Legal Factors and Psychological Stress of Health Professionals in the Forensic Area: A Systematic Review Protocol

Background: The illness of mental health workers in the forensic area has multifactorial causes, but among the main ones is the stress resulting from legal factors at work, such as workload; bylaws; wage; promotion; resignation; assignments; safety rules; legislation for the promotion, prevention and protection of health in the workplace; regulation of risky activities, as they signi�cantly vary the health-disease process of health personnel by directly interfering with their work mode and rhythm. Evidence shows that it is the population group more prone to stress, physical and mental exhaustion, and suicide, unlike the rest of the population. It is noteworthy the fact that 90% of the world population suffers from stress, according to the World Health Organization. Given the growth of primary research on the subject and its importance in the various health outcomes, it is necessary to start processes of compilation and synthesis of this evidence to facilitate understanding of the importance of legal factors as stressors to the work routine of health professionals in the forensic area. Methods: The studies included will be original qualitative and quantitative research articles. This systematic review protocol will be conducted in accordance with the Cochrane Manual and will follow PRISMA-P guidelines. Searches will take place from August 2021 to October 2021 and will be performed from the following electronic databases: APA PsycNet, Web of Science, Scopus, PubMed, Oxford Journals and ScienceDirect. Two reviewers will obtain eligible articles, published from 1990 to 2020, to assess the quality of each study and extract data. A narrative and qualitative synthesis will be used to analyze the primary results, and choose the articles relevant to the research objective. Discussion: The results of this review will contribute to a better understanding that stress in the workplace is not restricted to clinical and organizational factors, but also occurs as a result of legal factors. This expanded understanding of the causes of work stress can better support discussions on the reformulation of legislation related to prevention, promotion and recovery of workers' health effectively. Ethics and dissemination: Ethics committee approval is not required for a systematic review protocol. The results will be published in a peer-reviewed health or social science journal.


Introduction
By mental health is understood the state of well-being in which a person performs their skills, deals with the normal stresses of life, works productively and contributes to their community [1].One of the main factors that affect the balance of mental health is stress, and according to the World Health Organization (WHO) approximately 90% of the world population is affected by this condition, and that is precisely why this factor is considered to be global epidemic [2; 3].There is a growing concern of countries to build effective public policies in the promotion, prevention and recovery of the mental health of their population in relation to work and public health [4].
In the mid-twentieth century, stress was de ned as the General Adaptation Syndrome, which is the body's natural defense reaction to adverse situations [5].From this perspective, stress has the positive dimension, which is eustress, in which the individual is more productive and creative in their adaptive reactions, and the negative dimension, which is distress, a state in which there is excess or lack of adaptation, which leads the individual to express inappropriate responses [6].At the turn of the 21st century, stress had a greater incidence in the population and caused demands for psychiatric and psychological services, and came to be de ned as a psychological factor that represents a harmful relationship between the individual and the environment, which affects their mental health [7].
In 1990, WHO and PAHO (Pan American Health Organization) began the restructuring of psychiatric care in the region of the Americas, which resulted in the Declaration of Caracas.This document states that the development of psychiatric care in mental health is necessarily linked to the primary care of local health systems [8].As early as 1991, the United Nations General Assembly reinforced the principles for the protection of people with mental illness and the improvement of health care, with an emphasis on community services and the rights of people with mental illness [9].
To operationalize this restructuring, it was necessary to adapt the state and private sectors of the mental health eld to legislative, technical and organizational innovations and, in particular, the approximation of the judicial system to the health system [10].Bringing these systems together was essential in improving the guarantee of individual freedom and human dignity for the recipient of care, which includes those in custody of forensic psychiatric hospitals.
The forensic psychiatric hospital is part of the eld of forensic psychiatry, which in its essence is related to the assessment and treatment of people with mental disorders, who present antisocial or violent behavior, through the interface of mental health and law [11], which may include the correctional perspective [12].In conjunction with the forensic psychiatric hospital are general psychiatric hospitals, psychiatric wards in district general hospitals and prisons with regard to the European continent [11]; and in North and South America there are the Psychiatric Custody and Treatment Hospitals (HCTP) [13], which together constitute the forensic area of mental health, commonly called forensic psychiatry.
Forensic psychiatry, by adapting to the new guidelines of the WHO, PAHO and the United Nations General Assembly, inserted the multidisciplinary team in mental health throughout its eld of action, generally composed of physicians, psychologists, nurses and social workers [14], for an expanded assessment of the health conditions of those in custody in the process of progressive discharge.The professionals of the multidisciplinary mental health team are immersed in the physiological and psychodynamic healthdisease process of work, especially for carrying out medical risk assessments [15; 16; 17].
The daily performance of medical risk assessments subjects workers of multidisciplinary health teams to high levels of stress, due to experiencing the physical resistance of the custodian to the treatment, as well as violent behavior during personal care [17], emotional state and unstable mental disorders, impulsivity, side effects of medications, severe personality disorder, psychosis, and a history of violent crimes [16].The high level of stress for long periods can lead to the appearance of pathologies such as panic disorder, post-traumatic stress disorder (DSM, 2014) and Burnout [18], which increases the percentage of dissatisfaction with work, medical licenses, chemical dependency, exhaustion, drug addiction and physical-mental exhaustion of these health professionals, which consequently makes the maintenance of forensic psychiatry services for the State more expensive [19].
The forensic psychiatric hospital becomes a sickening workplace, by subsidizing high levels of stress to the multidisciplinary health team, which can cause some mental disorder.In Brazil, the most populous country in Latin America, mental and behavioral disorders are the third leading cause of absence from work, including absenteeism and sick leave [20].Piolli and Heloani [21], condense the causes of this scenario, the organizational, clinical and legal factors that permeate the health-disease process, which are present from hypercompetitiveness, human disposability to social Darwinism, which intensify the feeling of insecurity, frustration and angst around employment, which can turn into unemployment.
Evidence demonstrates that the health-disease process of forensic health professionals is directly in uenced by organizational, clinical and legal factors [22,23,24].Legal factors, such as workload; bylaws; code of ethics; disciplinary process; wage; possibility of promotion and dismissal; assignment de nitions; safety rules; legislation for the promotion, prevention and protection of health in the workplace; regulation of risky activities signi cantly varies the health-disease process of health personnel by directly interfering with their mode and pace of work [15].
The pace of work in the forensic area, as in any work activity, which is ultimately directly in uenced by legal factors and the logic of capital, on several occasions goes out of step with the biological and psychological pace of the health professional, when it precarious mental health of the latter [25].This con ict of rhythms is constant, as legal factors are present in the detailed aspects of the functioning of institutions in the forensic area and in uence their entire dynamics, from the professional's mental health, to the types of assessments he performs, instruments used, treatment model to the itinerary of risky activities.
Studies demonstrate that legal factors directly and concomitantly in uence clinical and organizational factors in the eld of health [26,27].The main systematic reviews analyzed these three factors separately, with a greater focus on the clinical and organizational [28], however, the interest in the in uence of the legal factor in the work environment and in the mental health status of professionals has gained increasing importance.This scenario of interest can be attributed to the fact that there is growing evidence that health professionals, especially those in the eld of mental health, are at increased risk of mental disorders [29,30], burnout [31,32] and suicide [ 33] than the rest of the population.
The causes of stress among mental health professionals are not easy to identify.Studies have evaluated two hypotheses: that the organizational environment of forensic psychiatry attracts a speci c group of people and that the di culty could be in the clinical condition of the patients they work with [34,35].However, these studies did not demonstrate that organizational and clinical aspects are more important than legal factors in causing stress.
The study by Deary, Agius and Sadler [35] also demonstrates that personality differences, such as neuroticism, affability and conscientiousness, between psychiatrists, general practitioners and surgeons in uence less stress than the workload.The study by Guppy and Gutteridge [34] ends up showing that job stress among British nurses was related both to relationships in the team and to technical and nancial resources determined by legislation, to the detriment of the clinical condition of the patient's imminent death.
Although these studies report stress on mental health professionals, it must be said that such analyzes, for the most part, focus only on clinical and organizational aspects to the detriment of legal aspects that are part of the health-disease process.To contribute to the understanding of the role and functions of legal factors in the stress of health professionals and thus ll this gap, this systematic review will be carried out in order to describe how the legal factors of work are related to the psychological stress of professionals of health in the forensic area.

Objectives
The main objective is to describe how the legal factors of work are related to the psychological stress of health professionals in the forensic area.Secondarily, the objective is to identify the main legal factors of work related to stress in this population.

Methods And Analysis
This systematic review will be carried out following the Cochrane Manual for Systematic Reviews [36] and the data obtained will be reported from the guidelines and recommendations of the 'Preferred Reporting Items for Systematic Reviews and Meta-Analytical Protocols' (PRISMA-P) model [ 37].Citations and references will be managed in the Mendeley software and data will be extracted and reported in a owchart.This systematic review protocol was registered in the International Prospective Registry of Systematic Reviews -PROSPERO (registration number: CRD42021225442).

Types of studies
The types of studies included will be primary case study, ethnographic, observational (cohort and casecontrol), clinical and cross-sectional studies, both in qualitative and quantitative perspectives.

Types of Participants
The articles retrieved from the databases will have health professionals working in the forensic care network as the research population.

Patient and Public Involvement
No patient involved.

Types of outcome measures
Their results will have to present the outcome or report that describes how the relationship between the legal factors of work and the psychological stress of this population occurs.The review will also consider, as an outcome measure, studies that identify the legal factor in psychological stress without a full description of the in uence relationship.

Electronic searches
We chose to search through the coffee system (Federated Academic Community), because it offers complete access to the main databases in the world, which expands the search eld and its quality.The electronic databases will be APA PsycNet (American Psychological Association), Web of Science (Clarivate Analytics), Scopus (Elsevier), PubMed, Oxford Journals (Oxford University Press) and ScienceDirect (Elsevier).

Research vocabular
The controlled vocabulary MeSH (Medical Subject Headings) will be used for the search strategy and for the establishment of the following keywords: Mental Health; Forensic Psychiatry; Health Personnel; Psychological stress.In addition, the Boolean operator "AND" will be used to specify the syntactic structure of the search terms, which have been tested and established for all databases: Mental Health AND Forensic Psychiatry; Mental Health AND Health Personnel; Mental Health AND Psychological stress; Forensic Psychiatry AND Health Personnel; Forensic Psychiatry AND Psychological stress; Health Personnel AND Psychological stress.

Search criteria
The writing language of the selected articles will be Portuguese, Spanish and English with the aim of gathering as many studies as possible.Studies referring to the period between 1990 and 2020 will be sought, as from that period onwards there were legislative changes in the international context that restructured health care in the forensic area.
The study selection criteria will be: type of study; language; year of publication; article format; full access to the study published through the CAFe system; answer the survey question.Gray literature (dissertations, books, chapters, reports, conference material, opinion articles, comments and reviews) will be excluded from the review, as this type of literature may contain anecdotal or re ective evidence based on primary studies that distort the results found. in research due to the possible absence of peer review.

Selection process
All study search results will be imported into Mendeley software to manage data and eliminate duplicate articles.Initially, the titles and abstracts of all retrieved studies will be selected by a reviewer to identify potentially eligible studies.A second reviewer will independently screen the articles selected by the rst reviewer, with a margin of disagreement of 10%, any discrepancies above this percentage will be resolved by a more experienced third reviewer.Full manuscripts will be obtained for all studies selected as potentially relevant.Articles will be subsequently selected for inclusion based on the eligibility criteria.

Data Extraction Process
A data table will be produced in Microsoft Excel and the Agency for Healthcare Research and Quality Systematic Review Data Repository (SRDRPlus) which is extremely useful in extracting, managing and archiving online data during systematic reviews.These tools will be essential later to thoroughly check all steps of the review for replicability.
The information extracted will include: types of studies (case, ethnographic, cohort and case-control and cross-sectional studies); objective and purposes of the research process; characteristics of participants; context (general psychiatric hospitals, psychiatric wards in district general hospitals, prisons and Hospitals for Custody and Psychiatric Treatment); methods of each study (design, reported and observed methodological limitations, data collection and analysis methods); primary and secondary outcomes and the main conclusions of the study.
After extracting the data, two of the reviewers will deal with disagreements through consensus and, if necessary, a third reviewer will be involved.The main themes identi ed by the authors of the articles will be brie y summarized at this stage, before the meta-synthesis of the articles.The selection procedure will be documented in accordance with PRISMA-P guidelines and reported in a owchart.

Quality assessment
The assessment of the quality of qualitative studies will be assessed using the Critical Appraisal Skills Program (CASP) [38] tool, which has the following checklist: Qualitative Studies Checklist; Cohort Study Checklist and Case Control Study Checklist.The studies will be independently evaluated by two researchers.To resolve any divergences in the score of the articles, the opinion of a third researcher will be consulted.

Data synthesis
Data will be synthesized from the thematic synthesis [39].The ndings of the studies that will be used for analysis include all text present in their results sections.The synthesis method involves three steps: the rst consists of analyzing the text line by line, to identify the results as each study is read.The second stage involves the grouping of descriptive themes through the process of identifying similarities and differences in the contents of the results section, in a hierarchical structure, using the NVivo® software.All sections of nal sample results will be translated into English, as the NVivo® software can only process single language texts.The nal step involves using the descriptive themes to answer the review question and, thus, generate content and information that go beyond the initial synthesis of the ndings of the primary articles.
The entire process will be done by two reviewers, independently, who will then discuss their results among themselves to verify issues that may still emerge.This process will be repeated until the themes generated su ciently represent the results of the studies and answer the review question.

Ethics and dissemination
The review will seek and evaluate primary sources obtained from previous research; therefore, no formal ethics committee approval is required.The results of the systematic review will be published in an international peer-reviewed journal.The authors will plan presentations at possible national or international conferences to disseminate the results among the academic community.

Discussion
The psychological stress of mental health professionals in the forensic area has been increasingly explored in health research, especially with evidence-based practices (EBP), a research modality that is emerging in the health eld.The results of this review will contribute to the understanding that stress in the workplace is not restricted to clinical and organizational factors, but also occurs as a result of legal factors.Gathering these primary data is important for possible construction of improvements in legal labor factors in relation to the mental health of forensic professionals, through EBP [40], as the estimated cost of stress-related illnesses in the United States of America, which concentrates the largest population of health professionals and industry in general, is approximately $13,000.00 per employee per year [41].
With a view to reducing costs with costly treatments and building prevention and mental health promotion policies for forensic workers, there is a need to expand the analysis of stressors.Classic studies in relation to stress in the work environment focus on the organizational and clinical aspects, to the detriment of the analysis and direct in uence of legal factors on workers' health [23].

Declarations
Ethics Ethics committee approval is not required for a systematic review protocol.The results will be published in a peer-reviewed health or social science journal.

Consent for publication
Not applicable.