Include all these in the Powerpoint assessment, Diagnosis, and SMART goal. ??Leadership Model/Theory and Plan, ?Implementation, Evaluation, Implement

A Call Light Responsiveness Program Maya Shamailov, MSN, APRN, AG-CNS, PCCN; Suzanne Neal, BSN, RN, CMSRN; James F. Bena, MS; Shannon L. Morrison, MS; Nancy M. Albert, PhD, CCNS, CHFN, CCRN, FAAN

ABSTRACT Background: Purposeful hourly rounding and information on whiteboards in patients’ rooms have been known to reduce use of call lights. Problem: Call light activation was higher than desired. Methods: This continuous improvement initiative used retrospective data collection (pre-, early- and maintenance postintervention) to assess call light responsiveness. Intervention: A bundled purposeful hourly rounding approach was used. Results: Call light frequency was higher in the early postintervention period than in the preintervention; how- ever, there was no change in the frequency of call lights that extended beyond 5 minutes. In the maintenance postintervention period, compared with the pre- and early postintervention periods, call lights per patient/unit day and call lights extending beyond 5 minutes per patient/unit day decreased (all P < .001). Conclusions: Activation of a bundled purposeful hourly rounding approach was associated with a decrease in all call lights and call lights extending beyond 5 minutes per patient/unit day. Keywords: call lights, communication, hourly rounding, patient-centered care, whiteboards

When hospitalized, a patient’s experience isa sum of their interactions with clinical nursing teams and medical outcome. In 2 sys- tematic reviews1 ,2 and a report of best practice,3

hourly rounding was a surrogate for nurse communication and nurse responsiveness. Pur- poseful hourly rounding by nursing personnel traditionally includes 4 Ps: pain, personal needs, positioning, and possesions.3 ,4 Many hospital units endorse hourly rounding as a best practice to reduce call light usage and increase quality of care.1 ,5

Author Affiliations: Office of Advanced Practice Nursing (Ms Shamailov), Bariatric and Metabolic Surgery Unit (Ms Neal), Quantitative Health Sciences (Mr Bena and Ms Morrison), and Office of Nursing Research and Innovation (Dr Albert), Cleveland Clinic, Cleveland, Ohio.

We thank Jennifer E. King, BSN, RN, nurse manager, for her full support of this initiative during all phases of development and implementation, and Kevin Gazley, MBA, senior continuous improvement specialist, who guided the team through the change process.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com).

Correspondence: Maya Shamailov, MSN, APRN, AG-CNS, PCCN, 2070 East 90th St, P32, Cleveland OH 44195 ([email protected]).

Accepted for publication: August 3, 2020

Published ahead of print: September 17, 2020

DOI: 10.1097/NCQ.0000000000000517

A call light system is the primary method of patient-nurse communication in a hospital set- ting, and is often used as a metric of nurse responsiveness.6 Reasons for calls included a need for assistance or medications, to initiate communication with the nurse, and to meet the needs of patients who have other requests.6 In a qualitative study on patients’ perceptions of using call lights, researchers believed that call lights were part of a system of care; in other words, call lights were not to be considered a de- vice; rather, call lights were a way to assure care connections.6 However, call lights can create un- necessary noise for clinicians and patients, that when mitigated could improve patient satisfac- tion with care. Further, when call lights are acti- vated, they create an audible signal that provides a cue to nursing personnel to take action. When nursing personnel respond to call light needs that could have been addressed in a systematic way during rounds, they create a disruption in the care needs and priorities of other patients and in the general workflow.

Purposeful hourly rounding programs may use protocols; however, there is no one standard- ized best practice beyond programs that uses the 4 Ps,3,4 and in a systematic review program features and interventions had heterogeneity.1

Thus, there was not one best practice available to guide nursing personnel in action steps to reduce call light use. Within the Digestive Disease and

Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

J Nurs Care Qual • Vol. 36, No. 3, pp. 257–261 • Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. www.jncqjournal.com 257

258 A Call Light Responsiveness Program Journal of Nursing Care Quality

Surgery Institute, the call light system was pre- viously set to maintain a blinking light until the system was deactivated in patient rooms. Nurs- ing practice stipulated that call lights were deac- tivated after patients’ needs were met. Prior to this intervention, factors associated with timely call light responsiveness were assessed. When summarizing patients’ rationale for call light ac- tivation, 80% of calls were related to needing items, toileting, pain management, and alarm- ing intravenous (IV) pumps. Institute leaders be- lieved that nonadherence to hourly rounding and inconsistent use of communication boards (whiteboards) were issues that affected call light responsiveness. The purpose of this continuous improvement initiative was to enhance nursing responsiveness to patients’ needs, as determined by call light activity, using a bundled intervention approach. The specific aims were to decrease the total number of calls and the number of calls that extend beyond 5 minutes.

METHODS This continuous improvement initiative was con- ducted at a large, urban quaternary care med- ical center in the Midwest United States. The site was a bariatric medical-surgical unit that had 10 private rooms. The patient population was predominantly patients who were recover- ing from bariatric surgery; however, when other units within the Institute were full, overflow was accepted on this unit. The initiative outcomes in- volved retrospective data collection of call light activity during 3 periods: pre- (planning phase), early postperiod, and maintenance postinterven- tion period.

Interventions Based on previously assessed patient needs and using an hourly purposeful rounding framework, interventions were developed beyond the 4 Ps. First, when rounding, nurses updated the pa- tient whiteboard that included names of care providers and the plan for the day. Second, a fifth “P,” for pump, was added to proactively assess IV pump, IV solution, and IV site status and take actions to prevent an alarm. Third, a designated break room was provided that allowed nurses to take a break and be considered off-unit. The des- ignated break room facilitated nursing personnel presence on the unit when not taking a formal break, thus enhancing unit presence and serving to increase responsiveness to call lights. In ad-

dition, unit presence enhanced visibility of nurs- ing personnel to patients, and facilitated meeting patients’ needs preemptively. The final interven- tion component was the creation of a recogni- tion board that acknowledged nursing personnel teamwork. Nursing personnel, including leader- ship, could recognize colleagues for their efforts in hourly rounding and call light responsiveness. Gift cards were delivered to one distinguished team member each month during the interven- tion period, and they were recognized on the board (name and photograph).

Data collection By day, the total of all call lights activated was re- trieved from the call light monitoring system re- port. The call light monitoring system report also provided the length of time the call light was acti- vated. Two coauthors manually counted all calls that exceeded 5 minutes in length. Data were en- tered into an Excel spreadsheet designed for this initiative by 2 of the coauthors. Data collection was completed over a 10-month period in 2018. The initiative preintervention data collection be- gan on January 15 and continued through April 16. The early postintervention period was initi- ated on April 17 and continued until July 16. The maintenance postintervention period initiated on July 17 and continued until November 16, 2018.

Statistical analysis Categorical measures were described using fre- quencies and percentages, and the relationship between time and categorical variables was assessed using Pearson’s χ 2 tests. Normally dis- tributed continuous variables were described us- ing means and standard deviations, and the rela- tionship between time and normally distributed continuous variables was assessed using analysis of variance tests. Nonnormally distributed con- tinuous variables were described using medians and quartiles, and the relationship between time and normally distributed continuous variables was assessed using Kruskal-Wallis tests. Poisson regression was used to compare call light rates between periods. In these models, the number of days in the unit was used as an offset to allow calculation of the rate per unit day. Relative risks with 95% confidence intervals (CIs) are presented. Analyses were performed using SAS Software (version 9.4; Cary, North Carolina).

Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

July–September 2021 • Volume 36 • Number 3 www.jncqjournal.com 259

RESULTS In total, 530 consecutive patients were as- sessed during the 3 assessment periods: 156 dur- ing the preintervention period, 145 during the early postintervention period, and 229 during the maintenance postintervention period. The pre- and early postintervention periods were 3 months in length, and the maintenance postinter- vention period was 4 months in length. Of pa- tients, mean (standard deviation) age was 49.5 (14.2) years, and 71.5% of patients were female. There were no differences in patient characteris- tics and surgical procedure themes based on time (see Supplemental Digital Content Table 1, avail- able at: http://links.lww.com/JNCQ/A766).

The number of call lights during each period varied. Call light use increased in the early post- intervention period, compared with the preinter- vention period; preintervention, 6538 calls/156 patients (41.9 calls/patient and 11.51 calls/ unit day) and early postintervention, 7282 calls/145 patients (50.2 calls/patient and 12.53 calls/unit day); relative risk (95% CI) = 1.08 (1.05-1.12), P < .001 (Figure 1 and see Sup- plemental Digital Content Table 2, available at: http://links.lww.com/JNCQ/A767). However, in the maintenance postintervention period, call lights were reduced by 13% and 20%, respec- tively, relative to the pre- and early postinter- vention periods, 9082 calls/229 patients (39.6 calls/patient and 10.07 calls/unit day) (Supple- mental Digital Content Table 2, available at: http://links.lww.com/JNCQ/A767, includes the relative risks).

Overall, there was a decline in the volume of call lights that were activated and remained acti- vated for over 5 minutes before nursing person- nel responded. The number of calls/unit day that exceeded 5 minutes decreased dramatically dur- ing the maintenance postintervention assessment period compared with the early postintervention assessment period; relative risk reduction was 32% (95% CI, 0.60-0.76); P < .001. By the numbers, the changes during the 3 assess- ment periods were 3.7 calls/patient or 1.03 calls/unit day pre-, 4.0 calls/patient or 1.01 calls/unit day early post-, and 2.7 calls/patient or 0.69 calls/unit day in the maintenance postintervention period (Figure 2 and see Sup- plemental Digital Content Table 2, available at: http://links.lww.com/JNCQ/A767).

DISCUSSION In this continuous improvement initiative, the bundled 4-component intervention to reduce call light activation by patients was successful. The interventions reduced call lights/patient and call lights greater than 5 minutes/patient when the early postintervention periods were compared with the maintenance postintervention periods; however, there was an increase in call light activ- ity when pre- and early postintervention periods were compared. Since hospitalized patients had similar characteristics at all 3 assessment periods, patient factors were not likely to be the reason for our reductions in call light activity. Although we do not have a clear rationale for an increase in

Figure 1. Number of call lights activated per patient/day during each assessment period.

Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

260 A Call Light Responsiveness Program Journal of Nursing Care Quality

Figure 2. Number of calls/unit day that exceeded 5 minutes.

call light activity early after initiative implemen- tation, we believe that adoption of the bundled intervention took time to diffuse into everyday practice.

Few reports in the literature discussed the effect of hourly rounding on call light use. Using a quasiexperimental design, an hourly round- ing intervention decreased 6-month call light use among the experimental group, compared with a usual care group; however, in the 6 months following the end of the data collec- tion period, there were no longer differences between groups.5 In another study, call light responsiveness did not differ between pre- and postintervention groups that were assessed 3 months apart.3 In the final study, the author provided a table that reflected that call light use trended lower at 9 months after initiat- ing hourly rounding4; however, no inferential statistics were provided to substantiate findings. Our call light activity/patient was significantly reduced over time, especially from the 3-month early postintervention data collection period to 7 months after the bundled intervention was introduced. It may be that the combination of a whiteboard that facilitated plan of care communication between patients and nurses, purposeful hourly rounding that included the fifth P, use of a designated break area that en- sured nurse visibility and presence on the unit when not on a break, and a recognition program was superior to initiatives that only focused on 1 intervention, especially in relation to sustaining outcomes.

Of the bundled intervention components, use of a patient whiteboard has been discussed in the health care literature. In 1 report, patients’ ability to remember their provider’s name and satisfaction with care improved when a vi- sual tool, specifically a whiteboard, was used.7

Whiteboards allow for transparency in commu- nication and individualization, both of which support patient-centered care8 and facilitate agreement of goals of care between providers (nurse caregiver, attending physician, nurse prac- titioner, or fellow).9 Whiteboard communication improved teamwork and supported interpro- fessional communication,8 possibly because messages were updated and displayed in loca- tions that fostered reading. The full potential and efficacy of whiteboards as a means of enhancing responsiveness has not been examined.8 Further, no literature was available that assessed the association between use of whiteboard messages and call light activation. Whiteboard use may be enhanced when there are established unit-based guidelines and best practices for content and for review and updates.

Limitations There were some limitations to this continuous improvement initiative. Data were assessed on 1 specialty unit of single center in a Midwest hospital, and involved a small number of care- givers. The population was younger than global medical-surgical patients treated in many adult hospitals. It is possible that the younger patient population may have had less (or more) needs

Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

July–September 2021 • Volume 36 • Number 3 www.jncqjournal.com 261

requiring call light responses. The bundled inter- vention may be more difficult to sustain than an intervention with 1 component. Sites with a cul- ture of responsiveness that differs from ours and those without diffusion plans, quality improve- ment leader monitoring, or evaluation of out- comes may have a difficult time with systematic uptake and utilization of the interventions.

CONCLUSIONS Total number of call lights and call lights with response time that extended beyond 5 minutes were reduced after introducing a bundled ap- proach that included 3 interventions: purposeful hourly rounding using 5 Ps and whiteboard com- munication, designation of an employee break room, and a unit-based employee recognition program. It is unknown which components of the intervention were most powerful, or if the combination of all components prompted im- provements in call light outcomes.

REFERENCES 1. Mitchell MD, Lavenberg JG, Trotta R, Umscheid CA. Hourly

rounding to improve nursing responsiveness: a systematic re- view. J Nurs Adm. 2014;44(9):462-472. doi:10.1097/NNA. 0000000000000101

2. Sims S, Leamy M, Davies N, et al. Realist synthesis of in- tentional rounding in hospital wards: exploring the evidence of what works, for whom, in what circumstances and why. BMJ Qual Saf. 2018;27(9):743-757. doi:10.1136/bmjqs- 2017-006757

3. Daniels JF. Purposeful and timely nursing rounds: a best prac- tice implementation project. JBI Database System Rev Imple- ment Rep. 2016;14(1):248-267. doi:10.11124/jbisrir-2016- 2537

4. Brosey LA, March KS. Effectiveness of structured hourly nursing rounding on patient satisfaction and clinical out- comes. J Nurs Care Qual. 2015;30:153-159. doi:10.1097/ NCQ0000000000000086

5. Krepper R, Vallejo B, Smith C, et al. Evaluation of a standard- ized hourly rounding process (SHaRP). J Healthc Qual. 2014; 36(2):62-69. doi:10.1111/j.1945-1474.2012.00222.x

6. Montie M, Shuman C, Galinato J, Patak L, Anderson CA, Titler MG. Conduits to care: call lights and patients’ percep- tions of communication. J Multidisc Healthc. 2017;10:359- 366. doi:10.2147/JMDH.S144152

7. Pimentel VM, Sun M, Bernstein PS, Ferzli M, Kim M, Goffman D. Whiteboard use in labor and delivery: a tool to improve patient knowledge of the name of the delivery provider and satisfaction with care. Matern Child Health J. 2018;22(4):565-570. doi:10.1007/s10995-017-2425-6

8. Cholli P, Meyer EC, David M, et al. Family perspectives on whiteboard use and recommendations for improved practices. Hosp Pediatr. 2016;6(7):426-430. doi:10.1542/hpeds.2015- 0182

9. Justice LB, Cooper DS, Henderson C, et al. Improv- ing communication during cardiac ICU multidisciplinary rounds through visual display of patient daily goals. Pedi- atr Crit Care Med. 2016;17(7):677-683. doi:10.1097/PCC. 0000000000000790

Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

 Improving Hand-off Report

Student Names

Team Name and First/Last Names of Participants

Problem 

Report (timing and hand off errors):  The unit manager of a medical surgical unit has observed that change of shift report takes greater than 45 minutes.  In addition, staff has complained that their peers do not include vital data (IV sites, dressing sites, DVT prevention measures….) in report leading to errors, leave patients in disarray, and leave tasks incomplete.  Our task is to propose a change that will address these issues. 

Report (timing and hand off errors:  Unit managers observed that there was miscommunication between staff during shift report.  Often times leaving out important patient information as well as taking a significant amount of time to relay the information. Our goal it to offer a change that will address these issues. 

Now here is our SWOT analysis starting off with Derrick talking about the strengths.

Majka 

"Communication failures compromise patient treatment, care quality, and safety. It also leads to medical errors, the third leading cause of deaths in the United States" (Ghosh, et all., 2015)

"The varying parties and large amount of complex information included in patient handoff reports frequently contribute to informational gaps and omissions in the handoff report that can lead to sentinel events and patient hard" (Staggers & Blaz, 2013)

"Research has identifed handovers as a risky time in the care process, when information may be lost, distorted or misinterpreted (Borowitz et al 2008, Owen et al. 2009, Philibert 2009)

Report (timing and hand off errors):  The unit manager of a medical surgical unit has observed that change of shift report takes greater than 45 minutes.  In addition, staff has complained that their peers do not include vital data (IV sites, dressing sites, DVT prevention measures….) in report leading to errors, leave patients in disarray, and leave tasks incomplete.  Your task is to propose a change that will address these issues. 

Increase of errors during patient hand-off report leading to missed information and incomplete tasks 

Hand-off report time is taking a greater deal of time 

Our task is to implement the use of SBAR as the standard hand-off report between shifts in order to reduce errors and decrease the time spent giving report. 

2

SWOT

Strengths: Multidepartment focus addressing handoff report problems(Robins et al., 2017) Solutions shorten time taken in report while increasing quantity of pertinent information. (Stewart & Hand, 2017) SBAR is supported by the Joint Commision (Stewart & Hand, 2017) Proven error reduction due to use of SBAR tool. (Stewart & Hand, 2017) SBAR is an evidence-based hand-off tool (Eberhardt, 2014)	Weakness Use of the tool requires education to reduce user error (Stacey Eberhardt 2014) Medical personnel have personal bias on giving report (Ghosh et al.,  2018) Some staff are unreceptive to change (Robins & Dai, 2017). Evaluating execution of report can be affected by observer bias (Robins & Dai, 2017)
Opportunities SBAR is inexpensive as a tool and will earn its cost in education by the reduction of sentinel events (Stewart, 2017) Improve patient handoff by implementing an evidence-based handoff tool in SBAR format  (Eberhardt, 2014) For continued nursing education in standardizing hand-off report (Ghosh et al., 2018).	Threats Due to the variety of the change-of-shift reporting process, the findings of the study may not be applicable across similar settings (Ghosh et at., 2018). Some staff are unreceptive to change (Robins et al., 2017). Evaluating execution of report is subject to observer bias (Drach-Zahavy, 2014)  Small sample sizes from 2 studies: only one randomized control study (Stewart, 2017)

Strengths:

Multidepartment focus on addressing problems with handoff report (Robins et al., 2017)

Solutions manage to shorten time taken to give report while increasing the amount of pertinent information given in that time frame. (Stewart & Hand, 2017)

SBAR is supported by the Joint Commision (Stewart & Hand, 2017)

Error reduction due to use of SBAR tool. (Stewart & Hand, 2017)

SBAR is an evidence-based hand-off tool (Eberhardt, 2014)

Weakness (Wendy) 

Use of the tool requires education for all staff to reduce user error (Stacey Eberhardt 2014)

Medical personnel have personal bias on how they want to give report (Ghosh et al.,  2018)

Healthcare worker disinterest in changing how they give report. (Robins et al., 2017).

Subjective approach to measuring a handover’s strategies might be subject to bias, as participants may behave differently in the presence of an observer.

Opportunities (ashley) 

SBAR is inexpensive as a tool and will earn its cost in education by providers by the reduction of sentinel events (each of which carries a high expense). (Stewart, 2017)

Improve patient handoff by implementing an evidence-based handoff tool in Situation Background Assessment Recommendation (SBAR) format  (Eberhardt, 2014)

For continued nursing education in standardizing hand-off report (Ghosh et al., 2018).

Threats (Alma)

Due to the variety of the change-of-shift reporting process, the findings of the study may not be applicable across similar settings (Ghosh et at., 2018).

The acuity of patient injury and medical history can increase the amount of time for patient hand-off (Robins, 2017).

Small sample sizes from 2 studies: only one randomized control study (Stewart, 2017) and sample size of 200 handovers in 5 wards in another study(Drach-Zahavy, 2014)

3

Assessment 

Inefficient communication during hand off report is a challenge to patient care. (Ghosh, et al., 2018)​

Communication error given during report increases risk of poor patient outcomes. (Stewart, 2017)

​

Hand off communication between medical personnel leads to an increase in medication errors, incomplete tasks, disorder, and eventually poor patient outcomes (Robins et al., 2015)​

According to The Joint Commission, communication errors have been among the top three leading root causes of reported sentinel events every year since 2004. (Stewart, 2017)

The information we had gathered from our assessment on giving report overall was - 

1. Poor communication leads to poor patient outcome 

2. The Joint Commission has stated communication errors has been the top 3 leading root causes of unanticipated major events in the healthcare setting that results in death or serious physical or psychological injury to a client which require immediate investigation by the health care facility since 2004

3. And now we will be talking about our Diagnosis.

Goal should comes from assessments (SMART (MEASURABLE))

Assessment will be bullet points of why is this a problem 

Specific, measurable, attainable, realistic, timely

All RNs and assistive personnel will attend 1 or more in-services on the use of SBAR handoff report within three weeks.

During the same three week period, charge nurses and nursing management will include SBAR teaching in pre-shift meetings, encouraging staff to begin to practice using the SBAR template during report.  Following the three week introduction of SBAR to the staff, SBAR will be implemented on the unit for a trial period of 1 month with the goal of receiving ideas of how we can improve it from the staff at the end of the 1 month period.  At the end of the one month period, staff nurses and assistive personnel will be invited to discuss their experiences with SBAR, as well as any ideas they have to improve it, during pre-shift meetings, down-time during their shift, or via email with the nurse manager.

15 days into the trial month, as well as at the end of the trial month, the nurse manager will personally solicit input regarding SBAR from harvest nurses on the unit.

At the end of the 1 month trial period, metrics on sentinel events, falls, nosocomial infections, and other communication errors will be compared with the month prior to SBAR implementation and to the same month in the previous year. During the second month, a new SBAR form that includes select suggestions from staff will be used by those staff members while other staff members continue to use the known SBAR report. Communication errors, sentinal events, falls, nosocomial infections, et al will be compared between the two systems. 

Majka 

4

Diagnosis

Lack of standardization in report

Communication Barriers (Stewart & Hand, 2017) 

Communication practices learned by various career stages of nurses (promise, momentum, harvest) 

Different individual communication styles

Gaps in knowledge regarding lack of standardized reporting

A lack of standardization in report increases risk of error and poor patient outcomes

5

S.M.A.R.T. Goal

Use an evidence-based standardized hand-off report tool to reduce report times to less than 45 minutes while reducing report-based errors by 20% within 6-month period. 

Precontempemplation: Nurse manager goes to charge nurses, harvest nurses, and harvest support staff with the SBAR template and asks them to sit with it for one week. He or she will ask for feedback from these individuals about implementing it on the unit. 

Contemplation: Harvest nurses and support staff, and charge nurses spend a week with the SBAR template and consider its strengths, weaknesses, and or simply form an opinion around it.   Preparation: nurse manager introduces in-services on SBAR and charge nurses begin introducing the template during pre-shift meetings. 

Action: Nurses and support staff begin using the template during all hand-off reports for a one month period. Nurse manager seeks input from harvest staff on ways to improve the system and attempts to include their input on a trial period, thereby extending the practice of the original SBAR for another month with most staff, and offering a personalization to those interested in improving the system.  Maintenance: Nurse manager compares statistics from the same time period one year ago, to the same length of time prior to using the SBAR report, and the data from the SBAR report compared with the modified SBAR report and presents the data to the staff at a staff meeting. At the meeting the nurse manager encourages public input and opinions on the SBAR report. If there is resistance, the manager asks that SBAR be continued in practice for a 3 month period in which he or she will personally receive report from individuals on their patients – helping those nurses who need it with ways to be more succinct. At this point,

Collepals.com Plagiarism Free Papers

Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.

Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS

Why Hire Collepals.com writers to do your paper?

Quality- We are experienced and have access to ample research materials.

We write plagiarism Free Content

Confidential- We never share or sell your personal information to third parties.

Support-Chat with us today! We are always waiting to answer all your questions.