Palliative Care Essay Example for Free

Palliative Care Essay Within this assignment the writer aims to identify and explore in depth the role development of the specialist palliative care nurses in the community setting, and in particular how their role has evolved over the last 5 years. The writer aims for the first part of the assignment to provide the reader with a brief background into the development of palliative care and a history of how the traditional role of a palliative care nurse has expanded from a more generalist perspective to that of a position of specialism. The writer will highlight the essential skills and qualities deemed crucial from a professional perspective in implementing such an expanded nursing role, with particular attention focusing on the impact this role development has made to patient centred care. The writer will highlight the importance of inter-professional working in palliative care, and provide evidence of how the government priorities have changed the boundaries of palliative care and how this has impacted on provision of palliative care services. The second half of the assignment aims to show analysis of both the role development of community specialist palliative care nurses and the recent changes, and provide evidence of how this role has impacted on society. The writer will aim to show evidence of how the role has been successful by providing patients perspectives of the service, and more importantly what improvements could be made in order to ensure the safety of positions with the introduction of the new commissioning process being implemented. The World Health Organisation (2009) defines palliative care as supporting patients and their families with physical, psychological, social and spiritual aspects of care during a physically and emotionally difficult journey of living with a non-curative condition. People’s awareness of palliative care has been linked to the rise of the modern hospice movement back in 1967, when a doctor by the name of Dame Cicely Saunders was responsible for opening a hospice in London called St Christopher’s. Cicely voiced concerns about the way death was dealt with in hospitals around this time and focused her attention on approaching death of cancer patients with more dignity and humanity (Kearney and Richardson 2006). Cicely went on to write several articles for nursing journals and her work was thought to be key to the development of the role of the clinical specialist palliative care nurse (Payne 2008). In the 1970’s the first Macmillan nurses were introduced. Macmillan nurses were generally employed by the National Health Service owever their posts were funded by Macmillan cancer support. The charitable service provider offered local health authorities the opportunity to enrol on a programme that would fund a Macmillan nursing post for a period of 3 years. Once the 3 year period ceased the health authority would become solely responsible for continuing the service out of their budgets (Lugton and Mcintyre 2005). Primarily the role of the Macmillan nurse back in the 1970â€⠄¢s was to provide direct hands-on care for patients whose illness had progressed to the terminal stage as well as support for their families. The role of the Macmillan nurses today tends to focus on meeting the specialist palliative care needs of patients. They provide support with how to manage difficult symptoms associated with the illness and various pain control methods as well as advice on numerous other things, as opposed to the general palliative care in the form of hands on nursing care. This type of palliative care is provided by generalist nurses within the community, such as district and community nurses. Their caseload not only consists of patients requiring palliative care but patients with various other nursing needs. Not all specialist palliative care nurses have the title Macmillan nurse, only those whose post were initially funded by Macmillan Cancer Support and then the NHS. Macmillan nurses are registered nurses who have at least 5 years experience in nursing. In addition they have experience in cancer or palliative care and further to their general nurse training have completed specialist courses, which enable them to have the title specialist nurse (Macmillan Cancer Support 2010). The work carried out by both Macmillan nurses and clinical specialist palliative care nurses differ only slightly, regardless of where they work (Cambridge University Hospitals NHS 2007). According to Seymour et al (2002) the role of the Macmillan nurse has evolved to that of the clinical nurse specialist. A clinical nurse specialist was defined by The Royal College of Nursing in 1988 as having gained through further training an advanced expertise and knowledge in a particular branch of nursing care. They further clarified the role as having responsibility for clinical practice, education, management and having knowledge of relevant research on their specialist area of nursing (Newbury et al 2008). Palliative care patient’s medical needs can change rapidly and may require the expertise of specialist palliative care nurses. Unlike generalist nurses, specialist palliative care nurse’s sole priorities lie with patients with palliative care needs. Referrals to specialist nurses are made when the needs of palliative care patients are becoming more complex and their symptoms harder to manage (Buckley 2008). However a review carried out by Ahmed (2004) suggests that there is lack of understanding of when and to whom referrals should be made to making them inconsistent. This lack of knowledge could be a barrier to the specialist palliative care nurses success. Another view could be that generalist nurses have been providing palliative care for many years, so why should they feel they need to hand over the care of the patients? The Royal College of Nursing (2002) outlined essential skills that were thought to be necessary to the role of specialist palliative care nurses. These were effective communication and the ability to deal with people’s grief, loss and bereavement. Lugton and Mcintyre (2005) suggest that communication is the key attribute to the role of the specialist palliative care nurse however Penson (2000) argues that comfort is the key attribute. Community specialist palliative care nurses are just one group of professionals that make up the multi-disciplinary team providing patients with palliative care. Their work involves close contact and communication with patient’s general practitioners, district and community nurses as well as community matrons. Community matrons are a relatively new role development. They were introduced in 2006 and the role was thought to be developed as a result of the population of the United Kingdom living longer and living with long term conditions. Their work involves looking at the patient holistically and supporting them whilst addressing the complex needs associated with their long term condition. (Sines et al 2009). Supporting patients to manage their symptoms and aiding them to live independently was one of the main proposals set out in the National Service Framework for long term conditions (Department of Health 2005). Prior to the introduction of community specialist palliative care nurses palliative care for the past 150 years or more was provided by district and community nurses in the home environment (Pellett 2009). According to Meehan (2010) within the United Kingdom numbers of qualified district nurses working in the community has fallen dramatically. This questions whether the introduction of the specialist nurses such as community specialist palliative care nurses and community matrons has contributed to these numbers falling. With shortages of district nurses patients care will be impacted upon. Terminally ill patients who have agreed their preferred place of care may have this taken away if problems arise in their condition and they eventually end up having to be admitted to the hospital or hospice unnecessarily (National Audit Office 2008). This in turn will have an impact on the current trends at the heart of the government’s priorities which following the NHS next stage review looked at increasing areas of healthcare into the community and reducing hospital admissions in an attempt to cut NHS costs (Darzi 2008). When the government announced their financial cuts to the NHS back in 2007 specialist nurse posts came under attack. Specialist services as opposed to generalist services are expensive and specialist nurses are in a higher pay band making them more vulnerable to losing their positions in spending cuts (Dean 2010). This questions the government’s views on specialist nurses. Are they seen as additional extras that could cut back in future spending cuts, in turn having an effect on patient care? Although the role of the specialist palliative care nurse is not a recent development to community nursing their role has changed over the last five years. This is in response to the needs of the population and government priorities. Demographic changes are a feature that have impacted on the work of the community specialist palliative care nurse. According to Sines et al (2009) the United Kingdom’s population is set to increase by 7. 2% by the year 2016. The central reasons for this increase are due to the fact that individuals are living longer and migration. Gomes and Higginson (2008) suggest that by the year 2030, 22% of the United Kingdom and Wales will be aged 65 years and over, with two thirds of people being over 75 years old when they die. Older age inevitably increases the certainty that people are more likely to suffer from non communicable diseases as well as cancers and the presence of co-morbidities (Payne 2008). The needs of the aging population will mean that community specialist palliative care nurses will be called upon to deal with increasing demand on palliative care services. As well as the population of the United Kingdom increasing so has patient’s expectations of the NHS, health and social care due to the input from the media. The introduction of the white paper: Our Health, Our care, Our say: a new direction for community services (2006) set out by the Department of Health was thought to be responsible for these expectations. People up and down the country were asked what they liked and wanted from their local health and social care services. People responded with enthusiasm and the government listened and promised to give the public more choices, providing better information about their health and how to stay healthy. The paper gave people more power and influence over the type and recommended standard of service they were to be offered locally. People expect to be treated more as partners and equals and expect choices and options available to them (Department of Health 2006). The provision of palliative care has also changed, historically provision of palliative care focused on supporting patients with cancer however over the last few years moves have taken place to expand the scope of specialist palliative care in order to attend to needs of patients with non-malignant diseases (Small et al 2000). In 1997 the department of health released a white paper: The New NHS: Modern and Dependable which suggested that the Calman-Hine Report: A policy Framework for Commissioning Cancer Services (1995), which examined and proposed a restructuring to cancer services in the United Kingdom could extend its services even further to include people with non-malignant diseases (Department of Health 1997). Amongst the Calman-Hine report were recommendations that everyone with cancer should have equal access to high levels of expertise regardless of where they reside in the country, and a distinction between palliative and terminal care meaning that patients have access to services earlier on in their illness (Calman Hine 1995). Expanding specialist palliative care to patients with non-malignant diseases has had a significant impact on the work load of specialist palliative care services by stretching resources to the limit. Although emphasis has been on providing all patients with life limiting diseases palliative care, is this actually being done? According to Watson et al (2005) specialist palliative care services are not readily available to patients with non-malignant diseases as they are to cancer patients. There is also a lack of support for patients from the voluntary services such as Marie Curie. In order to assist nurses to deliver evidence based practise initiatives such as care pathways were developed. These developments were put in place following the introduction of the white paper: A First Class Service-Quality in the new NHS back in 1998. The white paper was proposed by the government and aimed at producing a strategy to improve the delivery of health care. Three national initiatives which are important parts to the palliative care approach are the Gold Standard Framework, Preferred Place of Care document and the Liverpool Care Pathway. The Gold Standard Framework is a programme of assessment and care. Its aims are to improve quality of life for both patients and their families in the last year of a patient’s life. The Liverpool Care Pathway was developed 10 years ago and is a tool to assist health care professionals care for those who are in their last few days of living. The third initiative preferred place of care document is aimed at putting the patient at the centre of care, giving patients the choice regarding where they would like to be cared for and where they choose to die (Ellershaw Wilkinson 2003). The preferred place of care document is important to the changing role of the community specialist palliative care nurse. The End of Life Strategy for England delivered by the Department of Health (2008) set out a comprehensive plan to improve end of life care for all dying people. This is the first strategy that does not solely concentrate on improving end of life care for people with cancer. Following on from the government’s proposals in 2003 one of the key components of the strategy is giving people the choice about where they choose to die. Given the choice many people would prefer to die in their own homes with adequate support from professionals, however this is not always possible (Thomas 2004). At the beginning of the 20th century the majority of people who were terminally ill died in their own homes whereas today statistics show that 66% of people die in hospitals and 19% at home (Ellershaw Wilkinson 2003). Some of the reasons why this is not possible are due to inadequate symptom control, which is an important role of the community specialist palliative care nurses. Community specialist palliative care nurses generally work normal working hours so what provision is there for patients outside of these hours and who covers the work of the nurses when their working day is complete? Palliative patient’s complex needs require swift responses from palliative specialists when it comes to out of hours services. If patients were receiving 24 hour care unnecessary emergency hospital admissions and suffering of patients would be reduced. A number of community specialist palliative care nurses within certain trusts have gone onto complete nurse prescribing courses. They have the ability to prescribe from the extended formulary making them independent prescribers. For specialist nurses’ having this expanded nursing skill means they have the opportunity to work more autonomously. As one of the key roles of the community specialist palliative care nurse is managing difficult symptoms having the ability to prescribe immediately and appropriately helps promote a service that will reduce patients and carers distress (Mula and Ware 2003). This further acknowledges the importance of specialist nurses working out of normal working hours. The National Institute for Clinical Excellence (2004) suggests that in order to provide good end of life care patients need to have access to specialist palliative care 24 hours a day, 7 days a week. However a report by the National Audit office (2008) reported that just over half of local health authorities provided such care. The last government promised that all cancer patients would have access to specialist nurses trained in their condition (Rose 2010) however generally this too is only available during normal working hours according to Macmillan Cancer Support (2010) meaning that it is then acceptable for such care to be provided by generalist nurses.

The Battle Continues When Soldiers Return from Iraq Essay -- Mental Il

The Battle Continues When Soldiers Return from Iraq Even though Jimmy Massey, a former U.S. solider in Iraq, was pulled out of the war almost two years ago, it remains at the center of his life. On May 15, 2003 Massey was flown back stateside and though he lives a life without bullets and tanks, he now fights off terrible nightmares, constant anxiety, and bouts of depression. Massey, 34, was a marine for almost 12 years before he was deployed to Iraq during the initial U.S. invasion. There he witnessed the shooting of more than 30 innocent civilians and his thoughts of war transformed forever. Massey was honorably discharged from the military with Post Traumatic Stress Disorder and suffered major depression. Despite being called a coward by his superiors Massey, with the help of his wife Jackie, sought the mental health treatment he needed. The Massey’s search for assistance proved not to be a simple task. â€Å"At first all he did was see therapists. It took us about six months to get him set up through the Veterans Administration to get his medicine and start therapy. There is such a huge waiting list that he doesn't get to go to therapy as often as he would like but I guess at this point something is better than nothing,† his wife, Jackie said. There have been times when the Massey’s feel they are fighting an uphill battle with the Department of Veterans Affairs (VA). Because there is no cure for Post-Traumatic Stress Disorder Massey will likely be in need of treatment for all his life. Post-Traumatic Stress Disorder (PTSD) is a mental illness that develops after a person experiences a horrific or traumatic event. More specifically, the term Combat PTSD was developed after Vietnam, even though the condition h... ...holism and PTSD go hand in hand and the VA Hospital made a terrible mistake that day,† Lessin said. MFSO never want a situation like Jeffery Lucey’s to occur again. Through working with organizations like MFSO and educating people about PTSD, people like the Massey’s hope the system can make progress within the system. Jackie Massey believes the blame should not only lie on the VA Hospital, but on the huge lack of funding and lack of staff. The VA reported that in 2003 almost 200,000 veterans were on waiting lists to receive health care. â€Å"I am working right now to make some changes. I want to have a database of therapists and doctors who will offer their services to returning soldiers for free or reduced costs so that these men and women can receive treatment outside the military. I think that is a very important key in the whole process,† Jackie Massey said.

Victorian Era Consciousness

How would you describe the consciousness of the Victorian Age? Think about their perception of their place in the world. The consciousness of society in the Victorian age is an interesting factor that greatly changed and evolved during the time period. The era’s beginning and end is marked by the birth and death of the reigning monarch of the time, Queen Victoria, spanning from 1837 to the early 1900s. With the effects of the Industrial Revolution distinctly felt by all classes within society, it was a time of significant social reformation and drastic change in all aspects of life, and in short was a diverse and complex though tremendously exciting period for those who were living in it. As a result of such rapid growth, expansion and change, it is only natural that there was widespread excitement and perhaps apprehension at the same time. A new world was being created away from the manual driven labour of the old, and one of steam power and coal was emerging, of urbanisation and industrialisation. This constantly transforming and thriving world to the people at the time must’ve been overwhelming and thrilling, as they gained a realisation that all aspects of their lives were becoming influenced in some way or other by the increasingly advanced technologies and innovation. As a result, there was a great influx of population from the countryside to the city, with the realisation that there was a quickly approaching transition away from an agricultural-based economy towards machine-based manufacturing. However there must’ve been a great deal of anxiety and people may well have been wary towards the great changes that were happening around them. There would’ve been a growing new consciousness as society had to perceive the world in a different way than they previously had in order to ‘keep up with the times. As one tiny pebble when thrown into a pond causes consequent ripples to spread throughout the surface, the Victorian Age was like a pond where a great many pebbles were being thrown into. As a result, their way of thinking and apprehending the constantly developing world around them had to be open-minded in the sense that they had to be prepared for more surprises. They had to become receptive to things previously thought impossibl e or perhaps not even imagined at all which came to life- it was supposed to be a new Golden Age and indeed it was. However, the Victorian Age also had its dark side- the side of child labour, devastating unemployment, opium and prostitution. Nothing was certain anymore and with the modernism movement arising towards the end of the 19th century, people began to question many values and concepts that had before been unarguably taken for granted and accepted within society. With the rejection of established patterns of thought, a new consciousness arose where old traditions and customs were critically examined and people realised they had more freedom of thought than ever.

Comparing The Landlady And Tell Tale Heart - 898 Words

Have you ever noticed the differences and similarities in the books, Or have you ever used a Venn diagram to compare the differences or similarities? There were 2 short stories which were read. They were The Landlady, and Tell Tale Heart. They were compared in a Venn diagram to show the differences and the similarities of the story. In this essay you will learn about the similarities of The Landlady , and Tell Tale Heart, You will also learn about the differences of the 2 short stories. The Landlady is a short story by author Roald Dahl. The story is about a man named Billy Weaver, who is on a work trip, and needs to find a cheap, and a quality hotel. He asks someone At the train Station and they refer him to a hotel Called The Bell And Dragon, Billy soon walks down the block to the hotel but he feels that it is not welcoming. So he walks down more and finds a place called the Bed And Breakfast, to Billy it looked very inviting. Billy walked up to the glass window and peeked through, he saw a dog curled up by a fireplace, a large sofa, and plump armchairs. He soon made his decision on which hotel to stay at, and chose the Bed And Breakfast. He rung the doorbell, and immediately the door swung wide open. The lady who owned it was about forty five to fifty years old , and welcomed billy with a warm smile. She soon welcomed billy into the house, Billy the asked â€Å"How Much do you charge?† â€Å"Five and sixpence is fine.† Billy said that it was less than half he wasShow MoreRelatedSniper and How Much Land Does Man Require5559 Words   |  23 PagesAction Climax Falling Resolution Conclusion The elder sister and younger sister fought over which is better, city life or peasant life. When Pahom realizes that he can have as much land as he needs. He buys more and more land and a tradesman comes and tells him that he can buy land from the Bashkirs for 1,000 roubles a day. When he visited the Bashkirs, he gave gifts and received special treatment. He slept with dreams of the devil laughing at his dead body. Pahoms greed brought him to his death and

Al-Qaeda and the US Patriot Act Essay - 1734 Words

Abstract This paper is on the terrorist group Al-Qaeda and the US Patriot Act. This paper will discuss the history, ideology, structure, targets and tactics of Al-Qaeda. I will discuss the history and goals of the US Patriot Act as well as the controversy that surrounds it. Finally I will discuss how the US Patriot Act serves as a deterrent to Al-Qaeda by enhancing domestic security against terrorism, enhancing surveillance procedures and removing obstacles to investigate terrorism. I hope that after you complete your review of my paper that you will have an appreciation for the creation of the US Patriot Act, because it protects Americans by making it difficult for terrorist groups like Al-Qaeda to operate in the United States.†¦show more content†¦The group was established around 1988. Al-Qaeda became a household name after the terrorist attacks of September 11, 2001, quickly surpassing the IRA, Hamas, and Hezbollah. Al-Qaida is a multi-national network possessing a global r each. .Al-Qaeda produced the Encyclopedia of the Afghan Jihad in the 90s, which served as a detailed how-to guide for using handguns, explosives, and biological and chemical weapons. Al-Qaedas goal is to overthrow regimes it considers non-Islamic and expel Westerners and non-Muslims from Muslim countries. Al-Qaeda believes it’s the duty of Muslims to kill US citizens both civilian and military and our allies. After Al-Qaeda’s September 11, 2001, attacks on America, the United States launched a war in Afghanistan to destroy al-Qaeda’s bases there and overthrow the Taliban. I have firsthand experience fighting terrorism. I was stationed in Afghanistan in 2008. I served on the front lines of the war against terror in support of Operation Enduring Freedom. I travelled to remote parts of Afghanistan and Pakistan searching for terror suspects. I feel proud to know that I made a difference by taking down members of the Taliban. Additional Al-Qaeda’s goals and objectives are as follows: establishing the rule of God on earth, attaining martyrdom in the cause of God and the purification of the ranks of Islam from the elements of depravity. Some of the tactics Al-Qaeda employs are asShow MoreRelatedEssay about Homeland Security1415 Words   |  6 Pagesofficials responded in the only way that felt suitable, attacking terrorism. The group responsible for the events of 9/11 is called the Al Qaeda. Al Qaeda is one of the most well known terrorist groups in the world. Because of past issues with the Muslim community, the United States should have been prepared for a retaliation from them. 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The organization is still currently active today, even though it has become largely decentralized with the deaths of many of its leaders following their attack on the twin towers in New York City, on September 11th, 2001. Al-Qaeda was founded towards the end of the Soviet Union’s attempted expansion into AfghanistanRead More The Patriot Act Essay1684 Words   |  7 PagesThe Patriot Act After the terrorist attacks of September 11th, 2001 our country underwent a change that has drastically affected the fundamental values that our founding fathers instilled in this country. Since that tragic day in September the aftermath of the attacks has started to implicate our Civil Liberties that in this country we hold so dear. Just 45 days after the September 11 attacks, with virtually no debate, Congress passed the USA Patriot Act on October 5th, 2001. 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The Effect Of Globalization On Communities - 1117 Words

The Effects of Globalization on Communities Cultures and societies evolve along with their growing abilities and changing environment, and each generation throughout history has had unique circumstances to learn from and deal with. The industrial revolution set the world on a much speedier path towards change which has been apparent in the last hundred years with growing cities and the rapid spread of technology. As the world establishes itself in the information age we find the connection between distant cultures becoming tighter and more intertwined. The effect of technology moving goods and information at increasing speeds is known as globalization. Globalization has already had profound effects throughout the continents and there†¦show more content†¦In this way, the irreversible trend of globalization can harm individuals as well as the social order of a region while escaping the grasp of those who could benefit the most. The globalization of local economies has real world effect on the lives of individuals and groups which should certainly be studied in order to reverse the known negative impacts. It would take both legislation and social work to allow those less fortunate to enjoy some benefits of our modern global society. An example of corporations benefitting from global import within larger industrialized nations can be seen across the United States with Wal-Mart’s long-growing takeover. For decades now, Wal-Mart has used its advantage of large-scale importing to stock its shelves with low priced home essentials. From the 80s to today, this successful company has crept over the American landscape, placing a location in every small town from the east to the west coasts. Wal-Mart offers a wide variety of merchandise under one roof, and has recently begun to incorporate a grocery into their buildings. Their merchandise purchases are large scale, normally overseas orders, the size of which allow a lower price that proves difficult competition for small businesses making smaller and more local purchases. The availability of inexpensive merchandise gathered during a single trip would seem to benefit a consumer on a budget, but this short term savings makes ripples

On Discourse Analysis, Looking at a Sample of Spoken Discourse from Michelle Obama’s Democratic National Conference Presentation free essay sample

On Discourse Analysis, looking at a sample of spoken discourse from Michelle Obama’s Democratic National Conference Presentation. In this paper I aim to apply different methods of discourse analysis to a selected extract of transcribed language. I have chosen to transcribe a speech given by the First Lady of the United States, Michelle Obama. Firstly, to briefly outline the context, the speech was given during the Democratic National Convention in September 2012, in the run up to the presidential election in which her husband, Barack Obama is rallying for re-election. Michelle is introduced by Elaine Brye, a ‘fellow mom’ and what’s more, ‘military mom’ of 5 sons, four of whom cover all of the American forces. Byre appropriately asks â€Å"What’s a mom like me doing in a place like this? I’m not even a political person! † She talks of her children as treasures, of how the Obama family have supported military families, and of how her and Michelle can relate ‘mom to mom’. This introduction sets the scene for what Michelle is about to talk about, giving rise to the topics of ‘ordinary-ness’, the stories of rags-to-riches, and the duty of ‘being mom-in-chief’, all of which appeals to the audience of American people. Michelle’s language has visible aims to make them feel united, empowered, proud, and hopeful. Michelle walks in wearing a cerise pink dress, waving and laughing and thanking the crowd for their applause, she is evidently humbled by the audience’s applause and cheer. There is also an apt choice of music by Stevie Wonder; with the lyrics â€Å"signed sealed delivered, I’m yours† this with a subtle, playful message perhaps hinting to their confidence in winning this election, given the physical acts of sealing and delivering a vote on election day, and of her husband ‘signing up’ for his new term in office. Michelle finally begins by thanking Elaine Brye, and uses the collective ‘we’, â€Å"We are so grateful for your family’s service and sacrifice, and we will always have your back† (YouTube clip 4:20)[1]. This ambiguous ‘we’ has the potential to be on behalf of either President Obama and herself, or indeed the American Public. Young and Fitzgerald (2006) state that â€Å"critical discourse analysts use several different methods to help them ‘dig’ beneath the surface of the discourse† (2006: 16). These include conversation analysis, and looking at politeness strategies, but for the purpose of my chosen sample, a public speech, one technique I have chosen to focus on, is Systemic Functional Linguistics, in an analysis ‘partnership’ with CDA. SFL is â€Å"a way of understanding the functions that language performs and the choices people make when they speak to exchange meaning with listeners† (2006: 16), and from my understanding of the process, it is necessary to ask a certain set of questions, when carrying out SFL research, which eventually lead us to answer â€Å"why a speaker or writer made these types of choices; and how they reflect relationships between powerful and weaker groups† (2006: 23). The first questions at this stage of SFL, is who is participating, and what are the processes and circumstances. Young and Fitzgerald comment: â€Å"When studying a discourse, SFL researchers are interested in the meanings that participants, processes and circumstances are creating. Using these labels helps analysts figure out ‘who is doing what to whom: when, where and how’ (2006: 16-17) There is the brief discourse between the first speaker Elaine, and Michelle, and between all speakers there is a sustained interaction with the audience, within the circumstance of a 23,000-seat North Carolina arena (MacAskill 2012). Therefore, for the most part, the purpose of Michelle’s language is to engage the American political supporters, although this audience is later extended to a world-wide audience due to the filming of the speech, it’s broadcast on ABC News, and subsequent access via the internet. She begins speaking, â€Å"with your help, with your help (4:00)† which immediately addresses the American audience, replying to their bellowing chants of â€Å"four more years†. This immediately creates a supportive atmosphere, a chant being something everyone in the audience can contribute to and participate in, Michelle is mirroring the three word phrase, as former Prime Minister Tony Blair once did, famously uttering the phrase Education, education, education! using reification to communicate a powerful message to the public. â€Å"Effective political communication has always relied on easily understood slogans and phrases† (Jones 1996: 27 cited in Charteris-Black 2011: 225), and in this context of a re-election campaign, MO effectively instills the fact that the desired outcome can only happen with the people’s help of going out to vote for her husband, Barack Obama. She continues to speak directly to Elaine, showing gratitude and making this beginning even more emotionally charged. In these foundations, a political underlay is felt, which may or may not have been intended. By having a ‘military mom’ introduce her, and by immediately talking about war and deployment, it could be inferred that she is encouraging and glorifying the concept, indeed going on to discuss the American Spirit, which she has â€Å"seen in our men and women in uniform in our proud military families (5:15)†. This inferred message is drawn from a Critical Discourse Analysis, whereby patterns which can be identified in a speech, using SFL, require further questioning, such as â€Å"What does this pattern mean? Does it have a purpose? And what does it show about his (her) intent? † (2006: 18). What is to be considered in the circumstance of this discourse, is it’s origin and originality, as any speech begs the question; â€Å"Do the words convey the speaker’s ‘real’ beliefs? † (Charteris-Black 2011: 5). Various newspaper articles, both in Britain and the USA, followed this speech with comment on the â€Å"personal thrust† (MacAskill 2012) MO displayed. Her role as First Lady is not an elected political role, and therefore her case here is as personal, as it is political. Throughout my analysis of this particular oral presentation, it has become apparent that a natural, well flowing narrative structure is present. It conceals, and is often broken with, rigid and fortified repetition, as in her use of the temporal adjective ‘everyday’ or an alliterative pattern of abstract nouns, as shown at (12:14) â€Å"dignity and decency†¦. honesty and integrity gratitude and humility†. Here she also repeats â€Å"we learned about†, initially addressing herself and Barack, MO â€Å"demonstrates what van Dijk describes as ‘positive self-representation’, in this case by attributing the above collection of desirable human qualities, which are emotionally appealing, to the audience† (cited in Charteris-Black 2011: 19). MO extends this to complement the audience by saying â€Å"those are the values that Barack and I and so many of you are trying to pass on to our own children† thus making the personal narrative inclusive and approving. Again, such a pattern has been observed using SFL, and it’s communications explored in CDA, whereby I believe this break from narrative structure puts a much increased emphasis on the keywords here which display features of alliteration and notably less spontaneity than the story they sit within. A study into the ‘Oral Versions of Personal Experience’ states that â€Å"Normally, narrative serves an additional function or personal interest determined by a stimulus in the social context in which the narrative occurs† (Labov and Waletzky 1966), which isn’t reflective of Michelle’s use of narrative in her speech. Due to the nature of the spoken discourse she doesn’t receive the external stimulus, she has the power to speak ‘at’ an unassuming audience, and her language is evidently more prepared and drafted, within the seemingly impromptu story-telling. Another spoken discourse feature which engages with the cohesion of the language is the list-of-three. Michelle uses this strategy almost seamlessly throughout, often employing the over-use of the conjunction ‘and’, such as â€Å"everywhere I’ve gone and the people I’ve met and the stories I’ve heard†¦Ã¢â‚¬  This elongates the utterance to emphasise her journey so far and the monotony in it’s assonance hint’s to the ‘never-ending’ experience as first lady of America. A CDA framework suggests her desire to remain in the White House, given her clues later in the speech which include semantic inferences of ‘unfinished business’, for example at (20:55), MO quotes her husband saying: â€Å"Michelle, We’ve got to keep working to fix this, we’ve got so much more to do! †, at which point she struggles to re-start through the repeated chants of ‘four more years’, giving her positive feedback and support her personal campaign. Michelle’s speech often chronicles the worries she had before her husband was elected President, four years prior to this speech. She keeps the parents and particularly the mothers in the audience involved, using a conversational style, â€Å"like any mother I was worried about what it would mean for our girls†, and retains the intimate style by asking rhetorical questions to the audience. â€Å"y’know, how would we keep them grounded?†. MO displays another example of the communicative power a list of three houses, when the â€Å"simple joys† of life before presidency arise: â€Å"Saturdays at soccer games, Sundays at Grandma’s house, and a date night for Barack and me†¦Ã¢â‚¬  whereby the two routine events precede the last which is more personal, and leads into a joke, â€Å"either dinner or a movie because as an exhausted mom I couldn’t stay awake for both! †. MO also uses a powerful list of three to introduce the topic of the ‘American Dream’, whilst simultaneously talking about her and Barack’s parents: â€Å"their unconditional love, their unflinching sacrifice and the chance to go places they had never imagined for themselves† (08:17). This is a clever lead into the topic, which is a known theme throughout Obama’s legacy. Such a visionary, and now almost controversial topic has been depicted as an unrealistic or unfulfilling struggle in renowned American literature such as ‘Of Mice and Men’ and ‘The Catcher in the Rye’. Charteris-Black states that President Obama is â€Å"The living embodiment of the policies he advocates as much as he provides their expressive medium† (2011: 280) which is interesting because Michelle also reflects this ‘dream life’ by employing the conceptual metaphor ‘The Nation is a Family’ which is broken down in Charteris-Black: â€Å"Ideas of the national family are persuasive because the family symbolises a source of security, and the desire to protect the family is at the basis of moral systems† (2011: 29). MO successfully unites the audience, as a family, in the context of the pre-election Democratic National Convention, so that her following speech relates even to those who perhaps don’t conform, struggle, work hard, or fight for their country in the military, and indeed those who are not living in an American Dream. This combination of language and pragmatics is working firstly to persuade supporters to vote, and secondly to support her husband in this credible narrative which their lives symbolise. â€Å"Barack knows what it means when a family struggles, he knows what it means to want something more for your kids and grandkids (17:40). Leading the audience back to the collective ‘we’, which is now strongly reinforced and familiar to the audience, she continues: â€Å"Barack knows the American dream because hes lived it, and he wants everyone in this country, everyone, to have that same opportunity, no matter who we are, or where were from, or what we look like, or who we love† (17:50). This resounding quote from the speech demonstrates the above observed SFL features, the elongated sentence which displays inclusiveness and again the ceaseless list of people who are accepted to, in a CDA inference, ‘vote Obama’. It also mentions ‘opportunity’ and is a very emotive and personal part of her speech, as she catches her breath and has tears in her eyes,. The act of persuasion is key in any political speech. Jowett and O’Donnell (1992) argue the three ways in which the persuader may seek to influence the receiver, including response shaping, response reinforcing and response changing. Michelle Obama is consistently reinforcing this American Dream discourse, moving from older stories about her and Barack’s grandparents, to future hope establishment for America’s children. The discourse always relates to ‘working a job’, fitting tight with Barack’s fair-pay and healthcare policies. Michelle announces a ‘fundamental American promise’ that â€Å"if you work hard and do what you’re supposed to do, you should be able to build a decent life for yourself, and an even better life for your kids and grand-kids (11:50)† and she speaks not as if people didn’t already believe or live by this, but as if it weren’t possible to believe this enough, and therefore reinforcement, and repetition reflect her attitude and stance in this section of the speech, an answer to the second question of SFL â€Å"What are the speaker’s or writer’s attitudes and stances? † (2006: 19). Jowett and O’Donnell continue to explain her persuasion technique: People are reluctant to change; thus, in order to convince them to do so, the persuader has to relate change to something in which the persuadee already believes. This is called an ‘anchor’ because it is already accepted by the persuadee and will be used to tie down new attitudes or behaviours† †¦ â€Å"A persuador analyses an audience in order to be able to express its needs, desires, personal and social beliefs, attitudes and values as well as its attitudes and concerns about the social outcome of the persuasive situation† (1992: 22-3 Cited in Charteris-Black 2011: 17-18). In this case the â€Å"anchor† as such, is Opportunity. And through the CDA framework, the ideology is now with working hard, taking your opportunities and creating the concept of a ‘better life’ for yourself and offspring. Ideology is explained by van Dijk as â€Å"the basis of the social representations shared by members of a group† (van Dijk 1998: 8 cited in Goatley 2007: 1) and Goatley neatly states â€Å"after all, we are all members of a community and share the thoughts and language that make action within that community or society possible† (2007: 1). MO has therefore created and reinforced an ideology which is appropriate and accessible to her audience, maintaining power and support in the discourse. This topic is notable because of the discussion of stance, in SFL, and the principles for CDA discussed in Young and Fitzgerald (2006: 24). Firstly using SFL to objectively note her position (stances) as a wife, mother, and First Lady, rather than that of a political figure, and her consequent stance when speaking at a Democratic National Convention. The CDA which stems from this enables an â€Å"explanation and interpretation of a discourse in terms of the relationships between language, power and ideology† (2006: 23). Ruth Wodak comments on the CDA principle that ‘discourse does ideological work’ in saying that â€Å"ideologies are particular ways of representing and constructing society, which reproduce unequal relations of power, relations of domination and exploitation’ and she notes that ‘they are often false and ungrounded’ (Wodak 1996: 17-20 cited in Young and Fitzgerald 2006: 24). Inherently, the conditional MO uses within the ‘American promise’ not only persuades ‘doing what you’re supposed to do†, it also inadvertently addresses issues of crime, alcohol and drug abuse, and other social problems which cost the government money and make it difficult for America to relieve their economic situation, things which challenge her husband’s job and reputation. In an emotive and personal way, Michelle is echoing Barack’s political ideologies and advocating whats is best for society. The combination of SFL and CDA however, â€Å"enables you to undertake a thoughtful and careful analysis that minimizes bias† (2006: 26), remembering that there are many more areas in a Presidents control which have altered the nations economic welfare. What is interestingly observed by Charteris-Black in his chapter which focuses solely on Barack Obama and the American Dream, is that this ‘dream’ can seem like a myth, in that it focuses so much on the future and the unknown but loosely possible, â€Å"The myth defies analysis and is even more irresistible when coming through someone who symbolises the dream† (2011: 309). Michelle’s reverberation of Obama’s initial 2008 policies, and her links to the present day, are all within this vocabulary chain of work and (financial) security, and the antecedent to â€Å"his agenda for the next term, which includes new jobs, new opportunity and new security for the middle class† (Curtis 2013), therefore leaving the audience member satisfied with consistency, optimism and hope, and the analyst very aware of the planning and intricacy in the core ideas that the Democratic speakers must exhibit in their language. At (26:20) she adds â€Å"surely, surely we can give everyone in this country a fair chance at that great American dream†. The third question highlighted in Young and Fitzgerald’s book is â€Å"what hold’s the discourse together? † (2006: 20). Cohesion and understandability in this speech is absolutely vital, because the secondary participant, the audience, is made up of such a vastly differing group of people, all of whom should relate to some extract from the speech. The camera angles cut to images of the young and old, certain public figures such as Lilly Ledbetter who influenced a bill for equal pay, and of course, to men and women of all classes and races in the crowd responding to MO. An observation in my analysis is the reference to feminism when Michelle tells the story of Barack’s grandmother. â€Å"she moved quickly up the ranks but like so many other women she hit a glass ceiling† (Clip 10:56) this not only reflects the inequalities of the time, but MO has retained the vocabulary chain of the war, struggle and military by choosing the metaphors â€Å"moving up ranks† and â€Å"hitting a glass ceiling†. In SFL question three these retentions are important in keeping the whole text’s Theme, â€Å"in SFL research, the term Theme, when capitalised has a more specific meaning; it refers to the initial words /phrases in a clause† (2006: 21). â€Å"In other words, why also encompasses questions of motivation, particularly with regard to how the speaker’s/writer’s choices constitute, maintain, and/or challenge relationships of power in our society† (2006:23). Not only this but here she subtly draws contrast with her husbands main opponent Mitt Romney, who’s policies on abortion and equal pay were deemed unclear, by â€Å"avoiding attacking him directly but making clear her belief that he was deeply our of touch with ordinary people† (MacAskill 2012). With regard to gender and language, â€Å"gender cannot be reduced simply to generalisations about all men or all women† (2006: 36). As mentioned previously, Michelle stands representing numerous female roles as a mother, wife and First Lady. Her language is highly emotive and this is typical of the female gender discourse, especially so when she discusses Barack’s grandmother’s circumstance in her job, talking of how â€Å"like so many women she hit a glass ceiling (10:56)†. The SFL analysis of this section not only highlights the use of the ‘glass ceiling’ metaphor, it notes the repetition of the agent/goal ‘men’, in comparison to the grandmother, men who â€Å"she had actually trained† who are being â€Å"no more qualified† yet â€Å"promoted up the ladder ahead of her†. This promotes a sense of ‘sisterhood’ and in CDA, given that it addresses social problems (Wodak cited in Young and Fitzgerald 2006: 14) would suggest that Michelle is emphasising the difference in today’s society, how times have changed even though what happened to Barack’s grandmother seemed acceptable at the time (â€Å"giving her best without complaint or regret† (11:19)) and cleverly makes link to her husbands campaign, â€Å"So when it comes to rebuilding our economy, Barack is thinking about folks like my dad and like his grandmother, he’s thinking about the pride that comes from a hard days work, thats why he signed the Lilly Ledbetter fair pay act, to help women get equal pay for equal work† (14:46) MO returns to these points of equality and fairness at (22:15) â€Å"for Barack there is no such thing as Us and Them†, having previously claimed at (16:25) â€Å"he believes that women are more than capable of making our own choices about our bodies and our healthcare, thats what my husband stands for†. For the audience, this is now more credible coming from a woman, and needless to say, a women who is thought to know the president and his thoughts better and truer than anyone else. Lastly in this section, at (24:05) â€Å"let us never forget that doing the impossible is the history of this nation it is who we are as Americans and it is how this country was built (24:05)†. One of her final statements in the speech, and one which was most poignant in headlines and reports following its execution, is at (27:00) â€Å"At the end of the day, my most important title is still mom in chief†. To conclude, Michelle is making a personal and political case for her husbands re-election. She is supporting, echoing and repeating some of his key ideas and policies, as well as engaging with an audience with whom she relates to in typical ways such as being a mom, a worker, and simply, an American. She stands as ‘living proof’ of the American Dream, (as does her husband), and says all the ‘right’ things about raising a family and wanting to better yourself through struggle and triumph. Thus making her speech inspirational and ‘feel-good’. Through the combination of Systemic Functional Linguistics and Critical Discourse Analysis, guided by a book entitled ‘The Power of Language’ by Young and Fitzgerald (2006), the concern with the interconnections among power, ideology and language has been explored in this particular extract to reveal the ways in which a speech of this personal and political hybrid nature, can influence thought and action within the audience. Mostly. Michelle Obama has done this by taking narrative-style, personal experience, and carefully structured language including simple phrases which will reverberate in the listeners mind, such as â€Å"with your help† and â€Å"forward†. These phrases became key elements in the branded ‘Obama’ campaign, seen all over the world. And at this time of writing, it is known he was re-elected and has just begun his second term as the President. The end of the speech is worth extracting, as it demonstrates the seamless cohesion of topics and captures the intrinsic message of the whole speech: â€Å"Today, I know from experience, if I truly want to leave a better world for my daughters, for all of our sons and daughters, if we wanna give all of our children a foundation for their dreams, and opportunities worthy of their promise, it, if we wanna give them that sense of limitless possibility, their belief that here in America there is always something better out there if you’re willing to work for it, then we must work like never before! And we must once again come together and stand together for the man we can trust to keep moving this great country forward, my husband, our president, Barack Obama! † (27:35) As she introduces her husband, there is further overwhelming support from the audience, who appear genuinely moved by the experience. van Dijk states that â€Å"CDA is designed to provide a more in-depth insight into the implications of the language we use; particularly the societal consequences† (1993).