The Nursing and Midwifery Council (NMC) is the main body for quality nursing practice. This assignment will examine the aspects of The Code
Are psycho physiological biofeedback techniques effective in the treatment of epilepsy? Discuss with reference to empirical studies.
Epilepsy is a relatively common neurological condition, and is defined by a person having more than one seizure. Anyone can develop epilepsy though it mostly occurs in people who have learning disabilities, and is usually diagnosed either before the age of twenty or after sixty years of age. Epilepsy is thought to occur when signals in the brain misfire, usually faster than normal and in bursts. The misfiring causes the body to have a seizure, which can be classified as either a generalised or partial seizure depending on where in the brain it occurs. A generalised seizure involves the whole brain, whilst a partial seizure originates in one part of the brain. The most customary way of treating epilepsy is by drug treatments that are effective in reducing, or even stopping seizures in the majority of cases. However for those sufferers who do not benefit from drug treatment, other methods of treating epilepsy are available. Although psycho physiological biofeedback techniques are not new, research looking into their effectiveness as an alternative to drug treatment for epileptics has recently become more popular. The development of biofeedback treatments is particularly useful for epilepsy sufferers who have not found drug treatment to be effective for them.
If you need assistance with writing your assignment, our professional assignment writing service is here to help!
Psycho physiological refers to studies that look at the interactions between the mind and the body, and how the body is functioning in relation to displayed behaviour. Most psycho physiological techniques are non-invasive and usually involve taking recordings from sensors placed on the surface of the skin. Biofeedback is chiefly used to assess brain processes and muscular tension, and can be used to correct irregular physiological functioning. By combining these two techniques an effective method of treatment for disorders such as epilepsy may be developed, without the need for drugs. Typically psycho physiological style sensors are used to assess biofeedback this is then used to teach epileptic participants to recognise behaviours prior to a seizure and try to control them. This is thought to be a technique that could help epilepsy sufferers manage the frequency of their seizures, because of the neurophysiological basis of epileptic seizures. Goldstein (1997) identifies a theory that was developed by Fenwick and Brown (1989; cited in Goldstein, 1997), which suggests that when a seizure occurs two groups of neurons are affected. Group 1 neurons fire continuously at the central point of the seizure, whilst group 2 neurons are proximal and can either fire normally or as the group 1 neuron’s do. Fenwick and Brown (1989; cited in Goldstein, 1997) suggest that because neurons surrounding an
epileptic episode can influence the occurrence and spread of the seizure, behaviour that affects activity in neurons can affect the occurrence of seizures. This theory is one of few that suggests a strong neurophysiological basis for epilepsy, as is research that utilises biofeedback techniques.
There are a number of psycho physiological biofeedback techniques that have been used to investigate treatment for epilepsy. Critchley, Melmed, Featherstone, Mathias and Dolan (2001) looked at brain activity during biofeedback relaxation. They trained participants to perform a biofeedback relaxation exercise, where participants used the information relayed from biofeedback to change their sympathetic tone by relaxing. Critchley et al (2001) then tested the participants using two control tasks, a task with biofeedback relaxation and a relaxation task without biofeedback. The results revealed that when participants used the biofeedback information during relaxation, activity in areas of the brain that had not been aroused during the control and relaxation tasks increased. These findings would suggest that deliberate control over ones brain activity is possible, and more specifically training can influence brain activity when a person is experiencing a particular sensation. When investigating the effectiveness of biofeedback relaxation in reducing seizures in epileptics, Puskarich et al (1992) looked at patients who had been trained with progressive muscular relaxation. The majority of the relaxation group found a reduction in the frequency of seizures over an eight-week period, whilst the control group did not encounter a significant reduction in seizure frequency over the same period. This would seem to show that biofeedback relaxation techniques can be successfully used to treat epilepsy, however research in this area often has small sample sizes and is time consuming. This means that small anomalies in the data can distort the final results and makes the study difficult to repeat.
Another psycho physiological biofeedback technique that has been investigated for the treatment of epilepsy is Galvanic skin response biofeedback. Nagai, Goldstein, Fenwick and Trimble (2004) examined the usefulness of galvanic skin response biofeedback training in reducing the frequency of seizures in adult epileptics. Two groups of participants, who suffered from drug-refractory epilepsy, were randomly assigned to either a biofeedback-training group or a sham control group. The participant’s galvanic skin response was measured during a biofeedback computer-training task for the experimental group, but during a modified computer
task for the sham control group. Nagai, Goldstein, Fenwick and Trimble (2004) found that a significant reduction in the frequency of seizures occurred for the biofeedback group, but not for the sham control group. This would suggest that the change was affected by the training given to the experimental participants, showing that the use of Galvanic skin response biofeedback is successful at treating epilepsy. Although Nagai et al (2004) suggest this particular study is only preliminary; the findings are encouraging and suggest that this type of research could produce an effective non-drug treatment for epilepsy.
Self-regulation of slow cortical potentials has been study in relation to treating epilepsy. Rockstroh et al (1993; cited in Monderer, Harrison and Haut, 2002) looked at self-regulation of slow cortical potentials at time of investigation and at a one-year follow up. Rockstroh et al (1993; cited in Monderer, Harrison and Haut, 2002) found that participants that were successful at modifying slow cortical potentials had a significant reduction in seizures. This would suggest that self-regulation of slow cortical potentials is an effective treatment for epilepsy, however subsequent research found that when other variables were also tested alongside self-regulation it was not such a prominent factor. Strehl, Kotchoubey, Trevorrow and Birbaumer (2005) researched the possibility of using the management of brain potentials to reduce the frequency of seizures in patients who are unresponsive to drug treatment. They suggest that negative slow cortical potential changes in the brain assist paroxysmal activity, and that the suppression of negative cortical responses is correlated with constrained epileptic discharge. By using a psycho physiological biofeedback technique along with assessment of other factors, such as personality variables and cortical excitability, Strehl et al (2005) examined 34 participants. They found that despite a reduction of seizure frequency in the majority of participants, the outcome may be more to do with factors other than EEG biofeedback and neuropsychological tests. Strehl et al (2005) propose that the participants who had a significant reduction in seizure frequency did not have large negative slow cortical potentials at the beginning of training, and show high levels of stress, epileptic focus and score low on life satisfaction measures.
Another psycho physiological biofeedback technique that has been considered as a treatment for epilepsy is sensorimotor rhythm biofeedback. Tozzo, Elfner and May, Jr. (1988) looked at young patients who had previously been resistant to
treatment for their epilepsy. Sensorimotor rhythm refers to the 12- to 20-Hz frequency found over the sensorimotor cortex during behaviour inhibition. Studies have shown that control of this rhythm is obtainable, and that this is significant for epileptics because seizures are thought to be accompanied by disruption to this rhythm. Being able to teach patients to gain control over their sensorimotor rhythm could result in significant reductions in the frequency of seizures. Tozzo, Elfner and May, Jr. (1988) tested epileptic participants using a multiple baseline design that incorporated a sensorimotor rhythm biofeedback technique. They found that all the participants were able to increase the time they spent in sensorimotor rhythm, and that a good proportion of participants saw a reduction in seizures. Lantz and Sterman (1988) also carried out a research investigation using sensorimotor rhythm biofeedback to treat unresponsive epilepsy. Lantz and Sterman (1988) found that by enhancing 11- to 15-Hz frequencies and decreasing 0- to 5-Hz and 20- to 25-Hz, the participants obtained a significant reduction in seizure frequency.
There are many different types of psycho physiological biofeedback techniques that have been researched as an alternative treatment for epilepsy, and the majority have shown promising results. There are some methodological problems that need to be considered for future research, especially in the case of slow cortical potential self-regulation. Large sample sizes have not often been used, and the unfortunate fact that these techniques are time consuming means that they are difficult to carry out and replicate. However for those epileptics that have not found help form drug treatments the development of biofeedback techniques is invaluable. As in the case of the majority of research utilising the sensorimotor rhythm method, the studies are over ten years old and therefore do not reflect the advancement in technology since. More accurate methods of obtaining biofeedback are currently available, and if this method of treatment is to be more extensively tested new technology should be used.
Critchley, H.D, Melmed, R.N, Featherstone, E., Mathias, C.J. and Dolan, R.J. (2001). Brain activity during biofeedback relaxation: A functional neuroimaging investigation. Brain, 124, 1003-1012.
Goldstein, L.H. (1997). Effectiveness of psychological interventions for people with poorly controlled epilepsy. Journal of neurology, neurosurgery and psychiatry, 63, 137-142.
Lantz D, and Sterman, M.B. (1988) Neuropsychological assessment of subjects with uncontrolled epilepsy: effects of EEG feedback training. Epilepsia, 29, 163-171.
Monderer, R.S, Harrison, D.M. and Haut, S.R. (2002) Neurofeedback and epilepsy. Epilepsy and behaviour, 3, 214-218.
Nagai, Y, Goldstein, L.H., Fenwick, P.B.C. and Trimble, M.R. (2004) Clinical efficacy of galvanic skin response biofeedback training in reducing seizures in adult epilepsy: a preliminary randomised controlled study. Epilepsy and behaviour, 5, 216-223.
Puskarich, C.A, Whitman, S, Dell, J, Hughes, J, Rosen, A.J, and Herman, B.P. (1992). Controlled examination of progressive relaxation training of seizure reduction. Epilepsia, 33, 675-680.
Strehl, U., Kotchoubey, B., Trevorrow, T. and Birbaumer, N. (2005) Predictors of seizure reduction after self-regulation of slow cortical potentials as a treatment of drug-resistant epilepsy. Epilepsy and behaviour, 6, 156-166.
Tozzo, C.A., Elfner, L.F. and May, Jr. J.G. (1988). EEG Biofeedback and relaxation training in the control of epileptic seizures. International journal of psychophysiology, 6, 185-194.
(NMC, 2015) that identifies to the skill of therapeutic communication. This essay will look at two issues identified in the Code: use a range of verbal and non-verbal communication methods, and consider cultural sensitivities, to better understand and respond to peoples personal and health needs and take reasonable steps to meet people’s language and communication needs, providing, wherever possible, assistance to those who need help to communicate their own or other people’s needs. This article will look at two issues identified in the Code. The Compassion in Practice policy document (Commissioning Board et al., 2012) identified communication as one of the 6Cs.
If you need assistance with writing your assignment, our professional assignment writing service is here to help!
According to (Russel 2010), therapeutic communication is a type of psychotherapy that uses vocal and non-verbal skills, which is in line with the practice whereby the nurse assists the client to a better understanding through verbal or nonverbal interaction (Mosley’s Medical Dictionary, 2009). However therapeutic communication like any other communication has its pros and cons as it is an exchange of information, thoughts and feelings. Failure to notice the two-way communication way often lead to negative conclusion and attitudes.
Peplau (1952) expressed that effective interpersonal skills are fundamental to mental health nurse’s ability to form a full therapeutic alliance and to the role of mental health nurses.
The importance of therapeutic communication in mental health nursing is that for gaining rapport with patients. Nurses should show openness, warmth, smile and are welcoming to patients as this approach may have a positive attitude from patients. As indicated by (Brown et al., 2009) another point is the patient safety and the ability to have trust and that information will be protected at times of vulnerability, which determines the level of disclosure. Nurses have a duty of care and will always keep patient’s information private and confidential. Therapeutic communication is a crucial intervention in a mental health setting, for the building of nurse client relationship, for exploring fundamental approach for patients about themselves and their illnesses (Morrissey and Callaghan, 2011). Communication is therapeutic and building relationships are the cornerstone of nursing work.
Friends and family members of patients can communicate in a therapeutic manner and the ideal exchange provides the patient with confidence to play an active role in their care. The development of trust is the most important characteristic of a therapeutic relationship. Trust facilitates communication, and this encourages confidence and autonomy. Being non-judgemental is important in verbal and non-verbal communication. People are accurately at identifying non-verbal signs that may communicate something very different from what is said. Therapeutic communication emphasizes a holistic view of a person and his network of people who provide support.
Banar (2012) indicated that the impact of therapeutic communication encourages client’s autonomy, stresses a holistic view of a person, communicate that nurse is here to listen, help and plan for the betterment. In contradicting, non -therapeutic communication (Morrissey and Callaghan 2011) argued that a patient’s dignity and care is not the priority which makes patients feeling disregarded and not valued. Patients will react by having behaviours as also the environment can be busy and challenging. Language can be a barrier, stereotyping, judgemental attitudes and stigmatisation as these all add up to the mental health issues.
The Nursing and Midwifery Council (2015) states that nurses must be able to communicate clearly and 7.3 states that use a range of verbal and non-verbal communication methods, consider cultural sensitivities, to better understand and respond to people’s personal health needs. Communication is critical in nursing because it is how people influence the behaviour of others, leading to the successful outcome of nursing intervention (Benbenishty and Hannink 2015). Studies from (Benbenishty and Hannink 2015) went on to acknowledge that communication comprises of verbal and non-verbal elements and psychologists specialising in communication often use a 55/38/7 formula, which considers communication to be 55% body language, 38% voice tone and 7% spoken words.
Verbal communication is spoken and written word. Verbal communication includes sentence construction, the content, the context, the surrounding, time, the physical, social, emotional and cultural environment. It is also handwritten letters, printed tabloids, emails and text messages.
Non-verbal communication forms the communication that supports or reinforces the spoken message. Non-verbal communication occurs where there is no speech and includes a smile, factual expression, or the manner of look. It has been approximately thirty years since Egan (1975) introduced his acronym SOLER as an aid for teaching and learning about non-verbal communication. (Egan,2002 as cited by Jootun and McGhee 2011), used the acronym SOLER which stands for sit facing the patient, maintain an open stance, learn forward to some extent, keep eye contact and adopt a comfortable position when involved in non-verbal communication. There is evidence that the SOLER framework has been widely used in nursing with little published critical appraisal. A new acronym that might be appropriate for non-verbal communication skills is proposed and this is SURETY which stands for, sit at an angle, Uncross legs and arms, Relax, Eye contact, Touch, Your Intuition. The new model advances the SOLER model by including the use of touch and the importance of individual intuition is emphasised. The model encourages nurses to think about therapeutic space when they take part in non-verbal communication. The SURETY model is designed to benefit nurses to communicate empathic skills for non-verbal communication hopefully, in an autonomous way than Egan originally proposed. In other cultures, like Moslem culture eye contact can be perceived as adultery. As for touch people with learning disabilities are very cautious with personal space and as with people who have been abused this will bring back memories and flash backs.
However (Stickley and Stacey, 2009), described the skill as a caring relationship in mental health nursing. Nurses need to be aware that their approach to patients will influence the way they respond to them. Listening and non-verbal communication, therefore, form an important part of the nurse–patient interaction and they are skills that require effort and discipline. Non-verbal communication is one of the concepts that suggest mental health problems can cause clients to become easily upset or lead them to misinterpret non-verbal behaviour. Nurses therefore should be aware of their own body signals and use these appropriately within a helping context, to create a rapport with the client. Patients responded positively to a quiet approach and silent communication. Certainly, the use of non-verbal communication through silence, facial expression, touch and close physical proximity appeared to facilitate active listening, and help to develop empathy, intuition and presence between the nurse and patient. Quietly being with patients and communicating non-verbally is an effective form of communication. It is suggested that effective communication dependents on the nurse’s ability to listen and utilise non-verbal communication skills. (Stickley and Freshwater, 2009:28) argued that for the preservation of therapeutic space and practice nurses should shifting from providing a therapeutic space to one that is more technical, driven by outcomes, policy and external formulaic objectives that attempt to measure efficacy. However, what needs to be created by non-verbal communication, is a therapeutic space where the patient experiences psychological safety and an opportunity to openly communicate with the nurse. Nurses can often take up too much space in their practice and not enough consideration is given to the space between people (interpersonal space). Rather, the focus appears to be more upon how this space can be filled with interventions and treatments, assessments and care plans. Non-verbal communication is about becoming aware of how we behave in the interpersonal space and deliberately creating an environment where space becomes therapeutic and not oppressive. Nurses who possess self-awareness and are skilled in effective communication practices are integral to the provision of non-verbal communication to patients and families.
Both verbal and non-verbal communication skills are essential to the development of rapport between patients and nurses. Verbal and non-verbal communication can be difficult to observe and interpret at times. (Trenholm and Jensen 2008) stated that by comparison of the two, non-verbal communication can be more difficult to interpret than verbal communication. People differ remarkably in their judging, understanding and using and non-verbal clues. People can construe/ interpret in different ways which mean different meanings to different people, them seems not to be any consistency in clinical areas as health-care professional will give conflicting information to patients.
Rogers (1961) developed the person-centred approach and the emphasis was on holism, the need to study the whole person. This was client -centred trust in the sense that clients would understand their world best, they have inner resources, listen to them, understand their world and respond to that. (Rogers 1961) went on to identify some core skills working with patients. Genuineness which is openness and honesty in communication and notwithstanding the need to suppress emotion. This does however not give one’s authority to one’s feelings without considering the impact that it may have. (Shea 1998; p.31-2) suggested that genuineness is frequently marked by three characteristics in the clinic which are spontaneity, awareness and consistency. Unconditional positive regard is about accepting a service user who has a right to care and treatment regardless of what they have done.
Our academic experts are ready and waiting to assist with any writing project you may have. From simple essay plans, through to full dissertations, you can guarantee we have a service perfectly matched to your needs.
Active listening is using therapeutic silence and observe verbal and non-verbal signals and behaviours during communication procedure. (Mineyama, Tsutsumi, Takao, Nishiuchi, and Kawakami, 2007; p81) describe active listening as a way of listening and responding to another person, which improves mutual understanding. The authors claim that active listening can be used to improve client-nurse relationships. The essential components of active listening are paying attention to detail, listening ability and attitude. Attitude refers to person-centred attitude based on empathy, congruence and unconditional positive regard. Listening includes replies and answers and the way of promoting conversation. (Mineyama et al. 2007) found that nurses who possess listening attitude and skills adopted to improved communication with work mates and increase the patients’ awareness that they are cared for. Effective communication is related to a perception of “favourable working conditions” and decreased psychological stress among workers. In addition, the listening attitude is associated with an increased sense of autonomy among nurses. The medical professional should be trained in the skills of active listening, and that such training may include discussion and role-playing in order for the participants to become competent and effective listeners. The use of silence and careful observation in understanding the sense of service user’s communication by nurses, demonstrates to the client the nurse’s willingness to understand the client’s needs. A non-judgemental approach is about the listener adopting a set of attitudes and using listening skills, verbal and non-verbal that allow the listener to hear and understand exactly what is being said and enable the person to talk freely and comfortably about problems without feeling being judged. Being non-judgemental makes people more likely to be honest, with less hostile conversation and can open their mind to other people’s thoughts and viewpoints.
Empathy is a key component of the rapport between patient and nurse and is observable and teachable skill that nurses can learn (Oscan et al. 2010) whilst (Rogers 1967:34) clarifies empathy as an ability to feel a continuing desire to understand and identifies empathy as a deep empathic understanding. Empathy is a skilled behaviour that can be learned and developed through education and practice. (Rogers 1961) also identified warmth as one of the core skills when working with patients with mental health issues. It may be right to disclose personal situation to demonstrate empathy however it can be imperative that the disclosure may not benefit to the client, rather a situation a nurse is finding difficult. At times nurses are dismissive or devaluing to patient’s experience rather than supporting them. There are also barriers and challenges to empathy. Nurses put a lot of pressure on themselves by trying to get things right and saying the perfect things and in so doing putting the biggest barrier to empathy. Empathy is hard to implement where patient turnover is quick and (Reynolds et al 2000) argued that lack of time, trust, privacy and support from work mates present barriers and challenges to empathy.
Roger’s nurse/client relationship to the level of a loving relationship, opened him up to the charge of demeaning psychotherapy in the view of some other professionals. A criticism of the client -centred therapy was that it is reasonably effective with less severe disorders but ineffective with severe mental health disorders (Eysenck 2009, p.27). Although Rogers did a lot of research with schizophrenia he never claimed that his theories were effective with those with serious mental health issues. (Halgin and Krauss Whitbourne 2009) also criticised the effectiveness of the client – centred approach for lacking some fundamental requirements of scientific approach and lacking scientific analysis.
According to the Oxford English Dictionary, diversity is “the condition of being diverse, different, or wide-ranging, difference, and unlikeness”, whilst (Mannix and Neale, 2005, p 31) defined diversity as “any trait that someone else may use to notice individual dissimilarities”. However, “diversity” proposes multidimensional judgements, reactions, thoughts, sentiments, and activities, some of which could have unfavorable social and wellbeing outcomes for health. Idealists claim that diversity will result in rising in the variety of sensitivities as patients contribute in challenging explanations. Unfortunately, there is more evidence to support the pessimists’ view that diversity “creates social divisions, which in turn create negative performance outcomes for the group” (Mannix &Neale, 2005, p.31).
The government introduced the Equality Act 2010 which makes decisions and has a duty to take into account the need to: eliminate discrimination, harassment and victimization advance equality of opportunity ,foster good relations between different parts of the community .This characteristics protected under the act are : age, disability, gender reassignment, marital or civil partnership status, pregnancy and motherhood, race (including ethnic or national origin, colour and nationality), religion or belief (including lack of belief), sex and sex orientation .
However, in relation to black and minority ethnic (BME) communities, the recent Count Me In census (Care Quality Commission 2010) shows that there is still inequalities and racism and it is still a long way to go. Black and ethnic minority people are still being discriminated, stereotyped even though there are all these government policies.
Lesbian, gay, bisexual and transgender (LGBT) people are vulnerable and disliked due to prejudiced attitudes amongst various and groups in society (Department of Health, 2008). However, it can be argued that people who identify as transgender experience these problems most because their acceptance is behind that of who are lesbian, gay and bisexual. In the United Kingdom the population of transgender is roughly between 65,000 to 300,000 (DH, 2008). To ascertain the level and nature of discrimination, inequality and social exclusion faced by the transgender community it is important to find the measures (DH, 2008). Although gender reassignment is protected in the UK by the Equality Act 2010, transgender healthcare staff and patients continue to experience discrimination, abuse and bullying (Somerville, 2015). Lack of clinical guidance implies that transgender needs are not considered, which has a negative effect on the value of the support provided.
The important part of a child development is the understanding of the language and how they communicate depends on age and stage of development. Children continue to develop their verbal ability throughout childhood although the main part takes place between birth and up to five years. Babies communicate their needs by crying and they also quickly discover how to communicate their pleasure through smiles and laughter. Older children will communicate not just through words but by the choice of clothes, choice of music and preferred leisure activities. (Bee 2000) suggested that bilingual child may be slower to verbalise than their monolingual peers, possibly in mixing words or grammar from the different languages but they catch up fast. Children are vulnerable when receiving healthcare and more care is needed with communication and getting information. Effective communication is built by being mindful that differences exist and reading a child’s parents body language can often tell more than their verbal response about how effective our communication with them has been. When looking after children from diverse cultural backgrounds remember that facial gestures, speech intonations and body language communicate more than the words you say. Care and concern can be conveyed in the absence of language.
The Disability Discrimination Act 2005 requires all public organizations to promote equality of opportunity between disabled persons and the other persons and eliminate discrimination. This means that people with disabilities must be offered services according to their needs, even offering them more than compared to people without disabilities (Disability Rights Commission 2005:2 .13). It is vital to identify that communication aids are important to deliver good healthcare and should be made available.
- Mosby’s Medical Dictionary, 8th edition. 2009 Elsevier
- Benbenishty J, Hannick, J 2015 Non-verbal communication to restore patient-provider trust. Intensive Care Medicine 41(7):1359
- Commissioning Board, Chief Nursing Officer and Department of Health Chief Nursing Adviser (2012) Compassion in Practice. Available online at www.commissioningboard.nhs.uk (accessed 23 October 2013)
- Nursing and Midwifery Council (NMC) 2015 The Code: Professional standards of practice and behaviour for nurses and midwives. NMC, London
- Trenholm, S., and Jenson, A. (2008). Interpersonal communication (6th ed.). New York: Oxford University
- Oscan CT, Oflaz F, and Sutcu Cicek H (2010) Empathy: the effects of undergraduate nursing education in Turkey. International Nursing Review 57, 493-499.
- Rogers C (1961) On Becoming a Person. Boston, MA: Houghton Mifflin.
- Egan, G., (1975). The Skilled Helper: A Systematic Approach to Effective Helping. Pacific Grove CA, Brooks/Cole.
- Stickley and Freshwater, 2009, T. Stickley, D. Freshwater, The concept of space in the context of the therapeutic relationship
- Mental Health Practice, 12 (6) (2009), pp. 28-30, CrossRefView Record in Scopus
- Mineyama, S., Tsutsumi, A., Takao, S., Nishiuchi, K., & Kawakami, N. (2007). Supervisors’ attitudes and skills for active acting regarding working conditions and psychological stress reactions among subordinate workers. Journal of Occupational Health, 49, 81-87. https://www.rethink.org/about-us/equality-and-diversity-vision-statement
- Care Quality Commission (2010) Count Me in Census 2010. CQC, London
- Department of Health (2008) Trans: A Practical Guide for the NHS.
- Somerville C (2015) Unhealthy Attitudes: The Treatment of LGBT People within Health and Social Care Services.
- Heron J (1989) Six –Category Analysis, ((3rd end). Human Potential Recourse Group, University of Surrey, Surrey, UK.
- Stickley 2009, T. Stickley, G Stacey, “Caring: the essence of mental health nursing
- Bee H (200) The Developing Child (9th edition). Boston, Allyn , and Bacon.