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Abstract
Introduction Comprehending informal coercion, which encompasses a wide range of phenomena characterised by subtle and non-legalised pressures, can be complex. Its use is underestimated within the continuum of coercion in mental health, although its application may have a negative impact on the persons involved. A better understanding of informal coercion is crucial for improving mental healthcare and informing future research. This scoping review aims to explore the nature, extent and consequences of informal coercion in mental health hospitalisation to clarify this phenomenon, establish its boundaries more clearly and identify knowledge gaps.
Methods and analysis Following the methodological framework from the Joanna Briggs Institute, this scoping review will encompass 10 key steps. Literature searches will be conducted in electronic databases, including CINAHL, PubMed, MEDLINE, EMBASE, Web of Science, PsycINFO, and ProQuest Dissertation and Theses. Then, a search in grey literature sources (Open Grey, Grey Guide), psychiatric and mental health journals, government agencies and among the references of selected studies will be conducted. The research will include all literature focusing on informal coercion with inpatients aged 18 and above. Data will be extracted and analysed descriptively, mapping the available knowledge and identifying thematic patterns. The quality of included studies will be assessed using appropriate appraisal tools. An exploratory search was conducted in November 2023 and will be updated in December 2023 when the selection of relevant evidence will begin.
Ethics and dissemination Ethical approval is not required as this study involves the analysis of existing published literature. The findings will be disseminated through a peer-reviewed publication and presentations at relevant conferences. They will be shared with people living with mental disorders and professionals working in mental healthcare.
- mental health
- adult psychiatry
- nursing care
- systematic review
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The involvement of a person with lived experience from the early stages of this scoping review is expected to enhance the preciseness and relevance of the search strategy and the depth of the findings.
To enhance the inclusivity of all relevant findings of this scoping review, outcomes will be presented from an exhaustive exploration of academic databases, specialised publications and grey literature sources.
By critically appraising the literature and assessing the quality of included studies, this review will pinpoint knowledge gaps and guide future research priorities in the field of informal coercion.
Limiting the review to English and French publications may result in the exclusion of relevant studies published in other languages.
Due to the heterogeneity of included studies, data synthesis may be challenging, and comparisons across different contexts may be limited.
Introduction
Coercion, referring to the act of compelling an individual to do or not do something during their psychiatric treatment, remains widespread in mental health inpatient care.1 Coercion in mental health can take various forms, ranging from informal coercion, which includes unregulated and implicit pressures based on the caregiver–patient relationship, to formal coercion, which encompasses legally mandated restraints such as seclusion, mechanical restraint and involuntary treatment.2 3 Studies on the patients’ subjective experience of coercion (perceived coercion) revealed that coercion can occur during voluntary and involuntary care, resulting from more subtle forms of coercion, including the sense of being compelled to adhere to one treatment over another.4
Particular attention has been given to formal coercion in recent years, with numerous studies revealing its deleterious consequences and focusing on the effectiveness of programmes aimed at reducing its use.5–7 This has had an impact on the legislative framework surrounding formal coercive measures, promoting policies aimed at minimising their use.8 This increased focus may have affected the continuum of coercion within adult psychiatric hospital services. For instance, in a Dutch study from 2016, a significant reduction in the use of seclusion was accompanied by an increase in forced medication, suggesting the substitution of one measure for the other.9 Hotzy and Jaeger10 and Andersson et al11 have highlighted the use of informal coercion as a means to avoid resorting to formal coercion in mental health hospital care.
Informal coercion is a broad phenomenon that can refer to any form of pressure exerted by one person on another with the aim of influencing them during mental healthcare.3 While reviewing the literature on the topic, diverse terminologies are employed to denote informal coercion, including terms such as ‘soft/er coercion’, ‘subtle coercion’, ‘informal coercion’, ‘treatment pressure’ or ‘covert coercion’. It manifests in a wide range of ways, from persuasion to manipulation, threats, deception and even displays of force.10 12–14 Despite its estimated prevalence ranging from 29% to 59% in mental healthcare settings,10 the use of informal coercion appears to be underestimated by mental health professionals15 and can be a point of tension among them,16 possibly due to the less tangible and formalised nature of this form of coercion. Underestimation may also be related to the caregiver’s perspective on coercion; the more they approve of coercion, the more likely they are to underestimate the level of informal coercion being exerted.17 Moreover, its use can have negative consequences on the identity of individuals hospitalised in mental healthcare and on the therapeutic relationship.12 It can also touch on issues of integrating human rights in care.3 Furthermore, some studies indicate that informal coercion is not only exercised by mental health professionals but also by the relatives of individuals hospitalised in mental healthcare.13 18
Understanding informal coercion, which encompasses a wide range of phenomena, can be complex within the continuum of coercion in mental health. Research has been conducted on knowledge syntheses regarding this phenomenon in PROSPERO, Joanna Briggs Institute (JBI) Evidence Synthesis, Cochrane Database of Systematic Reviews, CINAHL, Epistemonikos, Open Science Framework and Figshare19 as of July 2023. Despite the interest shown in Hem et al’s20 systematic review on ethical challenges related to the use of coercion in mental health, including its informal form, their results offer a limited representation of this specific form; among the 22 selected studies, only 2 specifically focused on informal coercion. Beames and Onwumere’s21 systematic review reports that risk factors related to informal forms of coercion remain lacking in the literature. The systematic review conducted by Hotzy and Jaeger10 specifically focuses on the clinical relevance of informal coercion, but it is limited to examining qualitative and quantitative studies published between 2000 and 2016. Yeeles22 scoping review is limited to publications on informal coercion in community mental healthcare published until June 2014. Lastly, Allison and Flemming’s12 qualitative synthesis on ‘soft’ coercion has an exclusion criterion to qualitative writings from the UK and Ireland. Therefore, given these highly heterogeneous results and to provide a more comprehensive, clearer and up-to-date picture of informal coercion in mental health hospital care, conducting a scoping review appears necessary. To this end, a scoping review method will be employed to gain a better understanding and representation of the phenomenon of informal coercion, including its characteristics, factors and consequences. The aim of this review will be to establish the breadth of knowledge on informal coercion in psychiatric inpatient care to clarify this phenomenon, better delineate its boundaries and identify knowledge gaps to guide further research.
The main research question is: What is the nature and extent of knowledge regarding informal coercion during mental health inpatient care? The subquestions are: (a) What are the definitions and characteristics of this phenomenon? and (b) What are the causes, associated factors, manifestations and consequences of this phenomenon?
Methods
This scoping review will be conducted following the methodological framework by Peters et al derived from the updated guidelines of the JBI.19 A scoping review generally aims to provide an overview and mapping of the literature on a specific topic, as well as to clarify the phenomenon and highlight the gaps in knowledge to guide future research. A scoping review can thus facilitate a comprehensive understanding of a phenomenon by identifying the different types of literature available on the topic and the key characteristics and factors associated with the phenomenon.19 These objectives are consistent with the main goal of this literature synthesis, which is exploratory in nature. The synthesis seeks to systematically provide a broad overview of the phenomenon of informal coercion within the context of psychiatric inpatient care.
The methodological framework consists of nine key steps for the successful completion of a scoping review: (a) defining and adjusting the objectives and questions; (b) developing inclusion criteria; (c) describing the study’s plan; (d) searching for relevant evidence; (e) selecting the relevant evidence; (f) extracting data from the selected evidence; (g) analysing the extracted data; (h) presenting the results and (i) synthesising the evidence.19 To enhance the relevance of this scoping review and value the experiential knowledge of individuals with mental health disorders, a 10th step has been added to this research process: the involvement of a mental health peer supporter with lived experience in psychiatry from the beginning of the project and throughout each stage of the study.23 The engagement has been structured and planned, incorporating the following elements: (1) The person with lived experience was chosen for her qualities, extensive experience and representation of a diverse group as the executive director of an association for individuals affected by mental health disorders; (2) Early meeting before the beginning of the project allowing the person with lived experience to contribute fully and building a clear and mutually agreed on purpose for her engagement in this scoping review; (3) The person with lived experience has been and will continue to be involved in every phase of the project, from refining the research question to dissemination; (4) Emphasis is placed on incorporating all feedback from the person with lived experience, acknowledging her deep involvement and considering her proposals as equally valid. This includes adding the perspective of witnessing coercion as a form to be considered in informal coercion and being attentive to populations studied in selected articles, with a focus on those often excluded from current evidence; (5) During the data collection phase, regular meetings between reviewers and the person with lived experience will be scheduled to discuss the relevance of literature selected; (6) The peer support worker will participate in discussions to refine themes and contribute insights. Additionally, collaborative efforts will involve explaining the analytical theme development process to ensure a comprehensive understanding, thereby facilitating meaningful consultation regarding the lived experience perspective in the analysis; (7) For the results, ongoing dialogue, and collaborative discussions within the research team, including regular meetings and reflective sessions, will capture diverse perspectives and (8) To support dissemination, the peer support worker expressed interest in reviewing and editing the protocol and future manuscripts, as well as communicating the findings to members of her association. To ensure comprehensive reporting of essential elements in the final scoping review, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines will be followed.24 For the design of this protocol, the PRISMA-Protocols checklist was followed25 (online supplemental additional file 1), and the protocol was registered on the Open Science Framework (https://osf.io/p7k6u). The selection of data sources for this exploratory examination will begin in December 2023. This scoping review is expected to be completed by November 2024.
Supplemental material
Inclusion criteria
The inclusion criteria were formulated using the format recommended by JBI: population, concept, context and type of evidence sources.19
Population
In this review, studies focusing on adult individuals aged 18 years and older will be included. This includes individuals receiving or having received inpatient psychiatric care, their relatives (family and close associates), and mental health professionals (such as nurses, psychiatrists, psychologists, caregivers). This scoping review will explore the multifaceted nature of informal coercion, considering diverse perspectives by incorporating all relevant stakeholders. It aims to capture the complex and nuanced variations in the understanding and experience of informal coercion. Studies involving minors will be included only if most of the participants were over 18 years old. Papers specifically addressing geriatric psychiatry, intellectual disabilities, eating disorders, child psychiatry, neurodegenerative disorders, cognitive disorders, perinatal psychiatry, forensic psychiatry and somatic comorbidities will be excluded due to the specificities associated with these specialties.
Concept
This synthesis will focus on literature addressing informal coercion in mental health, which refers to the use of subtle and non-legalised pressures and constraints on individuals receiving care to influence their actions or decisions during treatment, whether the care is voluntary or not.11 15–18 Informal coercion encompasses a wide range of techniques, including persuasion, negotiation, interpersonal leverage, inducement, restrictions, blackmail, deception, threats, witnessing coercion and/or displays of force. Articles predominantly focusing on formal coercion will be excluded.
Context
This review will consider literature focusing on inpatient hospitalisations in mental health services. Publications primarily targeting psychiatric outpatient care, home-based hospitalisations and/or somatic care services will be excluded.
Types of evidence sources
All existing literature on the concept of interest will be considered, without limitations on publication years. This may include primary studies (quantitative, qualitative, mixed methods), knowledge syntheses (systematic reviews, meta-analyses, etc), conference abstracts, opinion pieces, theoretical articles and grey literature (theses, etc). Only articles in English and French will be included to ensure valid translation of the literature and feasibility.
Search strategy
For this scoping review, the electronic databases CINAHL, PubMed, MEDLINE, EMBASE, Web of Science, PsycINFO, and ProQuest Dissertation and Theses will be used to ensure a comprehensive overview of the literature on the topic of interest. In partnership with a specialised mental health librarian, a search term plan was developed based on the main concepts of the research question, ‘informal coercion’ and ‘mental health and psychiatry’ (table 1). Using subject headings and keywords from this plan, a search strategy was developed and tested on PubMed in November 2023 (table 2). The search strategy, including all keywords and subject headings, will be adapted for each included database. An exploratory search in MEDLINE, EMBASE, PsycINFO and CINAHL was also conducted in November 2023 (online supplemental additional file 2) and will be updated when the selection of relevant evidence begins, which is scheduled for December 2023. There will be no restrictions on publication years. Additional searches will be conducted in grey literature sources (Open Grey, Grey Guide), psychiatry and mental health journals, government agencies and among the references lists of the included publications (snowballing). No language restrictions will be applied to provide a searchable list of articles in non-English or non-French languages for readers. Only articles available in full text will be included to not miss any relevant information. The literature search will be conducted iteratively, meaning that the search strategy may be adjusted gradually as evidence is discovered and a better understanding of the subject matter is gained.
Supplemental material
Main concepts and their associated lists of subject headings and keywords
Example of a pilot search
Selection of evidence sources
After the literature search, all identified records will be gathered and imported into the Covidence software, and duplicates will be removed. The two primary reviewers will independently screen the literature during a pilot test using a random sample of 25 selected titles/abstracts to compare their selection and confirm the accuracy and clarity of the eligibility criteria.19 Once inter-rater agreement reaches 75% or higher, the first stage of selection can proceed. During this initial selection, titles and abstracts will be independently reviewed by the two primary reviewers to assess their eligibility based on the inclusion criteria. Potentially relevant articles and those without abstracts will be directly included for full-text review. A second selection will be conducted by the two primary reviewers based on the examination of the full-text literature selected in the previous stage. In case of disagreements in the article selection, a third reviewer may be consulted. Reasons for excluding articles will be documented. A full report of the selection process results will be presented in a PRISMA-ScR flow diagram.24
Data extraction
The data will be extracted from the articles by the two primary reviewers using the data extraction form proposed by JBI and adapted to the purpose and research questions of this scoping review.19 This form will be presented as a table and will include the following categories, where applicable: authors; year of publication; country of origin; type of literature; aim/objectives; perspective/theoretical framework; methodology; target population; care context; sample size; measurement of informal coercion (scale, questionnaire, interview, etc); employed definition of informal coercion; presented forms of informal coercion; factors and causes of informal coercion; consequences of informal coercion; key findings relevant to the topic of interest based on the research questions; proposals for reducing informal coercion; strengths and limitations of the literature; identified knowledge gaps for the topic of interest. The data extraction form will be individually tested by the two primary reviewers on a set of common articles. They will then compare their categories and verify the relevance of the extracted data until inter-rater agreement is reached. The data extraction process will then be conducted independently by the two primary reviewers. Regular meetings will be scheduled between the two reviewers to discuss the relevance of the chosen categories for extraction. In case of disagreements during the data extraction, a third reviewer may be consulted. If necessary, the authors of the included articles will be contacted to request any missing or additional data.
Data analysis and presentation of results
Given the diverse nature of the selected literature, data analysis will be conducted in a descriptive manner to map the breadth of knowledge and address the aims and research questions of this study.19 To begin with, a description of the included literature, highlighting their key characteristics and the main data extracted that address the aims and research questions of this study (various manifestations of informal coercion, definitions, causes, factors, consequences associated with it, etc), will be conducted.26 Following data extraction, the data will be analysed using content analysis methods inspired by Miles and Huberman,27 involving three stages (using QDA Miner software): (1) condensation of data; (2) presentation of data to identify similarities and differences and (3) formulation and validation of conclusions, with a focus on recognising themes and subthemes. The results will be presented in tables and graphs accompanied by a narrative summary. Frequent meetings among the authors of this review will be conducted to refine the themes. To determine knowledge gaps, a critical appraisal and evaluation of the quality of the literature will be applied using the following tools: the Mixed Methods Appraisal Tool,28 the checklist for systematic reviews and research synthesis29 and the Authority, Accuracy, Coverage, Objectivity, Date, Significance checklist for grey literature.30 Finally, conclusions will be presented taking into consideration the current state of knowledge on the subject as well as any potential research gaps.
Patient and public involvement
A person (JT) who is, among other things, a certified peer support worker and a patient partner in mental health, was involved in the development of this review protocol and will also be involved in the data analysis and the dissemination of the results.
Ethics and dissemination
No ethics approval is required for this review. The outcomes of this scoping review will be submitted to a scientific journal for publication. Furthermore, the results will be showcased at global conferences focusing on mental health and shared with persons living with a mental disorder and clinicians working in mental healthcare.
Ethics statements
Patient consent for publication
Acknowledgments
The authors would like to acknowledge the contribution of Maria Pilar Ramírez-García, RN Ph.D., Associate professor at the Faculty of Nursing, Université de Montréal, for her guidance during the initial design of this protocol. The authors would also like to express their gratitude to Dr. Sashi Sashidharan and Dr. Eric O. Noorthoorn, the reviewers of the manuscript, for their valuable comments.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors VB designed and wrote the initial version of the scoping review protocol. MD, M-HG, CL-D, SS-R and JT offered guidance during the design of the protocol, critically reviewed and helped refine the protocol. All authors contributed to the final version of the manuscript.
Funding Funding for publication fees for this article was obtained in January 2024 through a dissemination grant from both the Research Center and the Foundation of the Institut Universitaire en Santé Mentale de Montréal.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.