Last Updated 18 Jun 2020

Effective Efficient Stroke Rehabilitation Programme Health And Social Care Essay

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The World Health Organisations Atlas of Heart Disease and Stroke states 15 million people worldwide suffer a shot each twelvemonth, ensuing in 5 million decease and 5 million instances of lasting disablement ( Mackay & A ; Mensah, 2004 ) . The European Stroke Initiative ( EUSI ) Guidelines noted that shot is either the 2nd or 3rd highest cause of decease in industrialized states ( Hacke et al, 2003 ) . In footings of consequence of shot on society, Stroke is projected to be around 61 million Disability Adjusted Life Years ( DALYs ) worldwide by 2020, compared to 38 million in 1990 which means an addition of 60 % ( Mackay & A ; Mensah,2004 ) .

Harmonizing to the World Health Organisation ( WHO ) , stroke takes the 2nd universe broad taking cause of mortality ensuing in 5.5 million deceases per twelvemonth. Two tierces of those deceases occur among people populating in developing states. In add-on, many subsisters of shot have to set to a life with changing grades of disablement ( World Health Organisation ) .

In the UK shot is the 3rd most common cause of decease, and the most common cause of disablement. More than 250.000 people live with damages due to stroke. Almost tierce of the people who had a shot are left with disablements. ( The Stroke Association,2010 ) . Stroke seashore England and Wales society about ?7 billion per annum.

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The World Health Organisation ( WHO ) defines Stroke as: '' quickly developed clinical marks of focal ( or planetary ) perturbations of intellectual map, enduring more than 24 hours or taking to decease, with no evident cause other than vascular beginning '' ( Edmans, 2001.P:1 )

The chief causes of Stroke are: 1. Ischemia taking to misdemeanor ( deficiency of bleed supply to a specific country taking to a hapless blood supply, caused by an intercalation by bosom, aorta, carotid or vertebral vass. 2. Bleeding ( shed blooding from a vas due to high blood pressure or unnatural coagulating it could be in subarachnoid, subdural, intracerebral or epidural countries ( Edmans, 2001 ) . 80 % are due to ischaemic causes and 20 % due to hemorrhagic causes. ( Bartel, 1998 )

Stroke can do any or all of the undermentioned neurological effects, which may or may non be transeunt, or even can be lasting and remain after rehabilitation ( The Stroke Association, 2010 ) :

Damage or loss of esthesis in the limbs or face.

Hemiplegia ( loss ) or Hemiparesis ( damage ) of motion in the limbs or face.

Aphasia ( loss ) or Dysphasia ( damage ) of the ability to bring forth ( expressive ) or to understand ( receptive ) address,

Dysphagia ( trouble get downing )

Apraxia ( deficiency of ) , or Dyspraxia ( damage ) in coordination of motion.

Neglect ( deficiency of or decrease of consciousness of one side of the ocular fieled )

Emotional instability.

Concern

Incontinence or jobs with bladder control.

Ocular shortages.

The bulk of Stroke subsisters need Rehabilitation to better Health and minimise disablements ( Aprile, 2008 ) . As a consequence shot subsisters comprise the largest class of patient in rehabilitation ( Gnocchi et al, 2008 ) . The EUSI guidelines noted that rehabilitation demands to get down every bit shortly as the patient is stable clinically, and should go on every bit far as betterment in map is observed.

Within the literature many writers define Rehabilitation ( Davis 2006 ) . ( Barne and Ward 2000 ) defined rehabilitation: '' An active and dynamic procedure by which a handicapped individual is helped to get cognition and accomplishments in order to maximise physical, psychological, and societal map. It is a procedure that maximizes functional ability and minimizes disablement and disability '' . ( P.4 )

In the recent twelvemonth Client centeredness has emerged as an of import rule for wellness bringing and rehabilitation services ( chooser institute, 2000 ) and it 's considered to be a cardinal constituent of good pattern ( Law et al, 1995 ) . Whiteneck ( 1994 ) noted that '' an person should be viewed as the primary focal point of the rehabilitation and end scene procedure and subjective perceptual experience are needed to make full the spreads left by nonsubjective appraisal '' ( P:1074 ) . However, the precedences between the wellness attention professionals and clients may differ, as a consequence patients may non desire to accomplish the identified end.

Client centred rehabilitation has been described as a plans that helps to run into persons ( people with long term disablement ) needs, by fixing them for life in the existent universe, engagement in end planning and determination doing with wellness attention professionals, and to affect the household throughout the rehabilitation procedure ( Cott,2004 ) . The authorities modernization docket for national wellness services ( NHS ) mentioned the demand for greater partnership and engagement of service users at every degree of health care system ( Department of Health ( DOH ) , 2005 ) . Peoples with shot should hold the opportunity when possible to take determination about their intervention and attention, with partnership of health care professionals ( NICE clinical guidelines 68-stroke, 2008 ) . Stewart ( 2001 ) noted that `` being patient centred really means taking into history the patients ' desire for information and for sharing determination devising and reacting suitably '' ( P: 445 ) .

Client centred attack has been defined as one that is '' based on the belief that the client is the of import individual in the relationship and that he has the resorts and ability to assist himself given the chance to make so '' ( Dexter & A ; Wash 1986, P ( 17 ) cited in Sumison T,2006 P ( 5 ) ) . Client centred pattern can be described as an attack that embraces partnership with people utilizing services ( Restall et al,2003 ) , it besides offers a displacement from the traditional medical theoretical account provided by the wellness attention practicians ( Wright & A ; Rowe,2005 ) . The medical theoretical account embarrasses the position that the wellness attention professionals are the experts, who have all the power and authorization to command others. In other words clients are defined through their medical conditions ( unwellness ) and treated as dependent on the wellness attention professionals ( Barbore, 1995 ) . Hunt ( 1993 ) noted that, the medical theoretical account was the dominant position for a long clip where wellness attention professionals held the position that `` rehabilitation can be used to cut down disablement be assisting people relearn accomplishments and adapt themselves to a universe in which able bodiedness is the norm '' ( P: 130 ) . On the other manus the societal theoretical account argues that it is the society that disabled the individual. How the society treats disablement ( Barnes & A ; Mercer, 2003 ) . Client centred can be applied in both the social/medical theoretical account environment as it creates a natural balance between them ( Falardeau & A ; Durand, 2002 ) .

Pollock ( 1993 ) noted that client centred attack takes into consideration ends that are set by the client harmonizing to his/her ain position of the job, as a consequence it encourages and increases the individuals possible and engagement during rehabilitation. In add-on puting ends may assist persons to work out his/her jobs and the feeling of control over their wellness addition.

Harmonizing to the shot statistic mentioned antecedently, and the extremely cost of intervention and rehabilitation for shot subsister. Therefore, to find an effectual and efficient rehabilitation plan, might better or find efficient and effectual overall results for these turning subsisters.

This thesis will consist the undermentioned chapters: the preliminary literature reappraisal where the organic structure of cognition will be discussed in deepness. This chapter sets to detect what is already known about client centred attention, its definitions, nucleus elements, barriers and restrictions, and client centred end scene, stoping with a clear statement of the research inquiry for this survey. The Methodology chapter will discourse and warrant the paradigm and methodological analysis used for this thesis and why is it appropriate for this survey. Then it will travel to the Methods chapter where the procedure of seeking the literature will be demonstrated, search term, inclusion and exclusion standards, and the chosen tools used to critically analysed, synthesise and analyze the cardinal articles. The consequences chapter will put to critically measure the cardinal articles utilizing `` measure by measure '' model to compare their strength and failing to be able to judge the consequences and findings of these surveies. In the Analysis chapter subjects and codifications that emerged from the cardinal documents will be presented, and compared harmonizing to the strength of the grounds. The treatment chapter will associate the findings and consequences from the analysis chapter ( subjects ) with what is already known about the subject from the literature reappraisal. Furthermore, restriction and recommendation for the current survey will be mentioned in this chapter. Finally, the in decision chapter the writer will summarize the findings, and do a recommendation for future academic work.

WHY THIS Question

Working in the UK in a neuro rehabilitation environment had been an oculus opening experience. This experience has unambiguously directed the writer towards the field of rehabilitation. What entreaties to the writer the most about rehabilitation is the client centred attack to patients attention. The purpose of this survey is to reexamine the literature about client cantered attention, taking to detect the benefits of implementing client centred attention in shot rehabilitation pattern, and what attitude should both wellness attention professionals and clients need to travel through to encompass client centred pattern. After deriving this Msc degree the writer is be aftering to travel back place and seek to implement and utilize the grounds gathered in this undertaking to educate wellness attention professional 's pupil. As in my state ( Jordan ) Client centred attack is non yet practised by both the persons and the professionals excessively in rehabilitation units. That means that while handling or even puting ends of a patient, household are the 1s involved chiefly in be aftering everything for the patient non the patient himself, in another words Professionals have to handle the whole household non the persons.

Chapter TWO

PRELIMINARY LITERATURE REVIEW

This chapter aims to put the land for the survey to be taking, by analyze the exciting cognition in client centred attack. Shadowing an overview of client centred pattern, a assortment of definition for Client centred will be discussed from medical, nursing and occupational therapy position. Subsequently on, the nucleus elements of client centred will be discussed in deepness.The chapter will besides discourse the challenges to implement client centred practise and how to get the better of them. Finally, client centred end scene will be defined and explained. By the terminal of this chapter the research inquiry will be demonstrated.

Rogers theory of therapy

Carl Rogers was the first to depict client centred, Rogers stated that the focal point of any intercession should be based on the clients concern `` The function of the healer harmonizing to Rogers is to ease job work outing through exciting the individuals desire and ability to understand jobs and suggest solution that are appropriate for his/her life '' ( jurisprudence & A ; Mills, 1998: Cited in Richared & A ; Lauri,2010 ) . Client centred therapy describes Carl Rogers manner of working with people sing jobs in populating due to personal perturbations ( Rogers,1980 Cited in Kazantzis & A ; Labate,2007 ) . In 1939, Rogers developed his ain theory of psychotherapeutics with troubled kids, so after that he tried to spread out this theory by including households, twosomes and groups. In 1959 his theory of group interaction and interpersonal relationship, every bit good as theory of motive and personality development was published. The theory of motive came up from Rogers observation to clients development within the curative relation ( Kazantzis & A ; Labate, 2007 ) . Based on his experience as a clinical psychologist, Rogers noted that `` individuals possess resources of self-knowledge and ego healing, and that personality alteration and developments are possible if a definable clime of facilitative conditions is present '' ( Rogers, 1980 Phosphorus: 115 ) . Ryan & A ; Deci ( 2000 ) besides noted that a ego directed/driven procedure might take to a better ego apprehension and credence. Witty ( 2007 ) demonstrated that `` Rogers felt that all life beings are continually realizing their potency, even under unfavorable fortunes '' ( P: 36 ) . Rogers ( 1980 ) did compose about a murphy in his male child hood place:

`` The actualizing inclination can, offcourse, be thwarted or warped, but it can non be destroyed without destructing the being. I remember that in m boyhood, the bin in which we stored our winter 's supply of murphies was in the cellar, several pess below a little window. The conditions were unfavorable, but the murphies would get down to shoot pale white sprouts, so unlike the healthy green shoots they sent up when planted in the dirt in the spring. But theses sad, spindly sprouts would turn 2 or 3 pess in length as they reached towards the distant visible radiation of the window. The sprouts were in their bizarre, ineffectual growing, a kind of despairing look of the directional inclination I have been depicting. They would ne'er go workss, ne'er mature, ne'er fulfil their existent potency. But under the most inauspicious fortunes, they were stiving to go. Life would non give up, even if it could non boom... .. This powerful constructive inclination is an implicit in footing of the person-centred attack ( Rogers,1980 P:118-119 )

Overview of the client centred attention construct

In 1980 Health publicity was established, it was based on, that the clients should be involved in wellness attention and to be responsible of their ain wellness, in add-on consumers right, technological revolution and human rights all of which helped to develop the construct of client centred pattern ( Gage, 1994, jurisprudence et al,1995 cited in Sumsion,2006 ) . Furthermore, the Canadian Association of Occupational Therapists ( CAOT ) has embraced the construct of client centred, as in 1980 ( CAOT ) and the Department on National Health and Welfare the Guidelines for Client Centred Practice of Occupational Therapy been produced ( Richared L & A ; Lauri K, 2010 ) , in add-on The American Occupational Therapy Association ( AOTA,1998 ) , the Commission on Accreditation of Rehabilitation Facilities ( CARF,1989 ) , and the Joint Commission on Accreditation of Healthcare Organization ( JCAHO,1992 ) all of those administrations did emphasized on the demand for client centred pattern. The chief end and purpose of The National Service Framework for Long Term Condition for people with long term conditions to to the full back up persons to be able to pull off themselves, maintain independency to acquire to the best possible quality of life. Universities are besides admiting the demand to alter the manner future healer and physicians are educated, for blink of an eye, the medical school at a Canadian university adapted a patient-centred method as the focal point of the course of study, as it acknowledge and belief that, a patient has a disease but besides an illness experience that differs from one to another ( Western Alumni,1997 ) . The above illustrations may take to a decision that client centred pattern is supported and recognised by wellness attention professionals and the wellness attention system.

What is client centred pattern?

Client centred attention has many definition within the literature, nevertheless, a cosmopolitan definition does non be ( Stewart, 2001 ) . Client centred pattern within occupational therapy is has been defined as `` an attack to supplying occupational therapy which embraces a doctrine of regard for and partnership with people having services. It recognises the liberty of persons, the demand for client pick in doing determination about occupational demand, the strength clients bring to an occupational therapy brush and the benefits of the client healer partnership and the demand to partnership and the demand to guarantee that services are accessible and fit the context in which a client lives '' P: 253 ( Law et al, 1995 cited Sumsion, 2006 Phosphorus: 5 ) . In add-on Sumsions ( 2000 ) conducted a interviews to find how client centred was define by occupational healer, and concluded the undermentioned definition of client centred pattern is `` a partnership between the client and the healer the empowers the client to prosecute in functional public presentation to carry through his or her occupational regulations in a assortment of environments, the clients participates actively in negociating ends which are given precedence and are at the Centre of appraisal, intercession and rating. Throughout the procedure the healer listen to and esteem the clients value, adapt the intercessions to run into the client 's demands and enables the client to do informed determination '' ( Sumsion, 2000 cited in Sumsion & A ; Law, 2006 ) ( P:308 ) .The British Association of Occupational healer ( 1994 ) definition of client centred pattern is '' the re-design of patient attention so that infirmary resorts and personal attention are organised around patients instead than around assorted specialised section '' ( P:1 ) . The College of Occupational Therapist supports the client-centred attack to intercession by saying within the codification of moralss and professional behavior that service should be client-centred and needs led ( College of Occupational healers 2000 ) .

In medical specialty, patient centred attack was seen as `` the physician attempts to bury the patients universe to see the unwellness through the patients eyes '' ( Mcwhinney,1989 cited in Mead & A ; Bower, 2000 ) . In the medical literature client centred pattern focal points on the issues of communicating between the wellness attention professionals ( Doctors ) and clients which is one constituent of client centeredness. Finally, in nursing literature client centred attention is a doctrine of attention, which includes the emotional, religious, societal and the physical demands of the client, and a common coaction between the client and wellness attention professionals ( Nurses ) ( Millers & A ; Koop, 1984 )

The above definitions might take to a decision that communicating, partnership and regard for patients is a nucleus demand for client centred attention.

The end of client-centred pattern is to explicate a stamp, lovingness, and authorising environment in which clients direct all of the procedure attention to rush the healing results ( Matheis-Kraft et Al, 1990 ) . In order for this to go on a repositioning in power should reassign from the healer to the client, with single authorization as cardinal ( Gage and Polatajko, 1995 ) .

Larsson Lund et Al ( 2001 ) mentioned that the client should be the one in charged over their wellness because the quality of life is more indispensable than curative jobs. Clients can take part in client centred pattern by being involved actively in treatment ( Degnen, 2002 ) , intervention planes and end settings. ( Gage,1994 ) . Stewart ( 2001 ) noted that `` being patient centred really means taking into history the patients desire for information and for sharing determination devising and reacting suitably '' ( P:445 )

One of the cardinal values of client-centred attack is for wellness attention professionals to bury patients universe through seeing their unwellness from the patients eyes ( Brown et al, 1989 ) , McCracken et Al ( 1983 ) besides agree with this value, by saying that client-centred attack is based on, that wellness attention professionals have to understand the unwellness from the patients perspective, non merely construing the unwellness from the medical point of position. Health attention professionals should seek to spread out the illness experience of patients by holding a clear thought about the patient 's feelings, frights and thoughts about what is incorrect, outlooks from wellness attention professionals and how did their unwellness affect on their operation ( Watson et al, 1989 ) .

Core elements of client centred pattern

Sumsion & A ; Law ( 2006 ) where the one time who delineated the five nucleus constructs of client centred pattern: a figure of old surveies came out with the same thoughts

This is besides referred in the literature reappraisal where it had been stated that..

Power

To understand the influence of power is a cardinal value to implementing and apprehension of client centred pattern. Control, strength and fight are cardinal constructs within the thought of power. To implement a client centred pattern wellness attention professionals needs to understand the balance of power between clients and healer ( Honey,1999 ) , the balance of power within client centred pattern means a displacement in power from the rigorous traditional medical paradigm to one the dressed ores on the clients need ( Falardeau & A ; Durand,2002 ) . nevertheless, Corring ( 1996 ) cited in sumsion & A ; jurisprudence ( 2006 ) found that wellness attention professionals might hold the power over the clients and that clients are disempowered by the wellness attention system, French ( 1994 ) agreed with Corring ( 1996 ) and did depict the relationship between healer and clients as `` is an unequal relationship with the professionals keeping most of the power. Traditionally professional workers have defined, planed and delivered services, while handicapped people have been inactive receivers with small if any chance to exert control '' . ( p103 ) . Once this power is accepted and understood from both the clients and wellness attention professionals, both can work collaboratively and clients can command their ain wellness and go equal spouse in wellness attention alternatively of ever seeking aid from professionals ( Sumsion, 1999 ) .

Listening and pass oning

Effective communicating by utilizing the appropriate linguistic communication is a cardinal component to see an effectual coaction and partnership between wellness attention professionals and clients ( Townsend,1998 ) , this communicating includes clients, his/her household and all of the squad member ( Kraft M et al,1990 ) , listening is an of import facet of communicating ( Webster,2001 ) , which can be addressed by leting the client to show his/her values, beliefs and issues they are confronting, sing his/her experience with damage ( Harrison,2001 ) , in order for this to go on healer should be patient and take clip to listen even though if what is expressed does non do sense to therapist. Otherwise, clients might experience non valued or respected ( Hanman, 2001 ) , as consequence, healer may experience pressured as they might happen it hard to give clients sufficient clip, ( Fondiller, Rosage & A ; Neuhaus, 1990 ( P:51 ) stated this remark `` When clip is measured in 15 units how can at that place be patient centred intervention? ''

Therefore, the wellness attention professionals might confront the challenge to alter the traditional relation with clients and switch it towards partnership ( Rosenbaum et al, 1998 ) which is traveling to be discussed following.

Partnership

Professional and affectional partnership between the client and wellness attention professional is needed to see that maximal attention is provided ( Levitan,1997 ) , in client centred pattern clients should play the major and active function in settings ends and results, on the other manus wellness attention professionals are the expert that provides information, cognition and intervention to assist clients to travel on ( Rosenbaum et al,1998 ) , being client centred is clip devouring, nevertheless the clip spent will heighten the relationship between clients and wellness attention professionals, which will take to a long term benefits ( Joness et al,2004 ) . The construct of client centred requires a partnership between health care professionals and the client, this partnership is chiefly based on healer willingness to listen to the clients point o position and position about disability/impairment and what is his/her experience of being disabled/impaired like ( Sumsion & A ; law,2006 )

Choice

Choice is an of import and a cardinal component in client centred pattern, nevertheless pick component depends on the degree of unwellness or disablement, and the capability/ability of client to do determination. Health attention professional should include a scope of picks for the client to take from throughout the intercession procedure ( Sumsion & A ; Law,2006 ) , and to bare on head that each client is a alone person who should be provided with the information in a apprehensible, and afford the client the opportunity and chance to take the best class of action harmonizing to his/her values and wants ( Law, Baptiste & A ; Mills,1995 )

Hope

`` Hope is the outlook that something good will go on in the hereafter and that the client ca n't populate without it `` ( Von gunten, 2002 Phosphorus: 1421 ) . Throughout client centred pattern, it is of import for clients to keep hope. Health attention professionals should understand the importance of spiritualty in each client, and to show regard for client 's personal definition of hope and position on each client 's journey towards health ( Sumsion & A ; jurisprudence, 2006 ) . Bays ( 2001 ) see religious strength as a cardinal constituent o hope. Spirit is recognised as `` the goaded force and motive for a individual to happen significance and intent in life '' ( Engquist et al, 1997 ) . Furthermore, '' Each persons spirit is expressed through his or her battle in mundane life, that is, his/her occupational public presentation in work, self-care and leisure '' ( Egan & A ; Delaat,1994 ( P:100 ) . Hope is a of import issue for clients, ( Bays 2001, P: 26 ) stated `` if you do n't hold the hope so you will be wholly lost ``

Client centred end scene

Barnes & A ; Ward ( 2000 ) did describe end scene as `` the kernel of rehabilitation '' ( P: 8 ) . Goal scenes helps to ease a client centred attack in rehabilitation, as it could be adapted to the client harmonizing to his/her damage ( Malec, 1999 ) , it besides provides a manner to mensurate the advancement in rehabilitation, and the effectivity of the chosen rehabilitation plans ( Lannin, 2003 ) . A successful rehabilitation is the 1 that is based on squad coaction, client oriented, and taking to aim the end instead than happening a solution for the job ( Gage, 1994 ) .

Goals are a major constituent of the rehabilitation procedure. The rehabilitation squad normally have a common end to the patient, that 's why it is of import to include the patient in the goal-setting procedure ( Wade, 1998 ) . Pollock ( 1993 ) noted that, patients should be the one to put the ends so he/she could work out their ain jobs, otherwise the patient will get down experiencing that they are non commanding their wellness. Furthermore, claims that, there might be an addition in patient engagement in the rehabilitation procedure, if patients did take part to put their ain ends and determination devising.

Barriers to implementing client centred pattern

Knowledge about implementing client centred over the past two decennaries has grown well ( Sumsion & A ; Law, 2006 ) , there are many issues that wellness attention professional must turn to before seeking to implement client centred pattern ( Sumsion,2006 ) , these issues and barriers may be due to the client, the healer and the on the job environment ( Law & A ; Britten,1995 ) .

Sumsion T ( 2006 ) noted that the barriers to client centred pattern were found when the wellness attention professionals and clients had different ends, when the wellness attention professional do n't accept the clients end, Lack of clip and ability to construct resonance with clients, wellness attention professionals lack the cognition about client centred pattern, and when the health care professional feels unhappy and uncomfortable to allow the clients put their ain ends. To get the better of these barriers he recommended the demand of direction, instruction, support, preparation in client centred pattern, and holding a structured doctrine.

A survey done by Sumison & A ; Smyth ( 2000 ) among 60 occupational healers utilizing a postal questionnaire in the United Kingdom, in which healer ranked 16 barriers to client centred pattern identified from the literature, the three highest barriers were:

wellness attention professional and the client have different end

heath attention professionals beliefs and value prevent them from accepting the client end

Health attention professionals feel uncomfortable allowing clients to make up one's mind in their ain about his/her ends.

Moats ( 2007 ) noted that clients with cognitive damages might do unrealistic and insecure picks, doing a restriction while seeking to implement client centred attention. A expolarity survey was conducted by Wressle & A ; Henriksson ( 1999 ) with geriatric shot patient during rehabilitation plan suggest that, clients normally do n't take part in end preparation and intervention program, they besides put frontward the demand of holding a construction theoretical account and doctrine to prosecute clients in the rehabilitation plan.

At the administration degree, Gage ( 1994 ) noted that a deficiency of interdisciplinary attention helping is considered to be a barrier of implementing client centred pattern, furthermore Wressler & A ; Samuelsson ( 2004 ) high spots that the deficiency of understanding about what is client centred pattern in general besides considered to be a barrier. In add-on, clip force per unit area placed on wellness attention professional might besides be a important factor that holds client centred pattern back ( Stewart et al, 2003 ) .

From the old treatment it may non be easy nor simple to implement a client centred attack ( Sumsion,2006 ) .

Decision

This chapter has provided an penetration into the different facet of client centred pattern, which will function as a base to steer the remainder of the survey. This survey will take a close expression at the benefits of client centred attack in pattern, this will be done by seeking to reply the undermentioned inquiry: how does research underpin the usage of client centred attack?

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Effective Efficient Stroke Rehabilitation Programme Health And Social Care Essay. (2018, Aug 17). Retrieved from https://phdessay.com/effective-efficient-stroke-rehabilitation-programme-health-and-social-care-essay/

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