Health‐care reform and the dimensions of professional autonomy

Abstract: A “managed competition” model was introduced in the Canadian province of Ontario as part of the government's reform of home care. With this model, it was assumed that competitive forces would encourage quality while driving down costs. While such reforms often achieve cost controls by constraining the incomes and practices of health‐care workers, there has been relatively little analysis of the extent to which self‐governing health‐care professionals, particularly those outside of medicine and nursing, may experience a decline in their ability to control the content and context of their professional work. In this article, the authors analyse the results of thirty‐six in‐depth interviews with representatives of Community Care Access Centres (CCACs), the organizations that purchase and coordinate the delivery of home‐care services, and rehabilitation provider agencies to examine the impact of Ontario's managed competition reform on rehabilitation professionals. Findings suggest that the impact of the reform varied across the economic, political, and clinical dimensions of professional autonomy and that, despite a general loss of autonomy under the managed competition model, market forces also served to mitigate the loss of autonomy, thus contributing to a remarkable resilience of professional autonomy. Sommaire: Un modèle de « concurrence dirigée » a été introduit récemment dans la province canadienne de l'Ontario dans le cadre de la réforme gouvernementale des soins à domicile. Avec ce modèle, il était présumé que les forces de la concurrence encourageraient la qualité tout en faisant baisser les coûts. Alors que de telles réformes parviennent souvent à maîtriser les coûts en réduisant les revenus et les pratiques des travailleurs de la santé, il y a eu relativement peu d'analyses de faites sur la mesure dans laquelle les professionnels de la santé autonomes, particulièrement ceux qui exercent en dehors de la médecine et de la profession infirmière, connaissent une perte de contrôle sur le contenu et le contexte de leur travail professionnel. Dans le présent article, les auteurs analysent les résultats de trente‐six entrevues en profondeur menées auprès de représentants des Centres d'accès aux soins communautaires (CASC), organismes qui achètent et coordonnent la prestation des services de soins à domicile, et organismes de prestation de soins de réadaptation, afin d'examiner les conséquences de la réforme de la concurrence dirigée de l'Ontario sur les professionnels de la réadaptation. Les résultats laissent entendre que l'effet de la réforme a varié en fonction des dimensions économiques, politiques et cliniques de l'autonomie professionnelle et que, malgré une perte d'autonomie générale liée au modèle de concurrence dirigée, les forces du marché ont également permis d'atténuer la perte d'autonomie, contribuant ainsi à la remarquable résilience dont font preuve ces professionnels en la matiére.     

A PRACTITIONER'S PERSPECTIVE ON UNIFIED FAMILY COURTS: CASE STUDIES

As a summary of simple examples demonstrating practical advantages of a family court, this article relates a few experiences from the perspective of a family law attorney who practices regularly in the Fulton County Family Division in Atlanta.     

COMMUNICATION STRATEGIES ON SOCIAL CORPORATE RESPONSIBILITY: THE ROLE OF FREEDOM OF EXPRESSION

The political and the economic spheres increasingly overlap. Consumption is viewed not only as an economic act, but also as an act of political and moral significance. Due to the blurring of the commercial and the political spheres, consumers use their purchasing power as a carrot and a stick for corporations to comply with corporate social responsibility (CSR) standards. As a consequence, corporate communication strategies tend to highlight commitment to CSR standards, portraying companies as “good corporate citizens.” Conversely, other stakeholders expose unethical business practices so as to induce corporate change. Both sides tend to invoke freedom of expression with a view to opposing limitations on their communication strategies. Taking two well-known examples as a starting point, the present article explores the role of freedom of expression as a means to incite corporate actors to both adopt and comply with CSR standards from a comparative perspective. Using an economic framework, it argues that non-commercial expression critical of corporate practices deserves a higher level of protection than corporate communication strategies.     

Who Can Deviate from the Party Line? Political Ideology Moderates Evaluation of Incongruent Policy Positions in Insula and Anterior Cingulate Cortex

Political polarization at the elite level is a major concern in many contemporary democracies, which is argued to alienate large swaths of the electorate and prevent meaningful social change from occurring, yet little is known about how individuals respond to political candidates who deviate from the party line and express policy positions incongruent with their party affiliations. This experiment examines the neural underpinnings of such evaluations using functional MRI (fMRI). During fMRI, participants completed an experimental task where they evaluated policy positions attributed to hypothetical political candidates. Each block of trials focused on one candidate (Democrat or Republican), but all participants saw two candidates from each party in a randomized order. On each trial, participants received information about whether the candidate supported or opposed a specific policy issue. These issue positions varied in terms of congruence between issue position and candidate party affiliation. We modeled neural activity as a function of incongruence and whether participants were viewing ingroup or outgroup party candidates. Results suggest that neural activity in brain regions previously implicated in both evaluative processing and work on ideological differences (insula and anterior cingulate cortex) differed as a function of the interaction between incongruence, candidate type (ingroup versus outgroup), and political ideology. More liberal participants showed greater activation to incongruent versus congruent trials in insula and ACC, primarily when viewing ingroup candidates. Implications for the study of democratic representation and linkages between citizens’ calls for social change and policy implementation are discussed.     

Gender and Race Differences in Delinquent Careers

Abstract Studies of delinquent careers have often tracked only male offenders, and have almost always failed to explore the interaction of race and gender in delinquency. This study tracks a cohort of youth whose first referral to juvenile court was in 1980, and explores the role played by both race and gender in official delinquent careers. Findings reveal that both race and gender play a significant role in official delinquency. Looking first at female delinquency, this research finds that white and nonwhite females do not differ significantly in the types of offenses they commit. Moreover, if girls are “chronic” delinquents, their offenses are most often trivial rather than serious. With males, racial differences emerge in both seriousness and chronic nature of delinquency. Nonwhite males in this cohort are more likely to be referred for personal offenses and less likely to be referred for public order and victimless offenses. Nonwhite males are also significantly more likely to become recidivists, and to have more seriously delinquent careers. This article discusses the implications of these findings, particularly with reference to the “convergence theory” of delinquency, which suggests that race plays a stronger role than gender in female delinquency. Finally, the article considers the policy implications of the current range of definitions of “chronic” delinquency.     

Familial functioning as a support system for adolescents' postdetention success

Youths transitioning out of detention are particularly in need of support systems that can divert them from recidivism. This article examines the relationship between incarcerated youths' sense of their families' functioning and their perceived likelihood for postdetention success. Despite the control of background variables, results reveal that delinquents who indicated stronger familial functioning also reported a greater likelihood of future success. Although interventions that focus on improving the supportive capacity of families have shown great promise, treatment drop-out rates remain high. To explore incarcerated youths' view of family focused interventions, respondents rated the potential utility of family and nonfamily focused intervention options. A majority of respondents reported that family focused interventions would be helpful. A group of respondents, overrepresented by adolescents with low family functioning, reported that this type of intervention would not be helpful. These results are discussed in terms of their impact on offering family focused interventions for juveniles.