IMPROVE HOSPITAL STAFF CULTURE, WELL-BEING & HOSPITAL FINANCES…
We make it simple to convert your culture…
- Kim Byrd-Rider travels to your hospital facility for all needed training, meetings and assessments.
- Software is provided for outcome measurement data collection.
- All mindful education materials are provided including power-points, videos and hardcopy.
The program is technology and video based, so no additional hospital employees nor mindful teachers need to be employed.
Brief Program Timeline
The Byrd Rider Rehab mindfulness hospital staff culture conversion consists of three phases over approximately a six month period. The lengthy time period ensures slow but sustainable staff buy-in. The first phase uses a sample size of 10-20 hospital staff supervisors for a six week application the Mindfulness Minute Intervention.
If successful, the second phase takes the Mindfulness Minute Intervention to every department of the hospital and includes outcome measurements before and after this second six week program. The outcome measurement tools provide information and support for continuing to phase three. If phase two is successful, phase three is the implementation of technology based mindfulness break-rooms with hospital staff incentives. In phase three tai chi, yoga and longer meditation interventions are added.
This is a very abbreviated overview. For detailed information, peer-reviewed evidence and hospital set up/implementation costs, please contact us at…
Email for Dr. Byrd-Rider: email@example.com
To view the entire 47 page literature by Dr. Kim Byrd-Rider, click here to go to Research Gate.
Abstract of Literature Review
Why Change Hospital Staff Culture? It is in Crisis.
How can hospital staff produce patient health when they don’t have mental or physical health themselves? America’s hospital staff have an abundance of health knowledge (ensured by the medical licensure process) with low level quality patient care application skills (Garthwaite, Gross, & Notowidigdo, 2018). The lack of health application skills is evident by the current poor state of hospital quality of patient care scores. (Garthwaite, Gross, & Notowidigdo, 2018). The staff mental is a major culprit. The staff cannot be blamed for their working conditions. People are extremely sick, needy and drugged all around them. Their working conditions cannot be changed. but the staff can be equipped with tools to combat those conditions.
Staff Mindlessness Epidemic
The current state of hospital staff health is congruent with an interceding state of mindlessness as described by Dr. Ellen Langer of Harvard University psychology department (2012). Without mindful training, the alternative is mindlessness which is the natural and common human mind state (Langer, 2012). Mindlessness is an inactive state of mind characterized by reliance on distinctions drawn from the past (Langer, 2012). In mindlessness, the past over-determines the present and one is trapped in a single perspective which is not context driven. Rules and routines govern one’s life. Mindless awareness people error frequently in recall but rarely doubt themselves (Langer, 2012).
Current Poor Hospital Staff Mental Health
Many hospital employees operate under some level of post-traumatic stress disorder (PTSD) due to their hospital job. An average of 40% of U.S. nurses meet the diagnostic criteria for PTSD (Mealer, Burnham, Goode, Rothbaum, & Moss, 2009). Long-hours, under-staffing and poor stress coping skills escalate job burnout, fatigue and poor health, which are ever-present risk factors prohibiting hospital staff from producing quality patient care (Mealer, et al., 2009). Hospital employees experience the third largest amount of workplace violence in the nation (King, Angstadt, Sripada, & Liberzon, 2017). Hospital staff receive 10% of all workplace verbal and physical abuse (King, et al., 2017).
Workplace violence affects job performance, job productivity, job moral, job retention and job satisfaction (King, et al., 2017). As an example of the amount and kind of stressors hospital staff undergo in one year, a study by Speroni and colleagues (2014) explains that 76% of hospital nurses experience violence with emergency department nurses at 88.1%. The perpetrators are primarily 26-35-year-old white makes who are confused or influenced by drugs or alcohol (Speroni, Fitch, Dawson, Dugan, & Atherton, 2014). Events such as shouting, swearing, grabbing, scratching and kicking occur (Speroni, Fitch, Dawson, Dugan, & Atherton, 2014). Reported abuses are believed to be under-reported due to hospital employee justifications for their patients’ and visitors’ behavior (King, et al., 2017).
The stressed relationship problem between the staff and the patients/visitors ultimately fans out into a financial drain for the hospital with a loss of quality-based insurance reimbursements (Garthwaite, Gross, & Notowidigdo, 2018). Hospital staff continue to work with poor mental and physical health and no resolution is in sight (Mealer, 2009), to the detriment of hospital sustainability. Potential hospital financial sustainability may come in the form of a trans-disciplinary approach of mind, brain, health and education for a mindful hospital program.
Hospital Finances Affected by Poor Staff Mental Health
Compounding the hospital staff well-being problem, insurance companies mandate quality patient care measurement systems. Programs such as value-based purchasing for federal insurance incentives pay hospitals for quality patient care (Barnes, Oner, Ray, & Zengul, 2018). Pay for performance is a system where the amount of insurance payments for services is congruent with measurable positive patient outcomes (Barnes, et al. 2018). Also, accountable care organizations are forming among doctors and hospitals where high quality patient care and wise spending provide sharing the savings with insurance companies (Barnes, et al., 2018). These are just a few quality care reimbursement tools implemented by federal and private insurance companies which increase or decrease hospital reimbursements (Barnes, et al., 2018). Value-based purchasing alone can penalize a hospital up to 2% of reimbursements and pay for performance can nullify a whole reimbursable patient case for certain departments (Barnes, et al., 2018).
Mindfulness programs improve hospital staff performance by improving staff well-being, improving patient quality care, decreasing staff mindlessness and decreasing staff cynicism. In turn, these results fiscally improve hospitals by increasing hospital insurance reimbursements and decreasing job turnover costs. These two financial factors plus the humanistic desire to improve the health of their staff provide hospital motivation to spend money and dedicate time to develop a mindfulness workplace culture. Changing hospital cultures to reflect health instead of post-traumatic stress disorder type anxieties and ensuring hospital financial sustainability for the future is the expanded extent of implementing mindfulness programs for improved staff performance.
The hospital system’s weak link is the condition of the staffs mental and physical well-being which is decreasing the staff’s performance level. The answer to the attached literature review (the link is at the end of this abstract) research question (How and to what extent do mindful awareness and mindful concentration programs improve hospital staff performance?) is anextremely important one. Two large systematic reviews (Glomb, et al., 2011; Good, et al., 2016), plus six additional studies listed in this paper’s literature review, establish worker performance improves with mindful programs as well as improved physical/psychological well-being and relationship quality. Not only is hospital staff performance important to patient quality care and hospital sustainability but job performance positively correlates toa staff member’s quality of life(Glomb, et al., 2011; Good, et al., 2016).
Mindfulness hospital models built on unified evidence from the fields of mind, body, brain and education are rare due to the need to analytically overlap different scientific fields. Currently in hospitals, mindful practices are considered a personal choice activity, like running or camping (Duggan, & Julliard, 2018). Healthy extra-curricular activities are encouraged by hospital administrations to their staff but are rarely wired into the daily workplace system to ensure execution (Duggan, & Julliard, 2018). Hospital administrations may not have examined how consistently positive the meta-analyses’ evidence is throughout the scientific fields.
All four fields of mind, body, brain and education are heavily and consistently presenting the same positive outcomes from mindfulness programs. Mental improvements are heavily documented in a 19 study meta-analysis (n= 1,1815) for mindfulness program and recommends implementation (McConville, et al., 2017). Physical improvements are also heavily documented in meta-analyses for mindfulness program benefits (Bibevski & Dunlap, 2011; Brittenden, et al., 1996; Diego, et al., 2004). Neuroimaging meta-analyses backup the other fields with evidence of physiological brain improvements with mindfulness; one using 78 studies and 527 participants (Fox, et al., 2016) and another using 21 studies and 300 participants (Fox, et al., 2014). A plethora of research has been focused on mindful techniques (Van Dam, van Vugt, Vago, Schmalzl, Saron, Olendzki, … & Fox, 2018) with little application to hospital work settings (Duggan & Julliard, 2018). There is sufficient evidence to support large-scale implementation of mindfulness practices.
Healthcare workers are also community health consultants, shoppers, car drivers, volunteers, husbands, wives, daughters, sons, friends and even parents. They participate in multiple aspects of their communities and there are over 12.5 million healthcare workers in the United States (Henry J. Kaiser Family Foundation, 2015). They live in almost every town in America. If mindful programs improve healthcare workers’ mental and physical health, it would affect everyone around them, not just themselves and their patients (Glomb, et al., 2011; Good, et al., 2016). The profound and significant positive mind, brain, health and education results found in this review of the literature have the potential to carry over into their private lives, improving not only the hospital culture but the American culture. To take this one step further, American culture influences world cultures.
To view the entire 47 page literature by Dr. Kim Byrd-Rider, click here to go to Research Gate.
For more information, peer-reviewed evidence and hospital set up/implementation costs, please contact us at…
Email for Dr. Byrd-Rider: firstname.lastname@example.org
Abraham R. (2000). Organizational cynicism: bases and consequences. Genetic, Social, and General Psychology Monographs 126, 269–292.
Barnes, M., Oner, N., Ray, M. N., & Zengul, F. D. (2018). Exploring the association between quality and financial performance in U.S. hospitals: A systematic review. Journal of Health Care Finance, 1-32.
Bibevski, S., & Dunlap, M. E. (2011). Evidence for impaired vagus nerve activity in heart failure. Heart Failure Reviews, 16, 129–135.
Boersma, K., & Lindblom, K. (2009). Stability and change in burnout profiles over time: a prospective study in the working population. Work & Stress 23, 264–283.
Brittenden, J., Heys, S. D., Ross, J., & Eremin, O. (1996). Natural killer cells and cancer. Cancer, 77(7), 1226-1243.
Brown, K. W., Ryan, R. M., & Creswell, J. D. (2007). Mindfulness: Theoretical foundations and evidence for its salutary effects. Psychological Inquiry, 18(4), 211-237.
Byron, G., Ziedonis, D. M., McGrath, C., Frazier, J. A., & Fulwiler, C. (2015). Implementation of mindfulness training for mental health staff: Organizational context and stakeholder perspectives. Mindfulness, 6(4), 861-872.
Canadian Nurses Association (2009). Tested solutions for eliminating Canada’s registered nurse shortage. Ottawa, Canada: Canadian Nurses Association. Downloaded 4 April 2018 from https://www.cna-aiic.ca/en/news-room/news-releases/2009/eliminating-canadas-rn-shortage
Castaneda, R. (2016). Where can undocumented immigrants go for healthcare? US News World Report. Downloaded on 15 March 2018 from https://health.usnews.com/wellness/articles/2016-11-02/where-can-undocumented-immigrants-go-for-health-care
Centers for Medicare and Medicaid Services (2018). National health expenditure fact sheet. National Health Expenditure Data. Downloaded on 15 March 2018 from https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html
Commonwealth Fund Biennial Health Insurance Survey (2017). The problem of underinsurance and how rising deductibles will make it worse. The Commonwealth Fund. Downloaded on 15 March 2018 from http://www.commonwealthfund.org/publications/issue-briefs/2015/may/problem-of-underinsurance
Couck, M. D., Marechal, R., Moorthamers, S., Laethem, J. L., & Gidron, Y. (2016). Vagal nerve activity predicts overall survival in metastatic pancreatic cancer, mediated by inflammation. Cancer Epidemiology, 40, 47-51.
Dane, E., & Brummel, B. J. (2014). Examining workplace mindfulness and its relations to job performance and turnover intention. Human Relations, 67(1), 105-128.
Diego, M. A., Field, T., Sanders, C., & Hernandez-Reif, M. (2004). Massage therapy of moderate and light pressure and vibrator effects on EEG and heart rate. International Journal of Neuroscience, 114(1), 31-44.
Duggan, K., & Julliard, K. (2018). Implementation of a mindfulness moment initiative for healthcare professionals: Perceptions of facilitators. Explore: The Journal of Science and Healing, 14(1), 44-58.
Falcone, G., & Jerram, M. (2018). Brain activity in mindfulness depends on experience: a meta-analysis of fMRI studies. Mindfulness, 1-11.
Fox, K. C., Dixon, M. L., Nijeboer, S., Girn, M., Floman, J. L., Lifshitz, M., … & Christoff, K. (2016). Functional neuroanatomy of meditation: A review and meta-analysis of 78 functional neuroimaging investigations. Neuroscience & Biobehavioral Reviews, 65, 208-228.
Fox, K.C., Nijeboer, S., Dixon, M., Floman, J.L., Ellamil, B., Rumak, R., … & Christoff, K. (2014). Is meditation associated with altered brain structure? A systematic review and meta-analysis of morphometric neuroimaging in meditation practitioners. Neuroscience and Biobehavioral Reviews, 43, 48-73.
Garthwaite, C., Gross, T., & Notowidigdo, M. J. (2018). Hospitals as insurers of last resort. American Economic Journal: Applied Economics, 10(1), 1-39.
Glomb, T.M., Duffy, M. K., Bono, J. E., & Yang, T. (2011). Mindfulness at work. Research on Personnel Human Resources Management, 30, 115.
Good, D. J., Lyddy, C. J., Glomb, T. M., Bono, J. E., Brown, K. W., Duffy, M. K., … & Lazar, S. W. (2016). Contemplating mindfulness at work: An integrative review. Journal of Management, 42(1), 114-142.
Harvard Medical School. (2008). Now and Zen. Longwood Seminar, 2008. Downloaded on 12 March 2018 from https://youtu.be/9MYvhJsmggA
Henry J. Kaiser Family Foundation (2015). Total healthcare employment. Henry J. Kaiser Family Foundation. Downloaded on 19 March 2018 from https://www.kff.org/other/state-indicator/total-health-care-employment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
Hernandez-Reif, M., Field, T., Ironson, G., Beutler, J., Vera, Y., Hurley, J., … & Hernandez-Reif, M. (2005). Natural killer cells and lymphocytes increase in women with breast cancer following massage therapy. International Journal of Neuroscience, 115(4), 495-510.
Hernandez-Reif, M., Ironson, G., Field, T., Hurley, J., Katz, G., Diego, M., … & Burman, I. (2004). Breast cancer patients have improved immune and neuroendocrine functions following massage therapy. Journal of Psychosomatic Research, 57(1), 45-52.
Hölzel, B. K., Carmody, J., Vangel, M., Congleton, C., Yerramsetti, S. M., Gard, T., & Lazar, S. W. (2011). Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Research: Neuroimaging, 191(1), 36-43.
Hsia, R. Y. J., & Shen, Y. C. (2011). Rising closures of hospital trauma centers disproportionately burden vulnerable populations. Health Affairs, 30(10), 1912-1920.
Huang, I., Chuang, C., & Lin H. (2003). The role of burnout in the relationship between perceptions of organizational politics and turnover intentions. Public Personnel Management, 32, 519–531.
Hülsheger, U. R., Alberts, H. J., Feinholdt, A., & Lang, J. W. (2013). Benefits of mindfulness at work: the role of mindfulness in emotion regulation, emotional exhaustion, and job satisfaction. Journal of Applied Psychology, 98(2), 310.
Hyland, P. K., Lee, R. A., & Mills, M. J. (2015). Mindfulness at work: A new approach to improving individual and organizational performance. Industrial and Organizational Psychology, 8(4), 576-602.
Jang, J. H., Jung, W. H., Kang, D. H., Byun, M. S., Kwon, S. J., Choi, C. H., & Kwon, J. S. (2011). Increased default mode network connectivity associated with meditation. Neuroscience Letters, 487(3), 358-362.
Jongman-Sereno, K. (2017). Personality and self-knowledge. Cambridge, MA: Harvard University, Psychology, E-1707.
Kabat-Zinn, J. (2013). What is mindfulness?.
(5:17). Downloaded 3 March 2018 from https://www.youtube.com/watch?v=HmEo6RI4Wvs
Kalyani, B., Venkatasubramanian, G., Arasappa, R., Rao, N., Kalmady, S., Behere, R., … & Gangadhar, B. (2011). Neuro-hemodynamic correlates of ′OM′ chanting: A pilot functional magnetic resonance imaging study. International Journal of Yoga, 4(1), 3-6.
Kang B., Twigg N.W. & Hertzman J. (2010). An examination of social support and social identity factors and their relationship to certified chefs’ burnout. International Journal of Hospitality Management, 29, 168–176.
Kayser, C., & Shams, L. (2015). Multisensory causal inference in the brain. PLoS biology, 13(2), e1002075.
Kelloway, E. K., Gottlieb, B. H., & Barham, L. (1999). The source, nature, and direction of work and family conflict: A longitudinal investigation. Journal of Occupational and Health Psychology 4(4): 337–346.
Kim, T. Y., Bateman, T. S., Gilbreath, B. & Andersson, L. M. (2009). Top management credibility and employee cynicism: a comprehensive model. Human Relations, 62, 1435–1458
King, A., Angstadt, M., Sripada, C., & Liberzon, I. (2017). Increased default mode network (DMN) connectivity with attention networks with a mindfulness-based intervention for PTSD: seed and whole brain connectomics analyses. Biological Psychiatry, 81(10), S43-S44.
Kok, B. E., Coffey, K. A., Cohn, M. A., Catalino, L. I., Vacharkulksemsuk, T., Algoe, S. B., … & Fredrickson, B. L. (2013). How positive emotions build physical health perceived positive social connections account for the upward spiral between positive emotions and vagal tone. Psychological Science, 24(7), 1123-1132.
Lamprecht, R., & LeDoux, J. (2004). Structural plasticity and memory. Nature Reviews Neuroscience, 5(1), 45.
Langer, E.J. (2012). Counterclockwise: the power of possibility.
(25:23). Downloaded on 18 March 2018 from https://www.youtube.com/watch?v=fZffBAefwUM
Leroy, H., Anseel, F., Dimitrova, N. G., & Sels, L. (2013). Mindfulness, authentic functioning, and work engagement: A growth modeling approach. Journal of Vocational Behavior, 82(3), 238-247.
Lindahl, J. R., Fisher, N. E., Cooper, D. J., Rosen, R. K., & Britton, W. B. (2017). The varieties of contemplative experience: A mixed-methods study of meditation-related challenges in western Buddhists. PloS One, 12(5).
Lucas, A. R., Klepin, H. D., Porges, S. W., & Rejeski, W. J. (2016). Mindfulness-based movement: a polyvagal perspective. Integrative Cancer Therapies, 1534735416682087.
Luchterhand, C., Rakel, D., Haq, C., Grant, L., & Byars-Winston, A. (2015). Creating a culture of mindfulness in medicine. Wisconsin Medical Society Journal, 114 (3), 105-109.
Luksyte, E., Spitzmeuller, C., & Maynard, D.C. (2011). Why do overqualified incumbents deviate? Examining multiple mediators. Journal of Occupational Health Psychology, 16, 279–296.
Magnon ,C., Hall, S. J., & Lin, J. (2013). Autonomic nerve development contributes to prostate cancer progression. Science, 341:1236361.
Mak, L. E., Minuzzi, L., MacQueen, G., Hall, G., Kennedy, S. H., & Milev, R. (2017). The default mode network in healthy individuals: a systematic review and meta-analysis. Brain Connectivity, 7(1), 25-33.
Mantler, J., Godin, J., Cameron, S. J., & Horsburgh, M. E. (2015). Cynicism in hospital staff nurses: The effect of intention to leave and job change over time. Journal of Nursing Management, 23(5), 577-587.
McConville, J., McAleer, R., & Hahne, A. (2017). Mindfulness training for health profession students—the effect of mindfulness training on psychological well-being, learning and clinical performance of health professional students: a systematic review of randomized and non-randomized controlled trials. Explore: The Journal of Science and Healing, 13(1), 26-45.
Mealer, M., Burnham, E. L., Goode, C. J., Rothbaum, B., & Moss, M. (2009). The prevalence and impact of post-traumatic stress disorder and burnout syndrome in nurses. Depression and Anxiety, 26(12), 1118-1126.
Reb, J., Narayanan, J., & Chaturvedi, S. (2012). Leading mindfully: two studies on the influence of supervisor trait mindfulness on employee well-being and performance. Mindfulness, 5(1), 36–45.
Reuter, M., Tisdall, M. D., Qureshi, A., Buckner, R. L., van der Kouwe, A. J., & Fischl, B. (2015). Head motion during MRI acquisition reduces gray matter volume and thickness estimates. NeuroImage, 107, 107–115.
Riley, K. E., & Park, C. L. (2015). How does yoga reduce stress? A systematic review of mechanisms of change and guide to future inquiry. Health Psychology Review, 9(3), 379-396.
Schaufeli, W. B., Salanova, M., González-Romá, V., & Bakker, A. B. (2002). The measurement of engagement and burnout: A two sample confirmatory factor analytic approach. Journal of Happiness Studies 3(1), 71–92.
Shin, L. M., & Liberzon, I. (2010). The Neurocircuitry of Fear, Stress, and Anxiety Disorders. Neuropsychopharmacology, 35(1), 169–191.
Shapiro, D. (1992). Adverse effects of meditation: a preliminary investigation of long-term meditators. International Journal of Psychosomatics, 39, 62-67.
Song, N., Liu, J., Proctor, M., & Yu, J. (2015). Right and left vagus nerves regulate breathing by multiplicative interaction. Respiratory Physiology & Neurobiology, 219, 25-29.
Speroni, K. G., Fitch, T., Dawson, E., Dugan, L., & Atherton, M. (2014). Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. Journal of Emergency Nursing, 40(3), 218-228.
Stanley, D. J., Meyer, J. P. & Topolnytsky, L. (2005). Employee cynicism and resistance to organizational change. Journal of Business and Psychology, 4, 429–459.
Sullivan, M. B., Erb, M., Schmalzl, L., Moonaz, S., Noggle Taylor, J., Porges, S. W., & Porges, S. W. (2018). Yoga therapy and polyvagal theory: the convergence of traditional wisdom and contemporary neuroscience for self-regulation and resilience. Frontiers in Human Neuroscience, 12, 67.
Thayer, J. F., & Sternberg, E. (2006). Beyond heart rate variability: Vagal regulation of allostatic systems. Annals of the New York Academy of Sciences, 1088, 361-372.
Thompson, D. (2017). Be ‘mindful’ of the hype; Scientists call for rigorous research to back up mindfulness marketing claims. Consumer Health News. Downloaded 4 April 2018 from https://consumer.healthday.com/alternative-medicine-information-3/meditation-news-467/be-mindful-of-the-hype-727395.html
University of New Mexico (2016). The cost of losing nurses. Downloaded 4 April 2018 from https://rnbsnonline.unm.edu/articles/high-cost-of-nurse-turnover.aspx
United States Census Bureau (2017). Health insurance coverage in the United States, 2016. Washington, DC: United States Census Bureau. Downloaded on 10 March 2018 from https://www.census.gov/library/publications/2017/demo/p60-260.html
Van Dam, N. T., van Vugt, M. K., Vago, D. R., Schmalzl, L., Saron, C. D., Olendzki, A., … & Fox, K. C. (2018). Mind the hype: A critical evaluation and prescriptive agenda for research on mindfulness and meditation. Perspectives on Psychological Science, 13(1), 36-61.
Van Dongen, J. M., Van Berkel, J., Boot, C. R., Bosmans, J. E., Proper, K. I., Bonges, P. M., … & Van Wier, M. F. (2016). Cost-effectiveness and financial return of a mindfulness-based worksite intervention aimed at improving work engagement: results of a randomized controlled trial. Journal of Occupational and Environmental Medicine, 58, 550-560.
Vanderkooi, L. (1997). Buddhist teachers’ experience with extreme mental states in western meditators. Journal of Transpersonal Psychology, 29, 31-46.
Waldman, J. D., Kelly, F., Aurora, S., & Smith, H. L. (2004). The shocking cost of turnover in health care. Health Care Management Review, 29(1), 2-7.
Wanous, J. P., Reichers, A. E., & Austin, J. T. (2000). Cynicism about organizational change: measurement, antecedents, and correlates. Group and Organization Management, 25, 132– 153.
Wei, G. X., Li, Y. F., Yue, X. L., Ma, X., Chang, Y. K., Yi, L. Y., … & Zuo, X. N. (2016). Tai Chi Chuan modulates heart rate variability during abdominal breathing in elderly adults. Psychology Journal, 5(1), 69-77.
Wilcox, R. R. (2005). Introduction to robust estimation and hypothesis testing (Statistical Modeling and Decision Science). Oxford, UK: Academic press.
Young, K. S., van der Velden, A. M., Craske, M. G., Pallesen, K. J., Fjorback, L., Roepstorff, A., & Parsons, C. E. (2017). The impact of mindfulness-based interventions on brain activity: a systematic review of functional magnetic resonance imaging studies. Neuroscience & Biobehavioral Reviews, 84, 424-433.
Zimmerman, K. (2016). Immune system: disease, disorder and dysfunction. Live Science. Downloaded on 9 March 2018 from https://www.livescience.com/26579-immune-system.html