

Because in that case various expertise pieces are potentially opposed to each other, it represents a particular way of using knowledge. Arguments, or messages, must be focused on a particular aspect of the subject, the disputed matter, rather than more holistic assessments of environmental issues. In addition, more than in other decision-making configurations, all assumptions, but also the sequences of reasoning, the data and their sources, the methodological choices and even the axiological orientations of the actors who use the knowledge, are likely to be intensely questioned and contradicted, with opponents devoting significant resource to that purpose. Instead of a decision stemming from a complete (although always stylized) representation of the world, decision-making here stems from a confrontation of partial and focused theses. Their requested qualities relate to their capacity to frame the issue and tell a story that fits the codified reality of the judiciary. They are loosely coupled with the ability to produce fact-based, value-neutral information or optimisation, as in the rationalist model. For instance, Marion Fourcade showed how the performative nature of assessments in support of oil spills trials depended on the profound adequacy between evaluation techniques and the deep cultural status of money in societies the judge belongs to: "I show that the mere availability of certain economic technologies does not guarantee their performative effects for the simple reasons that these technologies may not muster enough institutional and political support or that they may not resonate enough with the cultural claims they are supposed to represent." [START_REF] Fourcade | Cents and Sensibility: Economic Valuation and the Nature of "Nature[END_REF](Fourcade, , pp. 1724(Fourcade, -1725)).


Céline Slekovec

Amélie Varin

Contamination des VSAV : place des prélèvements environnementaux Ambulance contamination: place of environmental samples

Keywords: prélèvement d'environnement, VSAV, secours à personne, risque infectieux environmental sample, ambulance, rescue and assistance, infectious risk

Les auteurs déclarent ne pas avoir de liens d'intérêts.

Résumé

L'objectif de cet article est de détailler les stratégies impliquant des prélèvements d'environnement dans les véhicule de secours et d'assistance aux victimes (VSAV) ainsi que d'une manière plus large les éléments de maîtrise du risque infectieux dans le secours à personne.

Les prélèvements d'environnement ne sont pas obligatoires mais présentent un intérêt dans le cadre d'une démarche de validation d'une méthode ou encore dans celui d'une démarche pédagogique.

Dans ces deux situations, la réalisation des prélèvements doit faire partie intégrante d'une stratégie de surveillance mentionnant notamment le choix du type de prélèvements à réaliser, tout en privilégiant chaque fois que possible le prélèvement gélosé, les surfaces concernées, ou encore le moment idéal pour réaliser le prélèvement.

Si les prélèvements contribuent à une formalisation d'un risque à un moment et en un lieu donné, le risque infectieux dans les VSAV doit quant à lui faire l'objet d'une maîtrise continue par l'application de différentes mesures complémentaire de l'entretien telles que l'hygiène des mains, un usage raisonné du port de gants ou encore d'un port de masque dès lors qu'il existe un risque de projection.

INTRODUCTION

Il existe trois déterminants principaux à la survenue d'une infection : (i) l'environnement dans lequel les soins sont dispensés, (ii) le type d'actes réalisés et (iii) l'état du patient. La prise en charge pré-hospitalière peut donc, du fait de ces 3 facteurs, dans certaines situations s'avérer particulièrement favorable à la survenue d'infections. Si la prise en charge peut être initiée dans un environnement non dédié aux soins (domicile, extérieur etc.), elle sera poursuivie de façon privilégiée dans une ambulance ou véhicule de secours et d'assistance aux victimes (VSAV). Ces derniers sont donc le théâtre de gestes plus ou moins invasifs sur des victimes plus ou moins fragilisées par des pathologies sous-jacentes ainsi que par la situation ayant motivée l'intervention des secours.

Les différents micro-organismes (MO), qu'il s'agisse de bactéries (notamment de bactéries multi-résistantes (BMR)), virus (principalement grippe, gastro-entérite ou encore le SARS-CoV-2) champignons (aspergillus) ou encore de parasites (gale, poux), ont la capacité de survivre plus ou moins longuement dans l'environnement de quelques heures à plusieurs jours voire quelques mois. L'environnement joue donc le rôle de réservoir susceptible d'être à l'origine d'une infection chez la victime prise en charge mais également à une contamination des secouristes lors de la prise en charge de la victime. Le rôle de la contamination des surfaces, tout comme de l'équipement médical dans la survenue d'infection a été démontré dans de nombreuses études. [START_REF] Boyce | Environmental contamination makes an important contribution to hospital infection[END_REF][START_REF] Weber | The role of the environment in transmission of Clostridium difficile infection in healthcare facilities[END_REF][START_REF] Weber | Role of hospital surfaces in the transmission of emerging health care-associated pathogens: norovirus, Clostridium difficile, and Acinetobacter species[END_REF][START_REF] Otter | The role played by contaminated surfaces in the transmission of nosocomial pathogens[END_REF] Il s'agit donc de réduire ces réservoirs environnementaux par la mise en oeuvre de procédures de nettoyage voire de désinfection du matériel ainsi que des surfaces.

Dans les VSAV, les éléments susceptibles de faire l'objet de contrôles sont les surfaces pour s'assurer de la bonne réalisation des procédures de nettoyage et de désinfection. Les contrôles de l'eau (recherche de légionelles et de Pseudomonas aeruginosa) ne seront indiqués que dans les rares cas où un point d'eau serait présent dans le VSAV. Enfin, les prélèvements d'air ne concernent que les zones à environnement maîtrisé (ZEM) tels que les blocs opératoires. L'objectif de cet article est de détailler les stratégies impliquant des prélèvements d'environnement dans les véhicule de secours et d'assistance aux victimes (VSAV) ainsi que d'une manière plus large les éléments de maîtrise du risque infectieux dans le secours à personne.

CONTROLES ENVIRONNEMENTAUX DES VSAV

Il n'existe pas d'obligation réglementaire ni-même de recommandation à inclure une surveillance de la contamination environnementale. En effet, y compris en milieu hospitalier, la Société française d'hygiène hospitalière (SF2H) dans ses recommandations R14 et R15 recommande fortement en routine de ne pas réaliser de contrôle microbiologique de surfaces pour la recherche de virus, de bactéries multi-résistantes ou autres micro-organismes à potentiel épidémique. [START_REF]Place de la surveillance microbiologique de l'environnement dans la prévention des infections associées au soins[END_REF] Toutefois, parmi les différentes indications identifiées, dans le guide de bonnes pratiques pour la surveillance microbiologique de l'environnement dans les établissements de santé [START_REF]Centre de coordination de la lutte contre les infections nosocomiales inter-région Sud-Ouest (C-CLIN Sud-Ouest). Surveillance microbiologique de l'environnement dans les établissements de santé : guide de bonnes pratiques[END_REF], deux sont parfaitement transposables au secours à victimes. La réalisation de contrôles environnementaux sera donc intéressante dans le cadre d'une démarche de validation d'une méthode d'entretien mais aussi dans le cadre d'une démarche pédagogique.

Validation d'une méthode

Cette première indication consiste à vérifier l'efficacité d'une technique, d'un produit ou d'un procédé. Cela est intéressant lors d'un changement de méthode d'entretien (exemple : mise en place de la technique vapeur, changement de produit etc.) pour s'assurer que cette dernière est compatible avec l'organisation du service (encombrement, compatibilité avec les surfaces à nettoyer), ou pour valider une gestuelle/technique en vue d'établir un protocole.

Dans ce cas de figure il s'agit d'objectiver une baisse de la contamination en réalisant des prélèvements avant et après entretien en déterminant un pourcentage de décroissance ou en le comparant à une valeur de référence (Figure 1). Avant tout prélèvement, il est important de réaliser un cahier des charges de la démarche déterminant les prélèvements à réaliser, les points à contrôler, la méthode d'analyse retenue et le niveau de précision des résultats attendus (quantitatif, semi-quantitatif, avec ou sans identification des espèces bactériennes), l'identification du ou des préleveurs et du laboratoire réalisant l'analyse ainsi que les résultats acceptables et non-acceptables.

• Types de prélèvements. Le Tableau I synthétise les éléments de comparaison des différents types de prélèvement.

Tableau I. Synthèse des caractéristiques des principaux types de contrôles de surface.

Prélèvement gélosé Écouvillonnage ATPmétrie

Principe Mise en culture de bactéries détachées des surfaces directement une gélose spécifique.

Prélèvement par écouvillonnage d'une surface puis mise en culture sur un milieu de culture.

Mesure de l'ATP produite par toutes les cellules. • Points à prélever. Si la démarche est en lien avec un changement de produit, il s'agira de réaliser des tests sur des surfaces différentes (matières, textures etc.) de façon à s'assurer d'une parfaite compatibilité ou de la nécessité d'utiliser d'autres produits complémentaire. Lorsque la démarche est en lien avec une autre technique (ex : désinfection par voie aérienne, changement du schéma d'entretien etc.) il sera proposé de tester des surfaces plus ou moins accessibles de façon à identifier des points critiques.

Indications

• Méthode d'analyse retenue. Elle est à définir en lien avec le laboratoire prestataire en fonction du type de résultat attendu, elle pourra également prendre en compte le coût de l'analyse.

• Identification des préleveurs. Afin de pouvoir garantir la validité du résultat de l'analyse, le laboratoire peut demander à ce que le prélèvement soit effectué selon une méthodologie précise qui peut nécessiter l'intervention d'un préleveur qualifié ou à défaut d'un préleveur propre à la structure sous réserve d'utilisation des méthodes de standardisation du prélèvement (ex : applicateur ou gabarit cf. Tableau I).

• Qualification des résultats. Il n'existe pas de valeurs normales attendues réglementairement. Lors de la comparaison de techniques/produits : les résultats seront considérés comme acceptables s'ils sont comparables ou meilleurs (moindre contamination) que ceux obtenus avec la technique ou le produit de référence.

Visualisation de la contamination dans le cadre d'une démarche pédagogique

La démarche pédagogique consiste à faire prendre conscience aux secouristes du risque infectieux potentiel, pour la victime et eux-mêmes, lié à une contamination des mains, ou encore, de l'environnement (surfaces, matériel, tenue etc.).

Les prélèvements reflèteront alors l'exposition de la victime et des professionnels dans le VSAV à différents temps T. À l'instar de l'objectif de validation d'une méthode, l'élaboration d'une stratégie de prélèvement reste la même avec en plus l'identification et la traçabilité des temps considérés, la traçabilité des agents en charge de l'entretien est à prévoir si le retour prévoit un retour individuel.

Différents temps peuvent être considérés :

• T1 : avant un départ,

• T2 : avant entretien au centre hospitalier,

• T3 : après entretien au retour en caserne.

Ils représentent respectivement : 1) le risque auquel sont exposées les victimes prises en charge dans le VSAV (il est attendu que ces prélèvements soient peu contaminés), 2) la contamination liées à la prise en charge de la victime (ces prélèvements sont les plus contaminés) et 3) l'efficacité du nettoyage et la nécessité de cibler certaines surfaces potentiellement contaminées et oubliées.

Une différenciation de la flore environnementale de la flore bactérienne potentiellement pathogène pour l'Homme, peut être demandée au laboratoire.

Comme toute démarche pédagogique, celle-ci doit être précédée d'un briefing expliquant l'objectif de la démarche, la période de l'étude et être suivie d'un débriefing expliquant les résultats obtenus ainsi que l'identification d'actions d'amélioration.

Il est également possible de coupler une stratégie de prélèvement à d'autres approches pédagogiques telles que :

• Les audits de pratique qui sont chronophages, mais très informatifs notamment sur la technique de réalisation de l'entretien.

• Les techniques « fluo » qui sont de plus en plus souvent utilisées dans un contexte pédagogique tels que les « tutos fluo » disponibles sur YouTube montrant notamment une contamination des surfaces et des mains liées au port de gants et illustrée dans la Ces approches combinées permettent de minimiser les limites des prélèvements de surface.

LIMITES DES PRELEVEMENTS DE SURFACES

Chaque technique présente des avantages et des limites propres (détaillées dans le Tableau I), mais d'une manière générale les contrôles présentent des limites communes :

• Micro-organismes identifiés : les prélèvements ciblent plus particulièrement les bactéries ou les champignons, la recherche d'autres agents infectieux (virus, ou parasites) doit quant à elle faire l'objet d'une démarche particulière pour laquelle la pertinence de l'indication est à discuter.

• Au temps T et au niveau d'une surface S : les prélèvements mêmes s'ils sont réalisés dans les règles de l'art ne permettent pas d'avoir une vision parfaite. En effet, ils ne permettent d'avoir un reflet de la situation au temps T de la réalisation du prélèvement et uniquement pour la surface S ayant fait l'objet du prélèvement.

• La capacité des différentes techniques à « décrocher » des bactéries sur des surfaces n'est jamais parfaite, et les différentes techniques ne sont pas équivalentes. Toutefois, le pourcentage de récupération du prélèvement gélosé est supérieur à celui de l'écouvillonnage. [START_REF] Hoborn | Bacterial counts on fabrics: a comparative study of three methods[END_REF] Il est ainsi préconisé de privilégier la technique du prélèvement gélosé chaque fois que possible.

• Les analyses peuvent représenter un coût qu'il convient de ne pas négliger.

• Délai de résultat : hormis la technique d'ATPmétrie qui permet le rendu d'un résultat immédiat, les techniques de cultures prennent plus ou moins de temps selon le type de résultats attendus.

MAITRISE DU RISQUE INFECTIEUX DANS LES VSAV

Si la réalisation de prélèvements d'environnement permet d'objectiver la contamination d'une surface S à un temps T, le risque de contamination est quant à lui permanent et nécessite pour prévenir tout risque d'infection, la mise en place systématique de mesures barrière pour l'ensemble des personnes prises en charges. En effet, leur statut infectieux n'est pas nécessairement connu. Ces mesures regroupées sous le terme de « précautions standard » ont été actualisées en 2017 par la société française d'hygiène hospitalière. [START_REF]Actualisation des précautions standard[END_REF] Parmi les différentes mesures, en plus de l'entretien de l'environnement, il est indispensable d'assurer une bonne maîtrise de la transmission qu'elle soit liée à une contamination des mains (transmission manuportée) ou qu'il s'agisse d'une transmission par voie aérienne.

• La prévention de la transmission manuportée implique de bonnes pratiques d'hygiène des mains ainsi que du port de gants.

-Hygiène des mains. La désinfection des mains doit être régulière, réalisée minima avant chaque geste invasif ou contact avec la victime. Elle est assurée par l'utilisation d'un produit hydro-alcoolique sur des mains propres et sèches, selon une procédure permettant une désinfection de l'ensemble de la surface des mains.

-Port de gants. Le port de gants n'est attendu que lorsqu'il existe un risque de contact avec des liquides biologiques (sang, urines, selles etc.) ou avec les muqueuses de la victime ou lors de la manipulation d'objet piquant coupant ou tranchant. Il n'est donc pas indiqué lors de contact avec de la peau saine (exemple : prise de constantes). Dès lors que les gants ne sont plus indiqués ils doivent être ôtés et éliminés. En pratique, le port d'une même paire de gants en continu, à savoir du début de l'intervention à la dépose de la victime au centre hospitalier, est très fréquent.

Cette pratique, non conforme aux bonnes pratiques de port de gants, occasionne une contamination élevée de l'environnement avec le risque de ne pas avoir un entretien suffisant (oubli de surfaces manipulées) avant la prise en charge d'une autre victime et sont donc à fort risque de transmission croisée.

Il existe, en outre, un risque élevé de contamination des mains malgré un retrait minutieux des gants, justifiant la nécessité de réaliser une hygiène des mains après le retrait des gants.

Risque particulier : le port de gants est également attendu si une gale est suspectée chez la victime prise en charge (prurit important au niveau des mains), dans ce cas-là les gants doivent être portés pour tous contacts avec la victime et les manches de la tenue professionnelle seront baissées. Un lavage des mains à l'eau et au savon devra être réalisé après le retrait des gants.

• La prévention de la transmission par voie aérienne est, quant à elle, assurée par le port de masque dont la nature dépend des situations.

-Port d'un masque chirurgical : le masque chirurgical, conforme à la norme EN 14 683, doit être porté par toute personne (victimes comme secouristes) présentant une toux.

Risques particuliers : certaines pathologies se transmettent via des gouttelettes et nécessite le port d'un masque par les agents notamment en période épidémique, il s'agit notamment de la grippe ou encore du SARS-CoV-2.

-Port d'un masque FFP2 : le port de ces masques, conformes à la norme EN 149, est attendu par les secouristes exclusivement, chaque fois qu'il existe un risque d'aérosolisation (exemple : utilisation de l'aspirateur à mucosité). En cas de risque d'aérosolisation il convient de compléter l'équipement des agents par des lunettes de protection. Risques particuliers : ces masques doivent également être portés dès lors que certaines pathologies à transmission aérienne, telle que la tuberculose pulmonaire, sont suspectées.

Remarque. Lors de la prise en charge d'une victime qui tousse, (quelle que soit l'origine de la toux, tuberculose ou autre pathologie infectieuse), le port d'un masque chirurgical par la victime permet une protection efficace. Le port de masque (chirurgical ou FFP2) par les secouristes est particulièrement important si la victime ne peut pas être masquée.

Ces mesures, très générales, permettent donc une maîtrise du risque infectieux quelle que soit la nature de l'agent infectieux (bactérie, virus etc.).

CONCLUSION

La réalisation de prélèvements de surfaces dans les VSAV présente un intérêt particulier dans le cadre d'une démarche de validation d'une méthode ou d'un processus ou dans un contexte pédagogique. Toutefois, il s'agit de les intégrer systématiquement dans une réflexion globale afin d'identifier clairement l'objectif de la démarche ainsi que les avantages et limites associés. Les prélèvements sont complémentaires d'autres stratégies.

D'une manière générale, la maîtrise du risque infectieux implique un respect des mesures barrières telles que l'hygiène des mains, le port de gants restreint aux indications où ils sont attendus et au port de masque dans les situations à risque de projection.

Figure 1 .

 1 Figure 1. Temps de réalisation des prélèvements d'environnement et éléments mis en évidence en fonction de l'objectif. A : validation d'une méthode ou d'un processus et B : démarche pédagogique.

Figure 2 Figure 2 .

 22 Photo A


Alexandra Botero
email: alexandra.botero@aphp.fr

Maïté Berges

Lucie Clervoy

Marie Laurent

Catherine Bertrand

Éric Lecarpentier

Eric Lecarpentier

Cump Samu

Crise COVID-19 : soins médico-psychologiques et EHPAD

Keywords: crise sanitaire, COVID-19, EHPAD, SAMU, soins médico-psychologiques COVID-19 crisis, Nursing homes, French emergency call centers (SAMU), medico pyschological support

Introduction

Le mois de mars 2020 a marqué l'activité des SAMU-SMUR en les mettant au défi de répondre aux appels d'aide médicale urgente (AMU), doublés, triplés, voire quadruplés en quelques jours en raison de la crise sanitaire. Le SAMU doit mettre en place une nouvelle organisation pour garder la capacité de répondre aux urgences absolues d'une part (réponse de niveau 1) et absorber les flux de demandeurs de conseils médicaux sur la maladie COVID-19 (méthode du décroché-raccroché). Des formations à la régulation sont dispensées par le CESU à des médecins généralistes, des médecins spécialistes, des internes, des externes et des étudiants d'IFSI.

Fin mars, dans le cadre de la structuration d'un appui aux établissements d'hébergement pour personnes âgées dépendantes (EHPAD) en grande difficulté et à l'initiative du doyen de la faculté santé de Créteil, le SAMU a mis en place une cellule de crise COVID-19 dédiée aux 74 EHPADs du département, accessible H24, via un numéro spécifique.

Le dispositif d'aide téléphonique de la CUMP

Les appels pour conseils gériatriques ou autres besoins, émanant des EHPADs, via cette ligne dédiée, ont rapidement laissé percevoir une souffrance des appelants. Le SAMU a alors sollicité la CUMP pour proposer des soins médico-psychologiques aux personnels qui en exprimeraient le besoin et ce, à partir du 31 mars 2020.

La posture prise par la CUMP a été, dans un premier temps, d'offrir un contact téléphonique à destination :

• de l'encadrement des EHPAD (directeurs, médecins coordonnateurs, cadres, infirmiers, etc.) pour proposer un soutien et un accompagnement psychologique dans la gestion de la crise en délivrant une information sur les possibilités de soins médico-psychologiques à destination des équipes, en groupe ou en individuel. • de tous les salariés des EHPAD que ce soit dans le domaine du soin, de l'animation, des services techniques, de la cuisine… Pour ce faire, les soixante-trois volontaires inscrits à la CUMP 94 ont rappelé les EHPADs, d'abord celles classées prioritaires par la délégation départementale de l'agence régionale de santé (ARS) et par la cellule de crise, car en grande difficulté en raison du nombre de cas COVID positifs et de la pénurie en ressources humaines.

De façon parallèle, une sensibilisation et des formations ont été organisées à destination des volontaires de la CUMP (psychologues, infirmiers, cadres, médecins, psychiatres et logisticiens) pour leur apporter des connaissances sur les EHPADs et à destination des externes et internes chargés d'orienter les demandes des EHPADs vers les filières gériatriques, les réseaux et pouvant déceler dès l'appel une souffrance psychique. En plus d'une information sur les possibilités de prise en charge psychologique et les conseils pouvant être donnés par téléphone, la CUMP a été très attentive à l'impact de ces appels sur les externes, les internes et répondants de la cellule.

Cette période a été suivie d'une attitude proactive de la CUMP qui a appelé une quarantaine d'EHPADs afin de faire un point de situation avec les directions et l'encadrement. Ces appels ont été à la fois riches, synthétiques et empathiques.

A partir du 22 avril, les EHPADs ont eux-mêmes rappelé la CUMP, exposant des demandes :

• de soutien, conseil et accompagnement des responsables,

• de consultations individuelles des personnels,

• de groupe de parole, avec le soutien des cadres.

En raison du confinement, les soins médico-psychologiques ont été donnés par téléphone.

Les groupes de parole étaient centrés sur le vécu émotionnel.

Les interventions des équipes CUMP dans les EHPADs

Dès le 6 mai 2020, la cellule de crise a organisé des interventions d'équipes CUMP sur place avec l'aide logistique des associatifs en poste au SAMU et des professionnels du SAMU, volontaires, participant aux activités de la CUMP (ambulanciers, aides-soignants, assistants de régulation médicale, secrétaires). Toutes les mesures barrière ont été présentées aux équipes CUMP et respectées.

Un certain nombre d'EHPADs avaient des psychologues dans leurs équipes, le plus souvent dédiés aux résidents et parfois absents car contaminés. Les EHPADs ont justifié leurs demandes car elles appréciaient la neutralité d'un regard extérieur pour leurs personnels.

Les groupes de parole, axés sur le vécu émotionnel, ont mis en lumière l'impact de cette crise dans toutes les sphères de la vie :

• professionnelle en rapport avec :

la perte des résidents de façon souvent brutale et rapprochée, générant des sentiments de tristesse, d'impuissance et de frustration, ressentis en raison de la rudesse des consignes de soins post mortem et de l'absence des rites de deuil, notamment avec les proches pour pouvoir accompagner dignement le mourant ; -des sentiments d'insécurité en raison du flou et des changements fréquents des consignes de protection individuelle et du manque des équipements individuels de protection (EPI) ; -l'exacerbation ou l'émergence de difficultés institutionnelles suite aux glissements de tâches, à la communication complexe et au manque de moyens humains et en équipements de protection ; -des relations parfois complexes avec les proches des résidents : reconnaissance, mais aussi agressivité avec demandes d'explications de dossiers médicaux, voire dépôts de plaintes; sécurisation des visites post déconfinement.

• personnelle et familiale en rapport avec :

la peur d'être contaminé ou de contaminer ses proches, conduisant à des conflits de loyauté familles/travail ; -des isolements stricts difficiles à gérer, pour les personnels ayant été contaminés, surtout avec des enfants en bas âge ; -un sentiment d'insécurité en apprenant des hospitalisations parmi les personnels, voire des décès de proches ou amis.

L'élément dominant a été l'épuisement, particulièrement marqué suite aux adaptations répétées et à la charge psychique inhérente à la crise (informations continues et contradictoires dans les médias, bilan quotidien du nombre de morts en France, accent mis sur la mortalité en EHPAD). La pénurie de ressources humaines au pic de la crise a été un facteur majeur de déstabilisation. Le renfort en personnels extérieurs, parfois étrangers au milieu des EHPADs ou intermittents a été essentiel mais souvent tardif, insuffisant et exigeant en temps de formation. Le deuxième élément marquant a été la peur pour soi, ses proches et enfants confinés à domicile. Les équipes de la CUMP ont assisté, sans surprise, à la réactivation de traumatismes anciens.

Après avoir abordé les bouleversements psychiques, sans frontières, engendrés par une crise avec un virus invisible, potentiellement toujours menaçant, la CUMP a abordé les ressources groupales positives (solidarité souvent sans faille, partage des peines et des joies) et personnelles pour traverser cette crise. De nombreux témoignages écrits de familles ont été réconfortants. La CUMP a valorisé cette cohésion et conseillé de prendre des temps de repos et du recul pour se « ressourcer ».

En période de crise, la CUMP a pu contacter tous les EHPADs, au minimum une fois. Depuis juin, la CUMP 94 reste mobilisée sur toutes ces missions, en continuité des fonctionnalités de la cellule de crise dédiée aux EHPADs, facette gériatrique du futur service d'accès aux soins (SAS), favorisant le lien ville-hôpital.

Conclusion

La CUMP du SAMU a été sollicitée en période de crise pour apporter des soins médicopsychologiques dans les EHPADs par téléphone et lors de débriefings sur place. Les besoins en période post crise ne doivent pas être sous-estimés alors que la CUMP est moins disponible en raison de la réapparition d'autres demandes de soins médico psychologiques.

Les auteurs n'ont pas de conflit d'intérêt

Les auteurs remercient les EHPAD pour leur confiance, les équipes de la CUMP et du SAMU pour leur disponibilité.