Provide examples from your organization and describe how these behaviors can be used to support patient-centered or relationship-centered care. In addition, if applicable, tell us your COVID/patient story as it related to patient/family-centered care.

DNP-803-Leadership in Organizations and Systems

Module 3 DQ

Topic: Patient Centered Care; Toxic Leadership

1. There are four patient-centered leadership behaviors listed on page 335, table 12.1. Provide examples from your organization and describe how these behaviors can be used to support patient-centered or relationship-centered care. In addition, if applicable, tell us your COVID/patient story as it related to patient/family-centered care.

2. What behaviors can you identify in your organization that might create stagnation and/or chaos or diminish relationships, connections, and information sharing? These are toxic behaviors. What are the consequences to the team, the organization, and the system? How can the leader reverse these consequences? Post your article about toxic leadership here and incorporate it into the discussion as well.

3. Post your progress with your weekly self-care goal. Have you completed the self-care activity every week? What are the benefits to you of completing the weekly self-care activity? What are the barriers associated with completing your goal? What modifications can you make to increase your participation in the self-care activity between now and the end of the term?

Lecture Materials

Below is an outline of the 6 items for which you will be responsible throughout the module.

1. Textbook readings- Weberg and Davidson Chapter 12, 13 (MO 1, 2, 3, 4)

2. Review the audio PowerPoint presentation on Toxic Leadership

3.. Read the article:

4 steps to repairing a toxic culture.pdf

Sherman, R. (2019). 4 steps to repairing a toxic culture. American Nurse Today , 14(3), p. 5-7 (MO 3.4)

4. Review the literature on the topic of toxic leadership. Be prepared to post one article from your review in the DB.

5.. Read the article: Patient Centered Care During COVID.pdf

Ahmann.E .(2020), Resources and support to maintain the ‘essence’ of patient- and family-centered care during COVID-19. Pediatric Nursing.46(3): 154-155. (MO 1,2)

Amy Schmoll

1. There are four patient-centered leadership behaviors listed on page 335, table 12.1. Provide examples from your organization and describe how these behaviors can support patient-centered or relationship-centered care. In addition, if applicable, tell us your COVID/patient story as it related to patient/family-centered care.

According to Weberg & Davidson (2021), the four patient-centered leadership behaviors are building relationships, providing evidence, fostering shared decision-making, and involving the team. Relationship-centered care focuses on the patient-provider, provider community, and provider-provider relationships (Weberg & Davidson, 2021).

Relationships between the care team members, patients, and organization are needed to build the foundations of patient-centered leadership (Weberg & Davidson, 2021). In my facility, we always confer with patients, allowing them to express their fears or concerns about anesthesia. When available, we give them options for their anesthetic plan and encourage them to be active participants in their care. Addressing these concerns not only develops a trusting relationship with the patient, but their concerns provide evidence that we then use to develop their care plan (Weberg & Davidson, 2021). Our system and organization contribute to relationship building and providing evidence by allowing us the time necessary to form this bond with the patient , using the electronic medical record system to send the patients important data and research regarding their procedures, and utilizing a performance-based reimbursement model rather than a fee-for-service model (Weberg & Davidson, 2021).

Patients contribute to shared decision-making by being informed about their care Weberg & Davidson (2021). In anesthesia, patients are usually told in the clinics if they can receive a peripheral nerve block for post-operative pain control. This allows them time to research this procedure and come to us with their questions on the day of surgery; this also gives them time to seek second opinions (Weberg & Davidson, 2021). As providers, we supply the patients with information about their options and are supportive of their decisions regarding their care (Weberg & Davidson, 2021). The organization and system support shared decision-making at MUSC by utilizing conference rooms, teleconferencing, and video calls, and we give the patients the option to link their EMR to another family member (Weberg & Davidson, 2021).

Utilizing EPIC as our EMR makes facilitation and communication between specialists easy. When a patient arrives for surgery, I can easily access recommendations from their cardiologist, pulmonologist, etc., and integrate their recommendations into my anesthetic plan for that patient. This also relieves stress from the patient since they don’t have to worry about remembering what each physician said or bringing records with them. By utilizing this extended medical network, the organization and system at MUSC support and encourage teamwork between the patient, care members, and the organization (Weberg & Davidson, 2021).

Unfortunately, I do not have a COVID-19 patient story to share. I work in ambulatory surgery, and all elective surgeries at my facility were canceled during the pandemic surge. I spent the pandemic making sourdough bread.

Labrague (2021) discusses the influence of nurse manager’s toxic leadership behaviors on adverse events and quality of care; the article can be found here for your reference: https://doi-org.northernkentuckyuniversity.idm.oclc.org/10.1111/jonm.13228Links to an external site. . I will be utilizing this article for this week’s discussion.

In some areas of my organization, I have witnessed gossip and negativity, high absenteeism, distrust of senior leadership, and a lack of transparency with a previous pediatric CRNA. Sherman (2019) lists all these as toxic behaviors. She frequently exhibited favoritism and retaliation to certain staff members but remained in her position because she did what senior leadership told her to do. This distrust in leadership created stagnation and the feeling that it wouldn’t get better; gossip and negativity created diminished relationships and chaos; a lack of transparency affected the staff by distrusting information sharing.

Labrague (2021) defines toxic leadership as “a group of behaviors or actions that are destructive in nature, causing harm, indirectly or directly, to its followers and the organization” that can occur “as a result of the interface between a susceptible subordinate, a destructive leader and an unstable organization.” Toxic leadership affects the team by producing less productive nurses with low performance, high levels of stress, the emergence of physical and emotional distress, and low work satisfaction with high rates of turnover (Labrague, 2021). Impact on the organization and system can include low employee engagement, counterproductive work behaviors, poor communication with patients and their families resulting in complaints, increased patient falls, poor quality of care, medication areas, and increased hospital-acquired infections (Labrague, 2021). These can collectively lead to a failure to achieve the hospital’s mission and values, poor integration of EBP and interprofessional collaboration, and a lack of innovation (Labrague, 2021).

Leaders should be held accountable for their actions, and a no-tolerance policy of toxic should be instituted by senior leadership (Labrague, 2021). In the case of our pediatric chief, she was eventually removed from her position and left the institution. New leaders should be educated on toxic behaviors, given leadership support and opportunities for leader development (Labrague, 2021). Repairing a toxic work environment takes time and patience. Sherman (2019) suggests that instead of focusing on all of the problems, to focus on solutions, relationships, and teamwork to set a positive tone to the action plan. To repair a toxic culture, employees need to feel safe (both physically and psychologically), take ownership of the new behavioral expectations by holding each other accountable to the new goals; leaders should aim to create an environment of trust, hope, and optimism, celebrate and recognize those who are high performers, and most importantly lead by example (Sherman, 2019).

I am proud to say that I have completed my nightly meditation every night so far! The benefits are that I can “shut off” my brain and fall asleep much more quickly, and I feel MUCH more rested with more energy the next morning! The barriers are remembering to plug in my headband speakers in the morning. I am trying to remember to plug it in first thing in the morning after I wake up so that it is ready to go at night.

Labrague, L. (2021). Influence of nurse managers’ toxic leadership behaviors on nurse‐reported adverse events and quality of care. Journal of Nursing Management, 29(4), 855–863. https://doi-org.northernkentuckyuniversity.idm.oclc.org/10.1111/jonm.13228Links to an external site.

Sherman, R. (2019). 4 steps to repairing a toxic culture. American Nurse Today , 14(3), p. 5-7.

Weberg, D. & Davidson, S. (2021). From patient to person-centered care: Re-forming relationships in health care. In D. Weberg & S. Davidsons (Eds.), Leadership for evidence-based innovation in nursing and health professions (2nd ed., pp.317-343). Jones and Bartlett.

Teresia Johnson

There are four patient-centered leadership behaviors listed on page 335, table 12.1. Provide examples from your organization and describe how these behaviors can be used to support patient-centered or relationship-centered care. In addition, if applicable, tell us your COVID/patient story as it related to patient/family-centered care.

A supportive and accommodating built environment is an essential aspect of patient-centered care, Building relationships with patients involves promoting a positive climate, acknowledging patient contributions to his/her health care, forming a trusting relationship, and providing feedback as needed. where co-design with patients is crucial to ensure that patients feel comfortable, and welcomed and have their needs met (Santana et al., 2017). In my organization/psychiatry nursing during admissions, it’s essential to build a trusting relationship by being precise, and truthful with information about the length of treatment, expected discharge, options like signing the 24-hour letter for possible early release, and what it involves.

In providing evidence, providers are encouraged to partner with patients to co-design and deliver personalized care that provides people with the high-quality care they need and improves healthcare system efficiency and effectiveness (Santana et al., 2017). We prepare the patient for situations that warrant emergency medication mainly for the safety of self and others. Review medications including FDA-approved drugs to manage symptoms.

Shared decision-making, involves obtaining consent from parents before the initiation of medications or any procedures as it pertains to behavioral health. Adult clients too are allowed to consent for medications, and involve power of attorney for those who have one. The family especially for adolescents is involved in therapy and also for collateral information

Involve the team, we collaborate with other health care providers and network for the best care possible. If the patient has medical issues, we involve the medical doctor for specific medications. Other team members include social workers, therapists and community liaison

What behaviors can you identify in your organization that might create stagnation and/or chaos or diminish relationships, connections, and information sharing? These are toxic behaviors. What are the consequences to the team, the organization, and the system? How can the leader reverse these consequences? Post your article about toxic leadership here and incorporate it into the discussion as well.

Toxic leadership is a kind of disturbing, malcontent, and malevolent leadership by which an individual, destructive behavior and dysfunctional characteristics as a leader can inflict serious and enduring harm on individuals, groups, organizations, and communities (Milosevic et al., 2020). Some of the behaviors I can identify include lack of communication among team members, favoritism, and almost obviously unfair assignments creating disconnect and poor information sharing.

Consequences include avoiding discussions with certain leaders, calling in, and negative reviews on surveys. The leader can implement a rotating assignment on all units to prevent others from getting burned out from one side with high acuity patients. Leaders to address issues when they are constantly brought up. toxic leaders are described as narcissistic, self-promoters who engage in unpredictable abusive, and authoritarian supervision patterns (Milosevic et al., 2020).

The article states four patterns concerning toxic leadership: egotism are stated as self-centered, ethical failure such as lying, and blaming others, abuse of power, incompetence, poor human relations skills such as listening, and neuroticism (Milosevic et al., 2020). The article also highlights on empowering leadership qualities such as behaviors of sharing, promoting participation, autonomy, delegating activities and responsibilities (Miloseve et al., 2020).

Post your progress with your weekly self-care goal. Have you completed the self-care activity every week? What are the benefits to you of completing the weekly self-care activity? What are the barriers associated with completing your goal? What modifications can you make to increase your participation in the self-care activity between now and the end of term.

. My self-care goals include taking a 5-mile walk twice a week, eliminating meat in one meal add on more vegetables for proper nutrition, and drinking more water as opposed to sugary drinks

Weekly self-care goals – I take a 5 -10-mile walk once or twice a week, The benefits include improved sleep, and help relieve some stress related to work, studies, and family demands. I am including more variety of vegetables in my diet, this has helped me feel better, less bloating, and improved sleep too. I have improved on water consumption and less on “diet” cola. Challenges encountered are mainly finding time to socialize with friends. At the moment with what I have on my hand it’s probably difficult to increase more participation than am giving. When we get the short break from classes, I can have more time to walk more often or meet with friends

Milosevic, I., Maric, S., & Lončar, D. (2020). Defeating the Toxic Boss: The Nature of

Toxic Leadership and the Role of Followers. Journal of Leadership & Organizational Studies, 27(2), 117–137. https://doi.org/10.1177/1548051819833374Links to an external site.

Santana, M., Manalili, K., Jolley, R. J.,, Zelinsky, S., Quan, H., & Lu, M. (2017). How to

practice person-centred care: A conceptual framework. An International Journal of

Public Participation in Health Care & Health Policy, 21(2), 429-440.

https://doi.org/10.1111/hex.12640Links to an external site.

Ingrid LaRrett

-Build relationships- This is the concept of identifying roles, intentions, and purpose of the relationship. This can be relationships with patients, provider, care team, or other resources (Weberg and Davidson, 2021). In my organization, this is done by first establishing the intention of the relationship. This is done when the patient initiates care. They call and inform the office of their needs, whether it is therapy or medication management, and for what diagnoses they are seeking care. After that, they are provided information about the role of each provider and matched with a provider based on patient needs, preference, and availability. Once the relationship intention and roles are established, the patient meets with a therapist or medication provider and an interview/assessment occurs. It is during this time that relationship building really occurs. The patient and provider work together to establish a therapeutic relationship that then grows as they work together. The relationship must start to be established during the first visit due to the intimacy of the information being shared. If the patient or provider are not comfortable or fulfilled in the building of relationship, it is often determined that another provider may be better fitting to allow for building of a therapeutic, empathetic, and supportive relationship. This is an example of patient/ provider relationship building. We also build relationships daily with other providers, support staff, and outside resources.

-Provide evidence- This is the process of educating patients using evidence-based practice (Weberg & Davidson, 2021). This is done daily and with each visit in my organization. An example is when working with a patient after assessing and diagnosing them. It is my job to give them the most accurate and evidence-based information to support the reasoning behind treatment recommendations as well as when explaining risks and side effects of recommended treatments. The care goals and treatments are often determined using algorithms set forth by the DEA or medical boards, but this information is not often necessary to share with patients unless they are interested. My job is to ensure they are comfortable with their treatment goals and plan, as well as provide supporting evidence for these recommendations. Patients like to know the details behind their treatment as well as any supporting or negative evidence that may be prudent. I often share this information as conversation during visits and as printed patient education for external review by patient. This information improves understanding, eases anxiety, aids in decision making, encourages improved compliance, and overall patient outcomes. Studies show that while patients want evidence-based information surrounding their care, they want it to be short, easy to understand, and individualized to their situation (McCormack et al., 2003).

-Shared decision making- This is the concept of allowing patients to incorporate their own support system into their decision-making process rather than going solely on what the provider says (Weberg & Davidson, 2021). We encourage this element in my organization by allowing the patient to decide who and when they want to bring into their visit. We encourage them to have support because mental health and treatment for it are difficult and often controversial. Some patients don’t feel comfortable asking difficult questions, questioning providers, or advocating for their own preferences. This is when having a support person comes in handy for the patient. It is also helpful for the provider because this person can often provide collateral information to help assess patient symptoms and guide treatment. Sometimes it can be difficult because providers can ask questions that cause negative reactions, facilitate stereotypes, or disagree with the provider. In these cases, we must be very supportive and patient. Education is key in these situations.

-Involve the team- To provide good, effective patient- centered care, providers, patients, networks, and other teams must work together. Weberg and Davidson (2021) compares this to the solar system. We are all planets, suns, stars, etc. and the patient is the center that we all focus and revolve around. This is a great analogy and really puts the idea in perspective. Without all the moving parts working together the solar system wouldn’t function properly and ultimately the core, or patient, is the one who suffers. Not collaborating, sharing information, or letting egos stand in the way, can cause a collapse of not only patient- centered care, but the organization as a whole.

Behaviors I have observed within my current, as well as other organizations, are ego centric behaviors, arrogance, bias, professional and personal stigmas, allowing emotions to take control, poor work ethic, and competitiveness. There are any more issues that can create stagnation and diminish relationships. Lack of trust, micromanaging, self-serving leaders, lack of teamwork, and poor communication are a few more examples (Weberg & Davidson, 2021). These are behaviors seen in leaders as well as others and negatively impact the team as well as the organization. These behaviors lead to burnout, poor staff retention, lack of innovation, low productivity, and overall unhappiness of team members. Sherman (2019) describes four steps to repair these behaviors and the culture they create. These include “creating psychological safety, creating new visions and values, building staff ownership of new behavioral expectations, and celebrating successes” (p. 6-7). To create change and new cultural norms, it starts with the leader. Lead by example, be a picture of the change and behaviors you want to see, support and encourage staff, celebrate small and large successes, and involve the team in innovations. To remedy the consequences toxic behaviors, Sull, D. and Sull, C. (2022) describe using a process called “cultural detox”. Their reviewed study showed that the number one cause for stagnation and toxic culture was leadership. The behaviors discussed above are some of the many behaviors they indicate as being causation for toxic culture. Part of the cultural detox is identifying and taking responsibility for your role in the toxic situation. They discuss how toxic behaviors in management “trickles down” and becomes the cultural norm (Sull, D. & Sull C., 2022). To fix this, the leader must change their own behaviors first, practice them regularly, and commit to the change in themselves that they want to see in others.

3. Post your progress with your weekly self-care goal. Have you completed the self-care activity every week? What are the benefits to you of completing the weekly self-care activity? What are the barriers associated with completing your goal? What modifications can you make to increase your participation in self-care activity between now and the end of the term?

I have not done well with my weekly self-care goal. My goal was to complete an exercise at least two days a week. I have only done two since class started. I noticed improvements in my energy levels, mental clarity, and mood after those workouts and my goal was to continue so I could continue to feel those benefits. Sadly, I have fallen short on this goal because of fatigue at the end of the day. My sleep, work, and school life have been altered dramatically over the last three weeks and this has caused increased fatigue, lower energy, lack of motivation, and other priorities taking precedent. I still take time for some self-care, tub soaks, relaxing for ten to twenty minutes without electronics or distractions, and improving the food I eat. I am proud of the self-care I have been doing but I feel I would benefit even more from the original goal I set. To improve achievement of this goal, I could start doing them in the mornings to combat fatigue and start the day off better. I could also set alarms on my phone, set reminders in the area I would perform the goal, tell others about it so they could provide encouragement, or just improve self-discipline. It may also help to adjust the goal slightly and start smaller. Schawbel (2002) explains that self-care is essential for leaders for six clear reasons. Self-care improves productivity, improves mood, focus, decreases stress, improves decision making, re-focuses priorities, and decreases burnout. It also sets a good example for self-discipline, shows vulnerability if you share these struggles, and encourages others to be happy and improve themselves (Schawbel, 2022). I will work on improving and keep you all updated.

References

Chapter Twelve: Weberg, D. and Davidson, S. (2021). From patient0 to person- centered care. Re-forming relationships in healthcare. In Weberg & Davidsons (Eds.), Leadership for evidence-based innovation in nursing and health professions (2nd ed., pp. 317-342). Jones and Bartlett.

McCormack, J. P., Dolovich, L., Levine, M., Burns, S., Nair, K., Cassels, A., Mann, K., & Gray, J. (2003). Providing evidence-based information to patients in general practice and pharmacies: what is the acceptability, usefulness and impact on drug use?. Health expectations : an international journal of public participation in health care and health policy, 6(4), 281–289. https://doi.org/10.1046/j.1369-7625.2003.00226.xLinks to an external site.

Schawbel, D. (2022, February 21). 6 Reasons why leaders should prioritize self-care. Linkedin. https://www.linkedin.com/business/learning/blog/leadership-and-management/6-reasons-why-leaders-should-prioritize-self-careLinks to an external site. https://www.linkedin.com/business/learning/blog/leadership-and-management/6-reasons-why-leaders-should-prioritize-self-care article for db.pdf Download https://www.linkedin.com/business/learning/blog/leadership-and-management/6-reasons-why-leaders-should-prioritize-self-care article for db.pdf

Amanda Rowsey

Patient centered care requires effort from every member on a team and is essential to fully implement evidence-based care (Weberg & Davidson, 2021). Patient centered care leadership behaviors include building relationships, providing evidence, shared decision making, and involving the team. Within the hospice organization there is a great deal effort on building relationships. When I first started working within the organization there was a rift in between the palliative care office and the hospice portion of the organization. Over the past two years, under the direction of a new CEO, the director of nursing was placed over both departments. By doing this there has been increased communication and collaboration between the two departments. Further, by increasing this communication we are all providing better care to our patients in both palliative care and hospice services. Providing evidence-based care is slightly more difficult in the palliative care department, because we often have to deviate due to not having the resources available within the home setting. However, as an organization we do share the goals with the patient and family, as well as make changes as needed. For instance, when a patient needs a liquid medication, rather than pills, but it is not formulary, they support the reimbursement allotted to do what is best for each individual patient. Shared decision-making is at the forefront of each hospice admission. At each admission the policies and procedures are explained, there is time allotted for questions, and it is explained to all family and friends involved that they are an integral part of the care being provided. Lastly, involving the team is crucial in evidence-based care. This is also completed multiple times each week through interdisciplinary team meetings. These meetings are separated into different counties, and a separate one for palliative care. Each meeting involves the director of nursing, the medical directors, other physicians, nurses, social workers, and chaplains. The CEO often makes rounds throughout the facility to “check in” with the various departments, and to make sure all levels within the organization have the means to complete their job to the best of their ability. While the organization is not perfect, we do strive to provide the best environment for the staff and the patients.

Stagnation is defined as a failure to find a way to commit or to get others to commit (Cherry, 2022). Whereas toxic leaders fail to promote stability or often leave a work environment in chaotic condition (Weberg & Davidson, 2021). While I have not noted toxic leadership, there is stagnation within the organization. The organization is a smaller non-profit that has significantly struggled over the past several years, specifically due to the changes of reimbursement and as a reflection of how Covid-19 has affected so many organizations. Due to these barriers, benefits and salary are not comparable to other local facilities. In addition to those issues, providers have been allotted a specific budget for the past two years and we have been unable to use that benefit in its entirety on the education we have chosen due to management stating the funds were not available at the specific time. As a provider, I feel that this is a toxic behavior because it hurts the organization. When providers feel undercompensated, unappreciated, and unvalued it is hard to obtain and retain quality team members who will be willing to stay in that role. In the two and a half years that I have worked within the organization, there have been five nurse practitioners in the palliative care department, with the third resigning at the end of the month. With each one I have talked to, salary, benefits, and underappreciation have been factors in the decision to leave. This hurts the organization immensely because a new provider will have to be hired, oriented, credentialed, and have complete training completed prior to them being able to fill that role. This process can take up to a year, if not longer. This financially harms the organization as well as causes temporary chaos within the department and within the patient care. Consequences will continue until the provider is satisfied with all aspects of the chosen role.

While, I have never thought of my CEO or my CNO as toxic managers, an article by Abdelaliem, F., & Abou Zeid, M. (2023) discussed employee silence is a result of toxic leadership. I do feel like there has been multiple times within my career, that there has been employee silence. Specifically, there are times that there has been conflict and my coworker has decided to not defend herself as opposed to fighting to defend herself. Another instance is, even though we feel slighted over our salary and the educational issues, we chose not to say anything to avoid conflict. It was further reported that silence is defined as “any truthful declaration of an individual’s behavioral, cognitive, and/or affective appraisal of his or her organizational conditions withheld from others deemed capable of influencing change” (Abdelaliem, & Abou Zeid, 2023). On the other hand, they identify toxic leadership as a leader who humiliates employees, has narcissistic behaviors, is only concerned with self-promotion, and demonstrates irregular temperament. Those are not traits that I have noted in my leadership team, so I am currently conflicted on whether I can truly identify toxicity in the organization. Toxic leadership can happen on multiple levels within an organization and can create significant barriers within the organization and the level of patient safety.

My first two goals have not been met at this time. My initial goal was to improve my work life balance, with goal #2 being to take regular lunches. My barrier on my work life balance, is that I care to much about my patients, and I worry about them. For instance, with this being a holiday weekend, I was scheduled to be off work Saturday through Monday. On Sunday, I left my home to go to a funeral visitation for a patient that passed away. On early Monday, I was looking up laboratory results, and coordinating a treatment plan with home health nurses and family members. Then after that I was speaking to another family member regarding the death of another hospice patient. Despite wanting to be able to not work outside of office hours, I seem to be unable to hold myself to that goal currently. I will continue to work on improving that balance, but I am unsure that I will ever completely resolve that. As far as taking a daily lunch, I am continuing to work on that. I am currently drinking protein shakes while driving from patient to patient and I have not set aside a specific time of the day to have a meal. Modifications needing to be made are just setting a clearer boundary for myself. I need to realize that these are things that every employee deserves and to just take the time away from job to self-reflect and to avoid future burnout.

Cherry, K. (2022, February 15). How people develop a sense of generativity vs. stagnation. Verywell Mind. https://www.verywellmind.com/generativity-versus-stagnation-2795734

Abdelaliem, F., & Abou Zeid, M. (2023). The relationship between toxic leadership and organizational performance: the mediating effect of nurses’ silence. BMC Nursing, 22(1), 1–12. https://doi-org.northernkentuckyuniversity.idm.oclc.org/10.1186/s12912-022-01167-8

Weberg, D. R., & Davidson, S. (2021 ). In Leadership for evidence-based innovation in Nursing and Health Professions (pp. 334–367). Jones & Bartlett Learning.

Provide examples from your organization and describe how these behaviors can be used to support patient-centered or relationship-centered care. In addition, if applicable, tell us your COVID/patient story as it related to patient/family-centered care.

Order a plagiarism free paper now

Need your ASSIGNMENT done? Use our paper writing service to score better and meet your deadlines.

Recent Posts