Illness Essays and Research Papers

Instructions for Illness College Essay Examples

Title: Theory Research and Evidence based Practice

  • Total Pages: 2
  • Words: 723
  • Bibliography:2
  • Citation Style: APA
  • Document Type: Essay
Essay Instructions: Using Mishel’s theory below and the article, please write a two page summary paper that fits the requirements on the To prepare list below.

Theory, Research, and Evidence-Based Practice
As they explore the world around them, young children often want to know the “why” and “how” of the things they observe. This is similar to what researchers do when they approach a new problem. Researchers develop new theories or build on old ones to explain the “why” of the world around them. They use models and conceptual frameworks to help explain “how” the processes and events they observe occur. Together, theories and models provide an understanding of the world and allow researchers to explore it in meaningful ways.
Virtually all research questions can benefit from the use of an existing theory or model. Researchers should consider their research questions and select the most suitable theory or model, which then serves as a foundation for the research design. The selection of a theory or model is an important part of the research process.
In this Discussion, you focus on the role of theory and models in research and evidence-based practice.
To prepare:
• Review the information in Chapter 6 of the course text. Focus on the various conceptual theories and models that are currently used in nursing research.
• Select one of the theories or models described that is of interest to you.
• Using the Walden Library, search for and identify a research article that uses the theory or model you selected.
• Reflect on how the theory or model provides structure to the research study described in the article.
• Now, think about an issue in your practice area that you would be interested in exploring through research.
• Review this week’s media presentation and consider strategies for locating and identifying a relevant theory or model for a research study.
Post on or before Day 3 a summary of the article that you located and explain how the theory or model that you selected was used in the research study. Assess the value of basing research on an established theory or model.

Mishel's Uncertainty in lllness Theory (Mishel, 1990) focuses on the concept of uncertainty-the inability of a person to determine the meaning of ill- ness-related events. According to this theory, people develop subjective appraisals to assist them in interpreting the experience of illness and treatment. Uncertainty occurs when people are unable to recognize and categorize stimuli. Uncertainty results in the inability to obtain a clear conception of the situation, but a situation appraised as uncertain will mobilize individuals to use their resources to adapt to their situation. Mishel’s theory, as originally conceptualized, was most relevant to patients in an acute phase of illness or in a downward illness trajectory, but it has been reconceptualized to include constant uncertainty in chronic or recurrent illness. Mishel’s conceptualization of uncertainty (and her Uncertainty in Illness Scale) have been used in many nursing studies.

NURS 6052: Essentials of Evidence-Based Practice “Selecting a Framework”?Program Transcript
Have you ever had that same inexplicable event happen to you over and over again but still never found a way to explain it? Throughout their practice, nurses may encounter phenomena that they cannot fully explain. If nurses want to understand such phenomena, they may decide to conduct research on it.
Take Rachel, for example. Rachel is the manager of a group of nurses in a nursing home, and she has noticed that the stress and fatigue levels of the nurses under her direction vary considerably. She knows that the patients and caseloads of the nurses do not significantly differ, and those who seem most affected by stress include both new and veteran nurses. Rachel considers these phenomena and decides to further investigate them through research. But before she can begin gathering data, she must first select a framework to guide her research.
A framework is the overall conceptual basis or rationale for a study. There are two types of frameworks that can be used to guide research-- theoretical and conceptual. Theoretical frameworks are used for research studies related to a specific theory. A theory is a formalized explanation of how phenomena are interrelated.
Conceptual frameworks, on the other hand, are used for studies that are not rooted in a particular theory. This does not mean that conceptual frameworks are not based on existing knowledge and evidence. In fact, many conceptual frameworks are based on conceptual models, which are abstract methods of thinking about human beings, the environment, health, nursing, and so on.
There are many methods researchers use to identify a suitable framework for the phenomenon they are studying. Conceptualizing or targeting the specific factors related to the phenomena is one such method. In addition, researchers can
© 2012 Laureate Education, Inc. 1
peruse databases and printed materials for similar studies, search for established frameworks that take a position on factors related to the phenomena, and confer with people who are familiar with many theories and models, such as professors, advisers, and supervisors.
For example, in Rachel's study on stress and fatigue in the nursing home setting, the factors include the nurses, their stress levels, and how they respond to or cope with stress. Rachel uses these factors to conduct searches for similar research studies on stress and caregiver burdens. The information presented in these studies allows her to determine that the most appropriate framework for her study is Theory of Stress and Coping, developed by Lazarus and Folkman.
This theory provides an explanation for how different people deal with stress and how they develop and learn coping strategies. This theory gives Rachel a theoretical framework to begin crafting her research questions and plotting how to carry out her research.
It should also be noted that frameworks evolve as more research is conducted. Each new layer of research that uses a particular framework helps inform future studies using that same framework. But with the initial framework selection firmly in place, the stage is set for a successful research project that may benefit patients everywhere.
© 2012 Laureate Education, Inc. 2


Understanding a meningioma diagnosis using Mishel’s theory of uncertainty in illness

Kristen Guadalupe is assistant professor of nursing, Case Western Reserve University, Cleveland, Ohio, USA. Correspondence:
Meningiomas are mostly benign tumors originating from non-neuroepithelial progenitor cells, the arachnoid cap cells (Marosi et al, 2008). Meningiomas are typically divided into three main categories: benign, atypical, and malignant. The World Health Organization (WHO) (2000) has classified meningiomas as grade I (benign), grade II (atypical) and grade III (malignant).
Age and sex are associated with meningiomas, which occur more frequently in the elderly: the incidence in per- sons older than 70 years of age is 3.5 times higher than that in people younger than 70 years (Batesman et al, 2005). There is a greater incidence of meningiomas in females between the third and sixth decades of life, with an increase during the fifth and sixth decades. Atypical and malignant meningiomas are more common in males (Marosi et al, 2008). In children and adolescents, menin- giomas are equally rare in both sexes and show a tendency for aggressive subtypes (Marosi et al, 2008).
Risk factors
Several factors may be associated with meningioma for- mation: mutation of the neurofibromatosis type 2 (NF2) gene, ionizing radiation, head injury, female hormones. However, the evidence for these is currently inconclusive.
Mutation of the NF2 gene
The NF2 gene is located on chromosome 22 q12. One risk factor for meningioma is a mutation of the NF2 gene, frequently associated with a cytogenetically visible dele- tion of the long arm of chromosome 22 at q12 (Marosi et al, 2008). This mutation is an autosomal dominant genetic disorder??"i.e. there is a 50% chance of passing the muta- tion to offspring.
Ionizing radiation
Exposure to ionizing radiation is one of the more estab- lished risk factors for meningiomas (Jabbour et al, 2009; Kajiwara et al, 2008; Marosi et al, 2008). A meningioma diagnosis typically occurs several years after initial expo- sure to ionizing radiation.
Head injury
For many years, head injuries were thought to be a risk factor for meningiomas. However, data supporting head
trauma as a risk factor have been inconclusive at best. Annegers et al (1979) conducted a prospective study of 3000 people over 30 years and found that the incidence of meningioma following head trauma was not statistically significant.
Hormonal receptors
Approximately two thirds of meningiomas in females express progesterone receptors on the cell membrane (Marosi et al, 2008). While the exact role of sex hormones in the development of menigioma remains unclear, empir- ical evidence exists to support a relationship. Increased growth during pregnancy and certain phases in the men- strual cycle have been reported, but there is little evidence to support hormone replacement therapy and hormonal contraception as risk factors.
Treatment options
Surgery, stereotactic radiotherapy, and ‘watchful waiting’ are the most common treatment options for meningioma. Size, location and the presence of symptoms are among the factors that determine which treatment is the best option. The goal of surgical excision is complete resection

Uncertainty is probably the most certain thing a patient will experience when diagnosed with a potentially life-threatening illness. The diagnosis of a meningioma is no exception. The frequently benign, subtle, insidious growth of this tumor before diagnosis contributes to its uncertainty. The purpose of this article is to explore Mishel’s theory of uncertainty in illness as it applies to a meningioma diagnosis. The implications of this theory for nursing practice will be considered. It is argued that an understanding of patients’ response to the uncertainty surrounding a diagnosis of meningioma can help nurses offer women support to make more informed decisions about treatment options and subsequent interventions.
Key words
? Neuro-oncology ? Meningioma ? Diagnosis ? Uncertainty ? Mishel ? Mishel Uncertainty in Illness Scale
Accepted for publication following double-blind peer review 3 February 2010

British Journal of Neuroscience Nursing February 2010 Vol 6 No 2 77

of the tumor. Modern techniques have made possible the successful removal of meningiomas previously thought to be unresectable (Marosi et al, 2008).
Complete surgical removal provides the best opportu- nity for long-term remission (D’Ambrosio and Bruce, 2003). However, despite modern technology there is con- siderable risk of morbidity and mortality with surgical excision. Potential complications include cerebral spinal fluid (CSF) leakage meningitis, epilepsy, diabetes insip- idus, anosmia, and damage to the cranial nerves and major vessels (Klink et al, 2000; Kim et al, 2008). While some controversy exists over the use of radiotherapy, it has become a preferred treatment option for tumours less than 3 cm and/or those in which surgery is not an option because of their location (Marosi et al, 2008).
External beam fractioned radiotherapy is a treatment used to control tumour growth. A number of types of external beam fractioned radiotherapy have been devel- oped to destroy tumor cells, including:
? Three-dimensional conformal radiation therapy (3D- CRT)
? Intensity modulated radiation therapy (IMRT)
? Stereotactic radiotherapy (SRT)
? Stereotactic radiosurgery (SRS)
? Image-guided radiation therapy (IGRT).?According to a review of the literature by Chung et al (2008), in the treatment of benign meningiomas located in the base of the skull (WHO classification I), local tumor control rates and complication rates of radiosurgery, including gamma knife surgery (GKS), have been shown to be comparable to those achieved with microsurgery. When the tumor is benign, asymptomatic and small (<2 cm), close routine monitoring for rapid growth and/or symptoms of the tumor (‘watchful waiting’) is adopted. Sometimes a combination of treatments is used to achieve maximum benefit. Despite an array of treatment options, underlying uncertainty associated with choosing the best treatment is a reality for many meningioma patients. ?Uncertainty ?Uncertainty is a major stressor for those coping with life- threatening illnesses (Germino et al, 1998). Mishel (2006) has defined uncertainty in illness as: ?the inability to determine the meaning of illness-related events; this occurs in situations where the decision maker is unable to assign definite value to objects or events or is unable to accurately predict outcomes due to lack of sufficient cues. ?Uncertainty occurs in situations in which the decision- maker is unable to assign definitive value to objects or events and/or is unable to predict outcomes accurately (Mishel, 1984; 1988; Mishel and Braden, 1988; Mishel, 1990). A person’s inability to apply meaning to a specific event influences the coping strategies adopted. Several studies have explored the concept of uncertainty and its effect on illness (Galloway and Graydon, 1996;
Wonghongkul et al, 2000; Hurley et al, 2001; McCormick 2002; Brashers et al, 2003; Hsu et al, 2003; Santacroce 2003; Wallace, 2003; Schulman-Green et al, 2008).
McCormick et al (2005) designed a qualitative study using semi-structured interview questions based on Mishel’s theory of uncertainty to test the hypothesis that cardiac symptoms were antecedents to uncertainty and the positive and negative outcomes associated with them. McCormick et al (2005) found support for Mishel’s theory of uncertainty. For example, the longer women waited for a coronary artery bypass graft the more uncertain about the future they felt. Similarly, Schulman et al (2008) used the Mishel Uncertainty in Illness Scale (MUIS) (Mishel, 1981) to measure a variety of factors contributing to the quality of life of women who had undergone surgery for ovarian malignancies. This study indirectly demonstrated support for Mishel’s theory by confirming that psychoso- cial variables such as anxiety and depression play an important role in the determining the uncertainty a person feels during the trajectory of an illness.
Hsu et al (2003) examined the relationship of pain to uncertainty and hope in Taiwanese lung cancer patients. Results supported Mishel’s (1981) findings that higher levels of uncertainty were positively associated with a recognizable pattern of pain that interfered with normal activities. Conversely, the study did not show a relation- ship between severity of pain and uncertainty. According to Mishel’s theory, recurrent pain may trigger event famil- iarity and congruence, which may suggest a relationship associated with greater uncertainty. Pain can be a familiar, unpleasant experience that may generate more uncertain- ty. The frequently benign nature of meningiomas, coupled with an incidental diagnosis and often a lack of symptoms may add to patients’ uncertainty.
Mishel (1981, 1982, 1983) explored the role of uncer- tainty as one of the conditions that produced stress in hospitalized patients. She began by doing an exploratory study to identify which stages of illness patients perceived as uncertain. As a result of this work, Mishel (1981) developed a scale to measure uncertainty: the MUIS. The current version of the MUIS is a 34-item, two-factor Likert scale, which is still used to measure uncertainty relative to a specific illness experience. The MUIS has established reliability and validity (Schulman-Green et al, 2008; Hsu et al, 2003).
Mishel’s theory of uncertainty in illness
In 1988 Mishel developed a middle range uncertainty theory to explain how people with illness cognitively process illness-related stimuli in an attempt to construct meaning for illness events. This theory proposes that uncertainty occurs when people have difficulty construct- ing a cognitive schema for illness events. This theory is considered middle range because the concept of uncer- tainty is operational in the context of most, if not all, aspects of nursing practice. The manner in which Mishel conceptualizes uncertainty through antecedents contrib- utes to its suitability for empirical testing in a variety of

British Journal of Neuroscience Nursing February 2010 Vol 6 No 2

clinical settings. The theory includes antecedents of uncertainty. ‘Stimuli frame’ refers to the form, composi- tion, and structure of the stimuli produced as part of the illness and as a result of illness-related events. The stimu- li frame is subdivided into symptom pattern and event familiarity, which are both used by the person to decrease uncertainty. ‘Structure providers’ refer to cation, social support, and credible authority, which are thought to rce uncertainty, directly and indirectly.
Mishel (1987) stated that in the illness experience uncertainty has four forms:
? Ambiguity concerning the state of the illness
? Complexity associated with treatment and system of ?care
? Lack of information about the diagnosis and seriousness ?of the illness
? Unpredictability regarding disease progression and ?prognosis.?An asymptomatic meningioma diagnosed as an incidental finding lends itself well to the model of uncertainty pro- posed by Mishel. ?Each person formulates an appraisal of a diagnosis based on individual experience. Uncertainty associated with lack of knowledge about treatment options, likeli- hood of recurrence, morbidity and mortality associated with a meningioma diagnosis makes appraisal of the experience difficult, in part, because of the difficulty in classifying the illness as acute or long term. ?Acute illness ?Mishel (1988) developed a middle-range nursing theory to explain uncertainty of diagnosis, treatment, and recov- ery experienced by people during acute illness. Lazaraus and Folkman’s (1984) stress and coping framework was the foundation for this theory because it proposed rela- tionships between similar aspects of the illness experi-
ence, how uncertainty emerged, the individual’s appraisal of uncertainty and rction of uncertainty as the desired outcome when illness was successfully under control. A person’s ability to cope with a stressful situation is based on his/her assessment of the situation. For example, diffi- culty understanding a situation may cause a person to be uncertain, which would cause stress to be associated with the event. Mishel (1988) conceptualized the term uncer- tainty and combined its effect in illness with nursing research to come up with antecedents (e.g, stimuli frame- work, structure providers) of the concept.
Long-term illness
In 1990, Mishel expanded her theory of uncertainty in ill- ness to those experiencing a long-term illness. The new theory focused on people with a chronic illness incorpo- rating uncertainty into their lives rather than trying to eliminate it. With a potential risk for recurrence related to tumor size, location, and degree of resection meningiomas may create similar feelings of uncertainty associated with follow-up visits to health professionals. In Mishel’s expanded theory, the stimuli frame is comprised of symp- tom pattern, event familiarity, and event congruence that serve as antecedents to uncertainty (Figure 1).
Symptom pattern
Symptom pattern refers to the degree to which symptoms associated with the illness have a consistent pattern (Mishel, 1987). A desirable outcome is for the person experiencing the illness to be able to predict a pattern of symptoms. People diagnosed with lupus erythematosus have higher levels of uncertainty than people with illness characterized by reliable symptoms (Mishel, 1981) because they attach meaning based on the consistency of their symptom pattern. The vague symptom pattern asso- ciated with lupus erythematosus contributes to higher
Figure 1. Relationship between core concepts of Mishel’s theory of uncertainty in illness and their impact on the experience of illness

Stimuli frame

Cognitive capacity

Structure providers

Symptom pattern
Event familiarity
Event congruence

Social support


Credible authority


British Journal of Neuroscience Nursing February 2010 Vol 6 No 2 79

levels of uncertainty. Similarly, an asymptomatic menin- gioma lends itself to an unreliable pattern of symptoms which contributex to a person’s inability to attach meaning and ambiguity about the best treatment options.
Event familiarity
Event familiarity refers to the degree to which a situation is habitual, repetitive, or has cues that are recognizable to the person (Mishel, 1987). For example, haemodialysis patients may experience less uncertainty because the event is familiar (Mishel, 1981). When events are record- ed in a person’s memory, it becomes easier to attach meaning. Event familiarity is developed over time through experience. The frequently incidental finding of menigi- omas as well as their asymptomatic nature contributes to the difficulty in establishing event familiarity on diagno- sis.
Event congruence
Event congruence refers to consistency between an expected outcome and the actual outcome in illness- related events (Mishel, 1987). Healthy people who suffer an initial stroke experience more uncertainty than those who experience a second stroke because the event is familiar for the latter. Similarly, patients with a recurrent meningioma experience a greater degree of event congru- ence related to increased familiarity. Stability is altered when anticipated outcomes do not occur, thereby increas- ing the amount of uncertainty.
Cognitive capacity and structure
Cognitive capacity and structure providers are two varia- bles that influence the stimuli frame. Cognitive capacity refers to the cognitive ability of the person suffering with the illness (Mishel, 1987). Symptoms associated with intracranial pressure, medications, fatigue, and anxiety from the meningioma may alter a person’s true cognitive ability. Due to symptom variability, coping with the diag- nosis of a meningioma can be very uncertain. Therefore, structure providers or resources are very important for a meningioma patient. Mishel (1987) described structural providers to be cation, the social support, and credible authorities available to a person (Mishel, 1987).
Cognitive capacity and structure providers have an inverse relationship with the degree of the person’s uncer- tainty. In Mishel’s theory (1987), structure providers are divided into three subgroups (cation, social support, and credible authority).
The relationship between cation and uncertainty is unclear. A number of authors have found that uncertainty has an inconsistent relationship with cation (Mishel, 1984; Christman et al, 1988; Mishel and Braden, 1988; Wong and Bramwell, 1992). Education is proposed to have both an indirect as well as a direct relationship with uncertainty (Mishel, 1987). In the indirect relationship, cation enables the person to apply structure to events
surrounding the illness and consequently attach meaning. Later, Galloway (1984), King and Mishel (1986), and Mishel (1985) found that having less cation equated with higher levels of uncertainty. There is a gap in the literature about the relationship between uncertainty asso- ciated with diagnosis of a meningioma and associated uncertainty.
Social support
Social support has been examined as a major influence of many health-related outcomes (Mishel and Braden, 1987). The role of social support with uncertainty is dynamic. Support systems have a direct and indirect influence on uncertainty (Mishel, 1987). Social support can have dif- ferent meanings to various people, it can function as a source of information exchange, a foundation for building dependable relationships that promote trust, as well as providing a stable environment during times of chaos. A strong social safety net helps people dealing with illness to better adapt to sudden, unpleasant life changes with a greater degree of ease. The vague, unexpected, subtle and frequently absent symptoms associated with a meningi- oma diagnosis contribute to the need for social support. Regardless of the manner in which a meningioma is dis- covered, the diagnosis is associated with a range of feel- ings from being scared to being grateful. A supportive network of family, friends, and the health-care team is more meaningful to patients. As one meningioma patient described it (Wood, 1991):
one nurse never hesitated to hold my hand and often took time to talk with me; she stayed with me, held my hand, looked at me, and took talked to me quietly while my heart raced with fear.
Credible authority
Credible authority describes the ability of health-care providers to rce uncertainty. Health professionals have the ability to rce uncertainty by providing information and promoting confidence in their clinical expertise (Mishel, 1988). When the authority, e.g. the neurosur- geon, doctor or nurse, is viewed as credible, the level of uncertainty is lowered based on trust of the information.
Testing the model
Mishel and Braden (1987) designed a correlational descriptive study to test part of a theoretical model of uncertainty in illness. A sample of women (n=61) who were treated for gynecological cancer were asked to com- plete questionnaires. Uncertainty was measured using the MUIS, and the Norbeck Social Support Questionnaire measured social support. The findings supported Mishel’s hypothesis that there were influences (antecedents) that occurred before uncertainty and that opposing paths to uncertainty were created based on those influences. For example, social support, credible authority and event familiarity had the most influence on rcing uncertain- ty. Increased social support had the greatest impact on

British Journal of Neuroscience Nursing February 2010 Vol 6 No 2

rcing vagueness surrounding the illness. If social sup- port had the greatest influence in rcing uncertainty surrounding decisions about cancer, it is reasonable to assume that it may also have the strongest influence in rcing women’s uncertainty about a meningioma. Further studies to test this hypothesis are needed.
McCormick (2002) examined the concept of uncer- tainty in illness to propose an alternative model of uncer- tainty in the illness experience. McCormick concluded that uncertainty is a multidimensional concept that is a neutral cognitive state that should not be mistaken for its emotional outcomes. Additional research was recom- mended to further investigate relationships among aspects of uncertainty. The influential nature of uncertainty was shown, which supports the need for further exploration of related concepts that may influence decision-making about meningioma treatment options.
Application of Mishel’s theory
Uncertainty and misunderstanding of actual risk have been shown to be common. It is not uncommon for those diagnosed with a meningioma to feel uncertain about whether ‘watchful waiting’, surgical resection or radiosur- gery is the right option. There are many factors (tumour location, size, classification) involved in a decision about the best treatment option for a meningioma.
A person’s right to choose is fundamental to the proc- ess of decision-making about treatment. Surgical treat- ment may be associated with significant morbidity (Akagami et al, 2002). Patients need comprehensive information about the benefits and risks of surgery including alternatives, to ensure that decisions are based on factual information and not fear. Rction of uncer- tainty is among the reasons that surgery for asympto- matic meningiomas is often chosen.
Akagami et al (2002) studied outcomes of patients with basal meningiomas whose primary surgeon had a philoso- phy of aggressive surgical management. Prospective data for 269 patients (62 males, 207 females) were collected via follow-up visits, mailed follow-up questionnaires, and telephone interviews during a 7-year period (1993??"2000). The mean patient age was 50 years (SD 13.6 years). The mean tumor size was 3 cm (SD 1.24 cm). Mean follow-up time was 49 months (SD 26 months). At follow-up of the study, a total of 30 patients could not be contacted and 11 patients died of unrelated causes. A total of 90% of patients in this study reported that surgery had been a good treatment choice (p< 0.0001), and 95% reported that they would recommend the same treatment for a family member (p<0.0001). The findings in this study support the argument that patient satisfaction following surgery for basal meningioma can be high despite the complexity of these tumours.
Ong and Ferruci (2005) reported on a case study of a 50-year-old woman with a history of type 2 diabetes mel- litus for 20 years (controlled by diet), and hypertension for 4 years. The patient was in surgically induced meno- pause since a hysterectomy 5 years previously and had
also experienced lymphomatoid papulosis, a skin disor- der, for more than 20 years. The patient presented in Ong and Ferruci’s eye clinic with decreased vision in the right eye for one week, especially when reading. An MRI revealed a meningioma arising from the tuberculum sellae and planum sphenoidale area. Immediate surgical exci- sion of the meningioma was recommended to avoid fur- ther cranial nerve decompression and to stop the progres- sion of vision loss. The tumour was successfully resected with recommendation for a follow-up radiation therapy to treat the remaining tumor. The patient’s vision improved following surgical excision.
Kim et al (2008) conducted a retrospective review of medical records and radiological findings of 15 patients who had intraorbital lesions or lesions involving the bony orbit between 2003 and 2007. The mean age of the patients was 41 years with a range of 23??"75 years of age. Three of the patients were blind before surgery, the others reported symptoms including exophthalmos (n=8), ocular pain (n=3), headache (n=4), and diploplia (n=1). The diagnoses were meningioma (n=7), cavernous hemangi- oma (n=3), schwannoma (n=2), metastatic tumour (n=2), and adenoid cystic carcinoma of the lacrimal gland (n=1). Tumour control was achieved in 12 of the 15 patients (80%) at 6-month follow-up. These preliminary results suggested that gamma knife radiosurgery is a safe and effective alternative to surgery as a primary or adjuvant treatment for patients with orbital tumors. However, Kim et al (2008) cautioned that longer follow-up periods and more patients are needed to validate this conclusion.
Nursing implications
The area-specific, highly individualized complications associated with meningiomas??"such as increased intra- cranial pressure, vision disturbances, headaches, ataxia, confusion, seizures??"are usually the result of compres- sion of the tumour on brain tissue. The vague features of the symptoms contribute to delayed diagnosis in many instances. Nursing care of a postoperative patient with a meningioma is no different from care related to other patients who have undergone a craniotomy. However, as previously discussed not all patients choose a surgical intervention as treatment. Despite the usually benign nature of meningiomas, nurses should be attuned to the fact that the ‘benign’ diagnosis may have life-altering consequences before and after treatment.
Mishel’s uncertainty in illness theory provides a theo- retical framework for nurses to better understand factors that contribute to uncertainty about treatment options. Nurses who understand the role that uncertainty plays before and after a treatment decision is made have a unique opportunity in assisting the patient to understand the role of uncertainty on decisions surrounding a new diagnosis. Nurses may consider running support groups or referring patients to them, teaching about the importance of good nutrition, exercise and the need for balance in their lives. Providing social support may alleviate uncer- tainty and assist patients in coping with the diagnosis and

British Journal of Neuroscience Nursing February 2010 Vol 6 No 2 81

making informed decisions. Patients need information about what is happening and what to expect before and after treatment, advice, encouragement, and most of all reassurance that varying degrees of uncertainty are nor- mal and part of the illness continuum.
The literature reviewed in this article illustrates the highly variable nature of treatment options that add to the uncer- tain nature of the diagnosis. Despite vast research to study meningioma treatments, little is known about the factors such as uncertainty that affect the decision. Future studies aimed at further exploring a potential relationship between uncertainty and decision making about treatment are needed. Understanding the effect of uncertainty with a meningioma diagnosis may assist nurses to help women make more informed decisions about treatment options and subsequent interventions. BJNN
Conflict of interest: none declared
Akagami R, Napolitano M, Sekhar LN (2002) Patient-evaluated outcome after surgery for basal meningiomas. Neurosurgery 50(5): 941??"8
Annergers JF, Laws ER Jr, Kurland LT, Grabow JD (1979) Head Trauma and subsequent brain tumors. Neurosurgery 4(3): 203??"6
Bateman BT, Pile-Spellman J, Gutin PH, Berman MF (2005) Meningioma resection in the elderly: nationwide inpatient sample 1998-2002. Neurosurgery 57(5): 866??"72
Brashers DE, Neidig JL, Russell JA et al (2003) The medical, personal, and social causes of uncertainty in HIV illness. Issues Ment Health Nurs 24(5): 497??"522
Christman NJ, McConnell EA, Pfeiffer C, Webster KK, Schmitt M, Ries J (1998) Uncertainty, coping, and distress following myocardial infarction: transition from hospital to home. Research in Nursing & Health 11: 71??"82
Chung HT, Kim DT, Paek SH, Jung HW (2008) Development of dose- volume relation model for gamma knife surgery of non-skull base intracranial meningiomas. Int J Radiat Oncol Biol Phys 74(4): 1027??"32
D’Ambrosio AL, Bruce JN (2003) Treatment of a meningioma: an update. Curr Neurol Neurosci Rep 3(3): 206??"14
Galloway SC, Graydon JE (1996) Uncertainty, symptom distress, and information needs after surgery for cancer of the colon. Cancer Nurs 19(2): 112??"7
Germino BB, Mishel MH, Belyea M, Harris L, Ware A, Mohler J
(1998) Uncertainty in prostate cancer: ethnic and daily patterns.
Cancer Pract 6(2): 107??"13.=?Goldsmith BJ, Wara WM, Wilson CB (1994). Postoperative irradiation
for subtotally resected meningiomas. A retrospective analysis of 140
patients treated from 1967 to 1990. J Neurosurg 80(2): 195??"201 Hsu TH, Lu MS, Tsou TS, Lin CC (2003) The relationship of pain,
uncertainty, and hope in Taiwanese lung cancer patients. J Pain
Symptom Manage 26(3): 835??"42?Hurley KE, Costalas JW, Gillespie D, Daly MB (2001) Anxiety/
uncertainty rction as a motivation for interest in prophylactic oophorectomy in women with a family history of ovarian. J Womens Health Gend Based Med 10(2): 189??"99
Jabbour SK, Zhang Z, Arnold D, Wharam M (2009) Risk of second tumor in intracranial germinoma patients treated with radiation therapy: the Johns Hopkins experience. J Neurooncol 91(2): 227??"32
Kajiwara M, Kohsuke Y, Ueba T, Nishikawa T (2008) Normal pressure hydrocelphalus after radiosurgery for sphenoid ridge meningioma. Journal of Clinical Neuroscience 16(1): 162??"4
Kim M, Park K, Kim YD, Lee J (2008) Gamma knife radiosurgery for orbital tumors. Clin Neurol Neurosurg 110(10): 1003??"7
Klink DF, Sampath P, Miller NR (2000). Long-term visual outcome after nonradical microsurgery patients with parasellar and cavernous sinus meningiomas. Neurosurg 47(1): 24??"32
Lazarus RS, Folkman S (1984) Stress, appraisal and coping. Springer, New York
Marosi C, Hassler M, Roessler K, Reni M, Sant M, Mazza E, Vecht C (2008) Meningioma. Crit RevHematol Oncol 67(2): 153??"71
McCormick KM (2002) A concept analysis of uncertainty in illness. J Nurs Scholarsh 34(2): 127??"31
McCormick KM, McClement S, Naimark BJ (2005) A qualitative analysis of the experience of uncertainty while awaiting coronary artery bypass surgery. Can J Cardiovas Nurs 15(1):10??"22
Mishel M (1981) The measurement of uncertainty in illness. Nurs Res 30(5): 258??"63
Mishel M (1982) Parent’s perception of uncertainty concerning their hospitalized child. Nurs Res 32(6): 324??"30
Mishel M (1984) Perceived uncertainty and stress in illness. Res Nurs Health 7(3): 163??"71
Mishel M (1988) Uncertainty in illness. J Nurs Scholarsh 20(4): 225??" 32
Mishel M (1990) Reconceptualization of the uncertainty in illness theory. J Nurs Scholarsh 22(4): 256??"62
Mishel M, Braden CJ (1987) Uncertainty: a mediator between support and adjustment. West J Nurs Res 9(1): 43??"57
Mishel M, Braden CJ (1988) Finding meaning: antecedents of uncertainty in illness. Nurs Res 37(2): 98??"103
Mishel MH, Hostetter T, King B, Graham V (1984) Predictors of psychosocial adjustment in patients newly diagnosed with gynecological cancer. Cancer Nurs 7(4): 291??"99
Mishel M, Padilla G, Grant M, Sorenson DS (1991) Uncertainty in illness theory: a replacing of the mediating effects of mastery and coping. Nurs Res 40(4): 236??"40
Mishel M, Sorenson D (1991) Uncertainty in gynecological cancer: a test of the mediating functions of mastery and coping. Nurs Res 40(3): 167??"71
Mishel M, Germino BB, Belyea M et al (2003) Moderators of an uncertainty management intervention. Nurs Res 52(2): 89??"97
Mishel MH (2006) Uncertainty in illness. In: Fitzpatrick JJ, Wallace M, eds. Encyclopedia of Nursing Research. 2nd edn. Springer Publishing Inc, New York: 605??"7
Ong L, Ferrucci S (2005) Tubercullum sellae meningioma associated with lymphotoid papulosis, J Am Optom Assoc 76(3):165??"75
Santacroce SJ (2003) Parental uncertainty and postraumatic stress in serious childhood illness. J Nurs Scholarsh 35(1): 45??"51
Schulman-Green D, Ercolano E, Dowd M, Schwartz P, McCorkle R Quality of life among women after surgery for ovarian cancer. Palliat Support Care 6(3): 239??"47
Wallace M (2003) Uncertainty and quality of life of older men who undergo watchful waiting for prostate cancer. Oncol Nurs Forum 30(2): 303??"9
Wong CA, Bramwell L (1992) Uncertainty and anxiety after mastectomy for breast cancer. Cancer Nurs 15(5): 363??"71
Wonghongkul T, Moore SM, Musil C, Schneider S, Deimling G (2000) The influence of uncertainty in illness, stress appraisal, and hope on coping in survivors of breast cancer. Cancer Nurs 23(6): 422??"9
Wood W (1991) A perioperative case study of frontal lobe meningioma. J Post Anesth Nurs 6(4): 265??"68

Key Points
? Patients may be faced with a range of uncertainties and treatment options after a meningioma diagnosis
? Little is known about the effect of uncertainty on treatment decisions for benign meningiomas
? Understanding of patients’ experience of uncertainty after a meningioma diagnosis can help nurses offer support to patients who are faced with making difficult decisions
? These findings raise implications for the exploration of the proposed relationship between uncertainty and treatment options considered and pursued

British Journal of Neuroscience Nursing February 2010 Vol 6 No 2
Copyright of British Journal of Neuroscience Nursing is the property of Mark Allen Publishing Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Guadalupe, K. (2010). Understanding a meningioma diagnosis using Mishel's theory of uncertainty in illness. British Journal Of Neuroscience Nursing, 6(2), 77-82.

[ Order Custom Essay ]

[ View Full Essay ]

Excerpt From Essay:


Alligood, M. (2010). Nursing Theory: Utilization and Application. Denver, CO: Mosby.

Guadalupe, K. (2010, Feb.) Understanding a meningioma diagnosis using Mishel's theory of uncertainty in illness. British Journal of Neuroscience Nursing. 6 (2): 77-82.

Mishel, M. And Clayton, M. (2003). Theories of Uncertainty in Illness. In Smith, M. ed. Middle

Range Theory for Nursing. New York: Springer. Chapter 2.

Order Custom Essay On This Topic

Title: asthma illness

  • Total Pages: 7
  • Words: 2618
  • Sources:8
  • Citation Style: MLA
  • Document Type: Research Paper
Essay Instructions: Length: 2,000 words
Identify Asthma, either acute or chronic.
Through the use of the qualitative research and autobiographical literature, explore how one patient/person, or a group of patients/people, has/have experienced this illness.
To do this you will need to identify common illness experience themes that encapsulate the experience of being ill for the individual and/or their families. You will need to refer to the relevant qualitative research literature and show evidence of a conceptual understanding of how these identified themes illustrate the ill person’s and/or
their families’ experience.

Assessment Criteria
• Introduction gives background to the topic and states precisely what the essay intends to
• Body of essay shows evidence of critical analysis, synthesis and evaluation of relevant
qualitative research literature.
• The essay contains a coherent, appropriately substantiated and well-developed line of
• Conclusion draws evidence together, does not over-generalise.
• Well-structured, logically sequenced presentation in appropriate English (see Assignment
Presentation Requirements).
• Correct referencing technique (see Assignment Presentation Requirements).
• At least 8 qualitative research articles (identified from the qualitative research databases)
used to support the arguments.( must be in last 5 years)

[ Order Custom Essay ]

[ View Full Essay ]

Excerpt From Essay:


Ahluwalia, SK; Matsui, EC (2011). The indoor environment and its effects on childhood asthma. Current opinion in allergy and clinical immunology 11 (2): 137 -- 43.

Arshad, SH (2010). Does exposure to indoor allergens contribute to the development of asthma and allergy? Current allergy and asthma reports 10 (1): 49 -- 55.

Bornehag, CG; Nanberg, E (2010 Apr). Phthalate exposure and asthma in children. International journal of andrology 33 (2): 333 -- 45.

Brooks, C; Pearce, N; Douwes, J (2013). The hygiene hypothesis in allergy and asthma: an update. Current opinion in allergy and clinical immunology 13 (1): 70 -- 7.

Elward, Graham Douglas, Kurtis S. (2010). Asthma. London: Manson Pub. pp. 27 -- 29.

Halapi, E; Bjornsdottir, U.S. (2009). Overview on the current status of asthma genetics. The clinical respiratory journal 3 (1): 2 -- 7.

Jaakkola JJ, Knight TL. (2008). The role of exposure to phthalates from polyvinyl chloride products in the development of asthma and allergies: a systematic review and meta-analysis. Environ Health Perspect 116 (7): 845 -- 53. doi:10.1289/ehp.10846. PMC 2453150.

Murk, W; Risnes, KR, Bracken, MB (2011). Prenatal or early-life exposure to antibiotics and risk of childhood asthma: a systematic review. Pediatrics 127 (6): 1125 -- 38.

Order Custom Essay On This Topic

Title: mental health

  • Total Pages: 7
  • Words: 2556
  • References:15
  • Citation Style: APA
  • Document Type: Essay
Essay Instructions: Rationale
There are various views on what constitutes mental illness. There are authors who follow the medical model and look for aetiological causes of mental illness that are caused by chemical imbalances in the body or changes in organ function as compared to people who do not diagnose people with a mental illness, rather they need to be viewed according to their behaviour and how that behaviour can be managed. To develop an understanding of mental illness it is important to examine the various views related to labelling people with a mental illness diagnosis:

This assignment relates to the following subject objectives:

· develop an understanding or society's attitudes to abnormal behaviour

· discuss the implications of labelling people with a mental illness

· examine the proves of deinstitutionalization and its impact on people experiencing a mental illness

· examine the settings in which individuals may receive treatment for disturbed behaviour

· discuss the effect of culture on mental illness by identifying the particular problems for Indigenous and multicultural populations

On pages 95-96 of your textbook, Bentall, R. (2004) Madness Explained: Psychosis and Human Nature, Penguin: Suffolk is several authors views on mental illness as noted below.

'According to Kraepelin, people either suffer from mental illness or they do not, and we are not free to choose whether to regard some kind of unusual behaviour as evidence of madness or mere eccentricity'.

'For Carl Jaspers, the psychiatrist's inability for form an empathic appreciation of a patient's experiences was a sure sign of the patient's madness. For Kurt Schneider, the observation of certain behaviours and experiences (the first-rank symptoms) carried a similar implication. Only Eugen Bleuler was more flexible, conceiving of a continuum that ran from normality to the extreme experiences of people suffering from psychosis.'

Finally, another author Ludwig Wittenstein has the view that '…psychosis should be seen as just part and parcel or human variation, rather than as an illness.' Bentall (2004:96) argues that 'the attribution of mental illness, either to individuals or to particular types of behaviour, is arbitrarty rather than scientific, and that psychotic people are eccentrics who are misunderstood and victimised by society.

You are to read chapters 1 and 2 of your text Elder, R., Evans, K. & Nizette, D. 2005, Psychiatric and Mental health Nursing, Elsevier-Mosby, Sydney, pp. 2-27 that discusses: 'The Effective Nurse' and 'The Context of Practice'.

You are to analyse and discuss the various positions on mental illness provided above and conclude with discussing your position on the labeling/diagnosing a person with a mental illness.

NOTE: This is required to be an academic essay that follows the usual requirements for such a piece of work. This applies especially to use of the 3rd person.

Criteria for assessment of Assessment 1 - NRS243
Student Name: ______________________________________________
Value: 30%

Criteria grade

= excellent work
criterion met to an exceptionally high standard.

= well done
criterion met to a high standard.

= satisfactory
criterion met but depth and/or breadth somewhat limited.

= needs improvement
criterion met to an acceptable standard just, but there is much room for further development.

= poor
criterion not met; either not addressed or treated very superficially.


No marks awarded but up to 20 marks from total mark for work poorly presented


Grammar/use of English

Format (page nos, title page, etc.)

Essay structure/development
No marks awarded but up to 20 marks will be deducted from total mark for work poorly presented


Linking ideas/signposting


Body - evidence of a plan

Evidence of logical and reflective thinking


Content - 100%

Understanding of essay task and subject matter demonstrated

Information relevant to topic

Clear and logical answers to questions

Critical examination of the main issues related to the topic (analysis)

Synthesis of overall argument (evaluation) is clearly, logically and creatively developed and arises logically from the analysis

Academic Referencing Technique
No marks awarded but up to 20 marks will be deducted from total mark for work poorly referenced and resourced

Referencing system correct in paper

Referencing system correct in reference list

Appropriate use of nursing and other literature - at least 5 references are used as supporting evidence for 1000 words

Appropriate systematic reference to subject readings and textbooks

Correct use of quotes

[-i will email the resource material tomorow

Prescribed text(s)
Bentall, R. 2004, Madness explained: Psychosis and human nature. Penguin, London.
Elder, R., Evans, K. & Nizette, D. 2005, Psychiatric and mental health nursing. Mosby, Marrickville. ISBN: 07295 3729 3
Canadian/Off shore and other students can order these texts online using your credit card at:
(This is the University Cooperative Bookshop located at Charles Sturt University, Bathurst campus.)
Pedersen, D. 2005, Psych notes: Clinical pocket guide. FA Davis Co., Philadelphia.
These texts are shrink wrapped together.
Recommended reading
Freshwater, D. 2006, Mental health and illness: Questions and answers for counsellors and therapists. Whurr Publishers, Chichester.
Recommended reading
All readings in Modules 1 and 2.
Australian Health Ministers Advisory Council 2003, Evaluation of the Second National Mental Health Plan. Australian Government Publishers, Canberra.
New South Wales Mental Health Act 1990, Government Printers, Sydney.
Hatcher, S., Butler, R. & Oakley-Browne, M. 2005, Evidence-based mental health care, Elsevier, Sydney.
Sallah, D. & Clark, M. 2005, Research and development in mental health. Churchill Livingstone, Sydney.
Internet sites
Internet sites through CSU library health links
Information on Human Neurological Diseases - searchable database of resources. Recommended.
Internet Mental Health
Knowledge Exchange Network - information and resources on prevention, treatment, and rehabilitation services for mental illness (US).
Mental Health Matters - directory of mental health, mental illness resources for professionals, patients and families.
Mental Health and Wellbeing - Mental Health and Special Programs Branch - Dept. of Health and Aged Care.
Mental Health InfoSource - includes an A-Z Disorder search, articles, news and journal.
Mental Health Net
Mental Health Resources - links on child and adolescent mental health, ADHD, mood disorders, suicide, eating disorders and other topics. - online resource for schizophrenia and other mental health information.
National Child Protection Clearinghouse - publications, articles, links, newsletter and other resources.
Primary Mental Health Care Australian Resource Centre - database of resources.
Psychiatry and Psychology Resources (OMNI Gateway)
SANE Factsheets - disorders, treatments and statistics.
Alzheimer's Association (US)
Alzheimer's Association of Australia
American Psychiatric Nurses Association
American Psychological Association
Australian and New Zealand Association of Psychiatry, Psychology and Law
Australian and New Zealand College of Mental Health Nurses
Australian Drug Foundation
The Australian Early Intervention Network for Mental Health
Australian Institute for Suicide Research and Prevention
Australian Transcultural Mental Health Network
Centre for Evidence Based Mental Health
Centre for Mental Health Research (Australian National University)
Anxiety Disorders Foundation of Australia
SANE Australia
World Federation for Mental Health
Schizophrenia and other psychotic disorders
Bipolar Disorders Information Centre
Bipolar Disorders Portal - resources on medication, bipolar depression, manic depression, self-injury, suicide, panic and treatment.
Depression InfoCentre

There are faxes for this order.

[ Order Custom Essay ]

[ View Full Essay ]

Excerpt From Essay:


Bentall, R. 2004, Madness explained: Psychosis and human nature. Penguin, London, 95-96.

Boyce, P, 2006. Restoring wisdom to the practice of psychiatry. Australasian Psychiatry. 14(1), 3-7.

Clark, L. 2007. "http: Assessment and Diagnosis of Personality Disorder: Perennial Issues and an Emerging Reconceptualization Annual Review of Psychology 58, 227-257

Elder, R., Evans, K. & Nizette, D. 2005, Psychiatric and mental health nursing. Mosby, Marrickville, 51-63.

Feldman, D. & Crandall, C. 2007. Dimensions of Mental Illness Stigma: What About Mental Illness Causes Social Rejection? Journal of Social and Clinical Psychology. 26-92), 137-154

Ferney, V. 2003. www.newyorkcityvoices.orgThe Hierarchy of Mental Illness: Which diagnosis is the least debilitating? New York City Voices Jan/March. Retrieved September 3, 2007 at

Fothergill, a., Satherley, P., & I. Webber. 2003. A systematic review on the effectiveness of school nurse implemented mental health screening available for adolescents in schools. Journal of Psychiatric and Mental Health Nursing 10 (5), 625-626.

Goodwin, V. 2007. The Impact of History and Policy. Policy, Politics, & Nursing Practice, 8 (1), 55-63.

Griffiths K, Nakane Y, Christensen H, Yoshioka K, Jorm a, & Nakane H. 2006 in response to mental disorders: a comparison of Australia and Japan. BMC Psychiatry. May 23;6:2

Link, B., Yang, L. & Collins, P. 2004. Measuring Mental Illness Stigma.

Schizophrenia Bulletin. 30(3), 511-541;

Substance Abuse and Mental Health Services Administration (SAMHSA). 2007. Mental Illness is Not a Full Time Job. U.S. Department of Health and Human Services. Retrieved September 2, 2007 at

Stuart, H. 2006 www.medscape.comMental Illness and Employment Discrimination Current Opinion in Psychiatry 19(5), 522-526.

Stuart, H. 2003 and mental illness: an overview. World Psychiatry. June; 2(2), 121-124

Wahl, O.F. 2003 News Media Portrayal of Mental Illness: Implications for Public Policy American Behavioral Scientist. 46 (12), 1594-1600.

Waraich P, Goldner EM, Somers JM, & Hsu L. 2004. Prevalence and incidence studies of mood disorders: a systematic review of the literature. Can J. Psychiatry. Feb;49(2), 124-38.

Order Custom Essay On This Topic

Title: Bio medical ethics

  • Total Pages: 6
  • Words: 1926
  • Works Cited:0
  • Citation Style: MLA
  • Document Type: Research Paper

Write an essay of 6 pages (max) typed (double-spaced pages in eleven (Calibri) or twelve-point (times new roman) font with 1” margins) on one of the two following topics. Do not use quotations from the authors or copy whole sentences or sentence fragments from the texts or any other sources. Be careful of academic dishonesty. The whole essay must be in your own words. At least 12-15 references to the texts we have read are required for this paper, and they should be distributed equally throughout the paper. Explain the authors’ points in your own words; and then use a page citation to the Summer 2010 Cal Copy Reader (for example, 1.Sade, CC2010, p.00--) in order to indicate where the author makes the point or concept you are explaining or using. Number these page citations from ‘1’ to ‘12’ or ‘1’-‘15’, and put them in the body of your essay. Your essay should contain at least 12 page citations to the CAL COPY 2010 reader and cover all the authors and texts that you explain in your essay.
All papers are due in Center 214 on Saturday, July 31st between 10 and 11 am. And you must hand in your paper to your TA, Joyce or Veronica, in person. Return this question sheet with your paper.

Write your paper on:

Basic issues:
(1) Are there genuine mental illnesses and how are they different from physical illnesses, and everyday ethical, social and psychological problems?
(2) Does the concept of mental illness assume certain ethical values and norms? Whose values and norms? How? Why? Why not?
(3) If the concept of mental illness assumes ethical values and norms, does that destroy the objective and scientific status of psychiatry, psychoanalysis, or psychotherapy?
(a) Carefully explain how Szasz in “The Myth of Mental Illness” answers the above questions and defends his view that mental illness is a “Myth.” (2 pages)
(b) Carefully explain how Sedgewick answers the above questions. In your above explanation, explain how his answers challenge Szasz’s position. (2 pages)
(c) Choose either Boorse, Engelhardt or Edwards and explain how his account of mental health, mental disease and psychiatry challenges the critique of psychiatry in Szasz. Explain who has the more convincing position in your opinion, and why? (2 pages)

Rules Governing the Grading of these Papers:
1. All papers must be handed in to your TA in person in Center Hall 214 on Saturday, July 31st between 10 and 11am, and be 6 pages maximum.
2. Each part of your essay will count equally.
3. Papers without the required references to our cal Copy Summer 2010 texts will not receive a passing grade. Include at least 12-15 references.
4. Your 12-15 footnotes should be distributed over all the authors you treat in your essay.
5. In the case of this final paper, we cannot accept late papers.
6. You are responsible for making and keeping an extra copy of your paper, in case the original is lost or missing.
7. You are also responsible for knowing the university rules and procedures concerning plagiarism and cheating. Plagiarism or cheating may result in getting an ‘F’ for the whole course, may go on your permanent record, and can result in disciplinary action.
All papers must be submitted to TurnItIn by midnight on Saturday July 31st. To turn in your paper login onto the class WebCT and submit to the TurnItIn link there. After you have uploaded your paper a confirmation page will appear. Print out the confirmation page for your records in case your electronic submission is disputed.



U=Unclear or confused point


P=Poorly written or formulated

I=Your explanation, criticism, etc. is incomplete and misses important points

G=Good point, formulation of idea

W=Well organized explanation, discussion or criticism

X=Explain in more detail, clarify

E=Give an example to support the claim

There are faxes for this order.

[ Order Custom Essay ]

[ View Full Essay ]

Excerpt From Essay:
Order Custom Essay On This Topic
Request A Custom Essay On This Topic Request A Custom Essay
“I really do appreciate I'm not a good writer and the service really gets me going in the right direction. The staff gets back to me quickly with any concerns that I might have and they are always on time.’’ Tiffany R
“I have had all positive experiences with I will recommend your service to everyone I know. Thank you!’’ Charlotte H
“I am finished with school thanks to They really did help me graduate college.’’ Bill K