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Introduction

  1. Top of page
  2. Introduction
  3. Four Ways to Triangulate Different Theoretical Perspectives
  4. Why Focus on Rational Choice Institutionalism and the Institutionalist Sociology of Professions?
  5. Expectations in Relation to Professional Actors
  6. Expectations in Relation to Institutions
  7. Exploring the Potentials for Theoretical Triangulation of the Two Approaches
  8. The Specific Triangulation of the Two approaches and its Pros and Cons
  9. Conclusion
  10. References

Experts with a high level of specialized knowledge deliver many important services, especially in the public sector. New Public Management reforms have, however, challenged the entrenched role of expertise in public services (Clarke and Newman 1997; Exworthy and Halford 1999), and the classical sociology of professions has difficulty capturing the changing role of expertise (Brint 1993: 3; Scott 2008: 221). On the one hand, the introduction of a wide range of market mechanisms has challenged the traditional logic of governing based on expert authority. Instead, the role of micro-level institutions such as incentives has come to the fore. On the other hand, New Public Management reforms have occurred widely across different European countries, thus highlighting the need to understand the relationships among professional and public actors in different macro institutional set-ups. We, therefore, discuss one approach that is concerned with market mechanisms and economic incentives (rational choice institutionalism) and another approach that focuses on the broader institutional context (institutionalist sociology of professions). The central question in this article is how we can triangulate these two approaches in studies of how professional actors are governed and, thereby, adapt our theoretical tools to the changed context of expertise. How professional actors are governed (understood as both how others govern professional actors and how professional actors govern themselves) is an important question: professionalized services such as medicine and teaching are vital for individual citizens, and professional actors play a key role for these services in terms of both quality and costs.

The article explicitly discusses both professions as collective actors and individual professionals, and, thereby, addresses the duality of action in professional fields. On the one hand, due to strong intra-occupational norms and a (still) strong collective influence on policy making, we cannot understand individual professionals without also looking at the profession as a whole. On the other hand, New Public Management has increased the importance of individuals by placing many important decisions in the hands of the individual professionals, thereby making analyses of professions as collective actors incomplete. This means that we need to understand the interplay between the micro and macro levels, thereby making two specific bodies of institutionalist literatures particularly relevant. The rational choice institutional approach to public administration tries to understand public employee behavior based on microeconomic assumptions (Moe 1987; Miller 2005). In contrast, the institutionalist sociology of professions has its roots in sociological studies of occupations, but adopts an institutionalist approach to analyzing professions and their dynamics. As will be argued in more detail below, the two perspectives emerge as each others' blind corners; rational choice institutionalism primarily analyzes micro-level institutions and individual professionals, while the institutionalist sociology of professions focuses on macro-level institutions and collective actors. Importantly, however, the two approaches lend themselves to theoretical triangulation in that they offer different yet potentially complementary insights. We do not argue that the perspectives should be uncritically combined—the actor assumptions and understanding of central concepts are too dissimilar—but we suggest that analyses of how professional actors are governed can benefit from looking through the lenses of both approaches.

Against this background, the article proceeds as follows: we begin by discussing four ways to triangulate different theories. We then proceed to explain the choice of the two approaches and use this as a basis to identify their respective expectations in relation to professionalism and institutions. Following this, we offer empirical illustrations of how the triangulation of the two approaches can sharpen our understanding of how professional actors are governed. Subsequently, we discuss the pros and cons of the triangulation of the two approaches. We conclude by discussing how theoretical triangulation in future studies can help us to better understand professions, professionals, and the changing role of expertise.

Four Ways to Triangulate Different Theoretical Perspectives

  1. Top of page
  2. Introduction
  3. Four Ways to Triangulate Different Theoretical Perspectives
  4. Why Focus on Rational Choice Institutionalism and the Institutionalist Sociology of Professions?
  5. Expectations in Relation to Professional Actors
  6. Expectations in Relation to Institutions
  7. Exploring the Potentials for Theoretical Triangulation of the Two Approaches
  8. The Specific Triangulation of the Two approaches and its Pros and Cons
  9. Conclusion
  10. References

Our main argument is that the common interest in how professional actors are governed offers a springboard for a fruitful theoretical triangulation of rational choice institutionalism and the institutionalist sociology of professions. In this section, we explain what we understand by theoretical triangulation, while the next section explains in more detail the choice of theoretical approaches and identifies their expectations relative to professional actors and institutions.

Theoretical triangulation can be defined as the use of at least two theoretical perspectives within the same study, with the aim to eliminate, reduce, or counterbalance the shortcomings of a single approach, and, thereby, increase the ability to interpret the research findings at hand (Begley 1996; Denzin 2009/1970; Rennie et al. 2011; Thurmond 2004). Theoretical triangulation thus means applying multiple lenses, and the approaches used may have similar or opposing viewpoints, depending on what the researcher hopes to accomplish. The main objectives are to gain a broader, deeper analysis of our research findings, to look beyond the obvious explanations by having rival hypotheses and, thereby, prevent premature acceptance of plausible explanations, and to strengthen the confidence in the concepts developed. This can be achieved by theoretical triangulation; however, Thurmond (2004: 257) argues that theoretical triangulation comes at a cost, such as the risk of confusion if the frameworks and concepts used are not adequately defined. Others argue that the use of multiple theories in support of the same study can be faulty and epistemologically unsound (Lincoln and Guba 1985: 307). Nevertheless, there is much to be gained from theoretical triangulation.

We see the empirical world as infinitely complex and argue that social science understands the patterns of the empirical world by offering conceptual abstractions (theories). According to Kuhn (1962), theoretical perspectives differ at the paradigmatic level in what they observe and analyze, and in what kind of questions they ask and answer. A given theory also has a number of core assumptions, that is, propositions that are taken for granted (and not tested), and it develops more or less firm understandings of the observed phenomena, reflected, for example, in the way a given concept is defined. Furthermore, theories direct our attention towards those concepts and relationships that are considered fundamental and away from those concepts that are seen as peripheral (King 2004). Following this logic, multiple theories with nonconflicting assumptions can be used together to direct attention to additional concepts and relationships without problems. The shortcoming addressed by this first type of triangulation is the inherent and unavoidable tendency of theories to focus on some concepts and ignore others.

The second type of triangulation is linked to a geometric understanding of triangulation as a process of determining the location of a point by using different angles, rather than relying on straight lines only. If we accept that our analysis of a concept is ultimately imperfect and theory dependent, the robustness of a concept increases if it is analyzed from different angles. This does, of course, require that the approaches try to study the same phenomenon. The increased robustness is the result of reduced theory dependency, which is also the key shortcoming addressed by this type of triangulation. The aim is thus to increase the validity of the research results. This type of triangulation can be used for theories with both conflicting and nonconflicting assumptions, but we argue that it should be used more carefully in the first-mentioned case, to avoid the dangers of epistemological unsoundness mentioned by Lincoln and Guba (1985: 307). Sharpening the analysis by looking at something from different theoretical angles, therefore, also requires that theoretical approaches with conflicting assumptions should be kept separate in the discussion to avoid lack of consistency (which can be the result of eclecticism).

The third type of triangulation relates to the possibility of learning from other theories and, thereby, improving the original theoretical framework. This can relate to the definition of concepts as well as to the expected relationships among concepts. This type of triangulation addresses shortcomings within individual theories and increases theoretical coherence; however, it demands nonconflicting assumptions after the triangulation, given that learning from other theories will otherwise decrease rather than increase coherence in the theory that the triangulation aims to improve.

The last type of triangulation is specifically aimed at theories that have competing claims, and it actively exploits existing disagreements. The underlying assumption is that social science progresses by investigating theoretical propositions empirically, whereby propositions that are inconsistent with the evidence are rejected and those that are consistent are accepted provisionally pending further research (King 2004). Using one theory at a time allows investigating only one proposition per relationship, and if this proposition is rejected, we have to start over. If we choose instead to investigate two conflicting propositions, the chances that one survives empirical investigation are higher. In addition, applying more than one theoretical approach allows for a better informed choice as to whether to accept or reject a proposition. Consequently, this type of triangulation tries to overcome the tendency to look only at the most obvious explanations by using rival hypotheses to prevent premature acceptance of plausible explanations.

Thurmond (2004) recommends that researchers should be clear about what they hope to gain from theoretical triangulation, and we very much agree. The types of triangulation described above are very different, and in any given triangulation it should be clear what precise shortcoming the triangulation addresses and how the triangulation improves the theoretical framework. Is triangulation used to direct attention to more relevant concepts and relationships? Is the triangulation used to improve our analysis of the same concepts, or is it used to improve one of the theoretical perspectives? Or does the triangulation offer alternative expectations? Using triangulation to draw attention to different aspects in the same analysis (type 1) requires that the basic assumptions underlying the theoretical approaches are not conflicting. Looking at the same phenomenon from different angles (type 2) requires that the same empirical phenomenon is studied, but not necessarily that the theoretical approaches have similar assumptions. Similarly, learning through triangulation (type 3) requires that the approaches are concerned with the same phenomenon and that assumptions are compatible after the triangulation—but not necessarily from the outset, given that learning can also happen in relation to assumptions and in specifying what phenomenon is studied. Testing competing expectations in the same study (type 4) does not require similarity in assumptions, and the theoretical approaches need not study the same phenomenon, but they must still be minimally compatible so that they are able to propose relevant answers to the same research question. Indeed this is the absolute minimum requirement for theoretical triangulation to be possible at all. Table 1 summarizes the requirements for agreement/disagreement across the four types of theoretical triangulation.

Table 1. Overview of requirements for agreement/disagreement in different types of theoretical triangulation
 Relevant for same research questionLooking at the same empirical phenomenonUnderlying assumptions are nonconflicting
Type 1: Attention to other aspects
Type 2: Seeing from different anglesnot required
Type 3: Learning from other theory✓ ex post✓ ex post
Type 4: Testing competing claimsnot required/✓not required/✓

Regardless of the chosen type of triangulation, the benefits and drawbacks of triangulating should always be considered carefully. Against this background, what are the specific potentials for theoretical triangulation in the case of our two theories? Before we can answer this question, we need to offer more comprehensive arguments for the choice of the two approaches and to identify the approaches' understandings of professional actors and institutions together with the basic assumptions underlying the two approaches.

Why Focus on Rational Choice Institutionalism and the Institutionalist Sociology of Professions?

  1. Top of page
  2. Introduction
  3. Four Ways to Triangulate Different Theoretical Perspectives
  4. Why Focus on Rational Choice Institutionalism and the Institutionalist Sociology of Professions?
  5. Expectations in Relation to Professional Actors
  6. Expectations in Relation to Institutions
  7. Exploring the Potentials for Theoretical Triangulation of the Two Approaches
  8. The Specific Triangulation of the Two approaches and its Pros and Cons
  9. Conclusion
  10. References

The role of expertise in contemporary societies has been changing for two reasons. First, although professions as collective actors have long been (and still are) very important actors, New Public Management has introduced a range of market mechanisms into the public sector. These mechanisms have, to some extent, redefined professional actors as individual professionals rather than as collective actors called “professions.” In the past, the individual professional was primarily a part of a profession, following the professional norms of the occupation; this type of professional tended to be less visible as an individual. Presently, professionals emerge center stage and increasingly make important economic decisions. Nevertheless, professionals are still very much part of a profession. Actually, globalization has made sociologists return to the concept of professionalism in an attempt to understand occupational change in the global economy (Evetts 2003: 395). This implies that we need to consider both individual professionals and professions.

Second, New Public Management has challenged professional autonomy, for example, by introducing standards and measures of performance and by increasing competition and discipline in the use of resources (Hood 1991: 5). This means that many other actors (than professions and professionals) now have a say over professionalized services. How these other actors are positioned, both internally and relative to professional actors, depends very much on the macro institutional set-up. The emerging cross-country comparative literature on the effects of New Public Management (see, for example, Flynn 2000) thus points to the important role played by macro institutions in shaping the new governance arrangements. At the same time, the introduction of market mechanisms has also increased the importance of micro-level institutions, for example, by strengthening incentives in individual remuneration systems.

In sum, the discussion above underlines the need to look at both professionals and professions and at both micro institutions and macro institutional settings. In this article, we triangulate the institutionalist sociology of professions and rational choice institutionalism because we find that they can potentially contribute to each other by helping the other approach broaden its perspective. Following Table 1 and as argued in more detail below, the two theoretical approaches investigate similar research questions, namely, questions concerned with how professional actors are governed. The two approaches also investigate the same empirical phenomena, in that they have a focus on professional actors and on how the behavior of professional actors is shaped by institutions. In contrast, the two approaches have different underlying assumptions concerning professional actors and institutions. Taken together, this means that they best lend themselves to type 2, type 3, and type 4 theoretical triangulation, while type 1 theoretical triangulation is more problematic. However, as we illustrate in more detail below, this type of triangulation is also possible provided that studies stick to their respective underlying assumptions.

The strength of the institutionalist sociology of professions lies in the analysis of collective actors and macro-level institutions. The classical sociology of professions (Parsons 1951; Freidson 1970; Johnson 1972; Parkin 1979) primarily analyzed the internal workings of professions, and the long-standing dominance of Anglo-American studies in the field, together with the concern for dominant male professions (Burau, Henriksson, and Wrede 2004; Henriksson, Wrede, and Burau 2006), allowed holding (institutional) context factors constant. These context factors, however, have come to the fore as part of the more recent emergence of historical and cross-country comparative studies, which we refer to as the institutionalist sociology of professions (Burrage and Torstendahl 1990; DeVries et al. 2001; Hellberg, Saks, and Benoit 1999; Johnson, Larkin, and Saks 1995). The focus on collective actors and macro institutions allows for ample analyses of the governance of professions (but not governance of professionals). For example, in their study of the changing professional governance in health care, Kuhlmann and Burau (2008) are able to analyze how macro institutions (at national and international levels, especially the EU) affect the relations between the state and the professions. More specifically, regulatory tools such as evidence-based medicine can serve as a means to reassert professional power if they are combined with (international) professionalism (Kuhlmann and Burau 2008: 619). The authors do not, however, analyze how this affects the actual behavior of individual professionals. In general, the focus on the broader context and on macro institutions in the institutionalist sociology of professions means that this approach seldom accomplishes this.

The opposite is the case in the rational choice institutional approach, reflecting the fact that the approach's assumptions are rooted in methodological individualism and microeconomic assumptions. This leads to the claim that behavior reflects the choices made by individuals as they, constrained by institutions, try to maximize their benefits and minimize their costs. Even in the “public administration” version of rational choice institutionalism, which this article principally draws upon, the main focus is on how micro-level institutions impact on individual behavior and outcomes (see, for example, Miller 2000b: 535). Studies of employee behavior also reflect the approach's microeconomic legacy. Not surprisingly, only a small part of rational choice institutional public administration has rediscovered professions (Teodoro 2009; Tonon 2008; Miller and Whitford 2007: 230), although several classical public administration studies stress the role of professionalism for fostering good governance and good public policy (Kaufman 1956; Knott and Miller 1987). Rational choice institutionalism has, in other words, been so concerned with financial incentives that the approach has neglected both the role of professional constraints on individual behavior and the (collective) power of professions. An illustrative example is the “supplier induced demand” literature, which addresses the question whether in the case of too little demand health professionals themselves induce demand (Evans 1974; Richardson and Peacock 2006). The results are, however, very inconclusive, probably because the professions as collective actors have been ignored. Although the literature has begun to discuss the role of professional standards (Iversen and Lurås 2000: 447; Davis, Gribben, Scott, and Lay-Yee 2000: 407), the role of expertise is still treated only sporadically. In general, professional norms may mean that financial incentives (and performance standards, competition) work differently for professionals. Such tools may even leave professionals more ungoverned if they work to undermine the role of professions in regulating individual behavior. At the same time, performance standards, competition, and incentives have a central place in today's governance systems, and such tools have been shown to have very strong effects also on professionals (see, for example, Krasnik et al. 1990). The foundation of rational choice institutionalism (neoclassical microeconomic theory) can be found to be theoretically incoherent (Lee and Keen 2004), and the cost of its clear lines of reasoning can be the oversimplification of human motivation and interaction. Nevertheless, especially with the increased use of market mechanisms to govern professionals, the (mathematical and formal) modeling of individual behavior in rational choice institutionalism may offer social scientists new theoretical insights, which then can be subjected to empirical investigation. To counteract the above-mentioned risk of oversimplification, the approach can, however, fruitfully be triangulated with a more context-sensitive approach.

For the above-mentioned reasons, we focus on rational choice institutionalism and the institutionalist sociology of professions, but potentially there are other options. One option would be to focus on the role of professionals in organizations as discussed by contributions from organizational theorists on the topic of professional governance (see, for example, McNulty and Ferlie 2002; Kitchener 2002; Ackroyd, Kirkpatrick, and Walker 2007). However, the reason for choosing approaches dealing with professionals as individuals and the profession as collective actors, respectively, is that this is where the changes induced by New Public Management are biggest. Another option would be to triangulate two approaches from within the sociology of professions; micro institutions are not unknown within this literature (see, for example, Freidson 1970; Shuval 1999), but the attention to market mechanisms has not been as strong as within rational choice institutionalism. In sum, the dichotomies between micro and macro institutions and between individual professionals and professions do not comprehensively capture the role of expertise, but our purpose is to demonstrate how we can arrive at a better understanding of how professional actors are governed by triangulating two diametrically opposed approaches. Further, we hope that the discussion of triangulating rational choice institutionalism and the institutionalist sociology of professions can illustrate the more general benefits of theoretical triangulation and thus inspire other researchers to triangulate other relevant approaches.

At a basic level, triangulation is only relevant if the theoretical approaches in question have something to contribute to each other in relation to the empirical phenomenon to be explained. This is precisely what applies to rational choice institutionalism and the institutionalist sociology of professions, which have very different assumptions and correspondingly disparate expectations in relation to professional actors and institutions. We discuss this below before demonstrating how the approaches can be triangulated.

Expectations in Relation to Professional Actors

  1. Top of page
  2. Introduction
  3. Four Ways to Triangulate Different Theoretical Perspectives
  4. Why Focus on Rational Choice Institutionalism and the Institutionalist Sociology of Professions?
  5. Expectations in Relation to Professional Actors
  6. Expectations in Relation to Institutions
  7. Exploring the Potentials for Theoretical Triangulation of the Two Approaches
  8. The Specific Triangulation of the Two approaches and its Pros and Cons
  9. Conclusion
  10. References

The concept of “profession” has long been controversial (Freidson 1994; Evetts 2003), and while our two approaches both study professional actors, they have very different underlying assumptions and associated expectations. Rational choice institutionalism typically builds on the original functionalist approach within the sociology of professions, linking professional traits that can only be achieved collectively (a body of expert knowledge, specialized education, and a code of ethics) to rational choice assumptions concerning individual utility maximization. The argument is that if the production of a service demands special expertise, the usual information asymmetry in principal agent relationships is exacerbated by a knowledge asymmetry; there is insufficient knowledge about how an agent should do a job (Sharma 1997). If knowledge is theoretical and, therefore, less transferable, the information asymmetry is even stronger (Roberts and Dietrich 1999: 985), and even the principals might not be able to evaluate the outcome. This is where professional standards become relevant (Moe 1987: 261; Miller 2000a: 320; Andersen 2005). The argument is that politicians face a serious dilemma in relation to services demanding specialized, theoretical knowledge; although politicians cannot control service production, voters still hold them responsible. Politicians are, therefore, interested in a settlement with professional actors, whereby professionals promise to uphold certain standards in exchange for higher status and pecuniary rewards (Day and Klein 1987: 19; Watson 2003: 192). Here, professional status can be defined as the general public's recognition of an occupation's specialized, theoretical knowledge and professional norms (Andersen 2005: 27). Professional status is a collective asset, but from the perspective of rational choice institutionalism norms are only expected to be followed if there are sanctions at the level of individual professionals. Strict rational choice theory would thus expect professionals to balance individual costs against individual benefits (costs of sanctions/efforts to comply with norms relative to the benefits attached to the two different courses of action) and to choose the action that maximizes personal advantage. However, rational choice institutionalism is not a strict (that is, canonical as discussed by Miller 2005) rational choice theory alone because institutions are recognized as very important. In contrast, a canonical (methodological individualistic) rational choice approach does not include any socially instituted patterns of behavior.

Still, as seen from the perspective of rational choice institutionalism, sanctions for noncompliance are necessary for maintaining a profession's professional status in the long run, even if information is asymmetric. Given that professionals are seen as utility maximizing individuals, in the absence of sanctions sloppy practices are expected because professional status is a collective good for all professionals within the same occupation. The profession, therefore, needs to sustain its status by (boasting) careful and competitive selection procedures, training, and credentials, and by establishing protocols specifying best practices and creating ethics codes to limit agent discretion (Shapiro 2005: 276). In other words, the argument is that a profession needs to formulate and sanction professional norms. Such norms are seen as prescriptions commonly known and used by the members of an occupation, and refer to those actions that are required, prohibited, or permitted in a specific situation (Andersen 2005: 71–73; Tonon 2008: 286). In sum, rational choice institutionalism expects professional actors to act as individual professionals, incentivized by personal gain, but constrained by sanctioned intra-occupational norms.

The assumptions relating to professional actors in the institutionalist sociology of professions are linked to the social organization of power (Freidson 1970; Johnson 1972; Parkin 1979). This directs attention to “professional projects” that are concerned about attaining and maintaining a profession's autonomy over its work and the profession's dominance in the division of labor with other groups. However, defining professions as concerned with attaining and maintaining different forms of autonomy can easily lead to a teleological analysis that takes for granted how professions are (ultimately) governed; namely, that models of professional self-regulation as a form of private interest government prevail. From the viewpoint of historical and cross-country comparative studies and their interest in identifying and accounting for variance, this is problematic. The expectation of the institutionalist sociology of professions is that professional actors act collectively as professions and that the activities of professions take shape through specific, institutionally conditioned struggles for power (Burau 2005).

The work of Burrage and Torstendahl (1990) helps to further specify this expectation. The authors introduce an actor-based framework to studying professions that sets focus on the interplay among key actors who have a stake in the governance of a given profession. More specifically, the authors identify the state, organized users, and the practicing and university-based part of a profession. An alternative way of specifying the expectations relating to professions is to focus on the organization of work (Burau, Henriksson, and Wrede 2004). Here, individual professional groups emerge as part of a given field of work, such as health care or elderly care. The perspective highlights relations among professional groups in the context of the delivery of a given service. The approach has been particularly prominent in feminist analysis as it is inclusive in nature and does not privilege some professional groups over others (see, for example, Benoit 1994; Henriksson 2001).

In sum, the institutional sociology of professions and rational choice institutionalism operate with different expectations with respect to professional actors. The latter expects professional actors to act as individual professionals and for their behavior to depend on incentives and norms sanctioned by other professionals. In contrast, the institutionalist sociology of professions expects professional actors to act as collective professions and for the profession's activities to be contingent on the interplay among actors who have a stake in governance or as contingent on the specific organization of work.

The different expectations have implications for the study of how professional actors are governed. For example, the expectation that the behavior of professionals depends on the combinations of benefits and costs is well-suited for research questions concerned with incentive-based governing of professionals, whereas the expectation that the activities of professions are more contingent on the interaction with other professions is best suited for research questions concerned with understanding who professional actors are. Andersen and Serritzlew (2008), for instance, investigate whether the relative fees for different health services (for example, talk therapy and ordinary consultations) affect the behavior of Danish general practitioners (GPs), using a fixed definition of professionalism. In contrast, Burau's (2005) study focuses on understanding what community nursing is and this follows from analyzing the resources of key actors who have stakes in governing community nursing: the state, the purchasers and providers of health care, and professional organizations representing community nursing. The examples illustrate an old truth that the research problem in question should determine the choice of research design and method. However, this “old truth” disregards the possibility that different approaches can inspire each other, improving the quality of both. The study of the relationship between professionalism and public employee strategies could, for example, benefit from considering explicitly whether the same traits are relevant in different contexts, while the study of community nursing could gain from working towards a firmer definition of professionalism as this would strengthen the potential to generalize to other contexts. The different understandings of professionalism are not the only difference between the two approaches. The next section discusses the two approaches′ understanding of institutions.

Expectations in Relation to Institutions

  1. Top of page
  2. Introduction
  3. Four Ways to Triangulate Different Theoretical Perspectives
  4. Why Focus on Rational Choice Institutionalism and the Institutionalist Sociology of Professions?
  5. Expectations in Relation to Professional Actors
  6. Expectations in Relation to Institutions
  7. Exploring the Potentials for Theoretical Triangulation of the Two Approaches
  8. The Specific Triangulation of the Two approaches and its Pros and Cons
  9. Conclusion
  10. References

For the institutionalist sociology of professions, the understanding of institutions is inspired by the historical institutionalist approach in political science (Mahoney 2000; Thelen 1999; Thelen and Steinmo 1992). The approach defines institutions both as formal rules and informal procedures and through the concept of feedback mechanisms is able to capture specific effects of institutions on collective action. Feedback mechanisms consist of “coordination effects,” whereby actors adapt their strategies to existing institutions, as well as “distributional effects,” whereby institutions distribute power among actors in a specific and often uneven way. Here, the specific expectation is that institutionally embedded strategies of, and power relations among, the collective actors who have a stake in the governance of a given profession shape how professions are governed.

The institutionalist sociology of professions expects that both regulative and normative institutions impact on how professions are governed. Scott (2001) defines these institutions as follows: while the former are concerned with formal and informal rules backed up by power and coercion, the latter are about norms and values concerning desirable goals and legitimate means. The study of governing the medical profession by Burau and Vrangbæk (2008), for example, looks at both normative institutions (values underpinning medical authority) and regulative institutions (rules about the consumption of health care; rules defining how to raise and allocate health care resources; rules about the provision of health; and rules about the relative decentralization of governing arrangements).

As the example indicates, this approach expects that it is first and foremost institutions at the macro level that shape how professions are governed. This contrasts with the rational choice institutionalist approach, which expects that micro institutions such as remuneration schemes are key to how professionals are governed. Rational choice institutionalism traditionally has described institutions as collections of rules and incentives, often using the definition introduced by Elinor Ostrom. She sees institutions as prescriptions commonly known and used by a set of participants to order repetitive, interdependent relationships (Ostrom 1986: 4). Professional norms can thus be seen as a type of institution. Actors are expected to maneuver within institutional constraints to maximize personal utilities (Peters 1999: 44) and are only expected to follow institutional prescriptions if that optimizes their utility. Following the same logic, individual actors are also expected to try to create the institutions that will benefit themselves most (Knight 1992). The approaches thus have a different understanding of institutions. While the institutionalist sociology of professions includes both rules backed up by power and coercion and norms and values concerning desirable goals and legitimate means, rational choice institutionalism only includes the first-mentioned.

Triangulation, as mentioned above, is only relevant if the theoretical approaches in question have some distinct characteristics, so they can contribute to each other. This section has shown that this is clearly the case for rational choice institutionalism and the institutionalist sociology of professions. They differ especially in their respective focus on the micro and the macro level and their underlying assumptions (and corresponding expectations) in relation to professional actors and institutions.

Exploring the Potentials for Theoretical Triangulation of the Two Approaches

  1. Top of page
  2. Introduction
  3. Four Ways to Triangulate Different Theoretical Perspectives
  4. Why Focus on Rational Choice Institutionalism and the Institutionalist Sociology of Professions?
  5. Expectations in Relation to Professional Actors
  6. Expectations in Relation to Institutions
  7. Exploring the Potentials for Theoretical Triangulation of the Two Approaches
  8. The Specific Triangulation of the Two approaches and its Pros and Cons
  9. Conclusion
  10. References

Identifying the possibilities for theoretical triangulation in the abstract is one thing, but actually realizing these possibilities in practice is something else. Triangulation is, as mentioned, only possible if the theoretical approaches are compatible at a minimum level. Specifically, they must be relevant for the same research questions. As we have argued above, the two approaches are concerned with questions about how professional actors are governed. Yet, the specific questions asked can nevertheless be very different because rational choice institutionalism and the institutionalist sociology of professions operate with micro and macro perspectives, respectively. However, here we could argue that the two perspectives touch base at the meso level of the professional organization. As outlined above, rational choice institutionalism and the institutionalist sociology of professions have a common focus on professional actors and how professional actors act strategically in relation to the institutional context within which they are embedded. Further, while focusing on the micro level of individual professionals and institutions, rational choice institutionalism also recognizes the existence of the meso level by acknowledging the importance of intraprofessional norms. Similarly, while the central concern is for the macro level of collective professional actors and institutions, the institutionalist sociology of professions also recognizes the existence of the meso level by acknowledging the importance of the division of labour among professional groups and the corresponding interplay among organizational fields.

Notwithstanding the connections of the micro and the macro perspective to the meso level of the professional organization, the discussion above demonstrates that the specific expectations about professional actors and institutions at micro and macro levels also can be conflicting. For example, there is a fundamental difference between expecting that professional actors' behavior is determined primarily by micro-level institutions related to positive/ negative sanctions and expecting that professional actors' behavior is primarily shaped by macro-level institutions and a related logic of institutional appropriateness. In this case, the types of triangulation where consistent assumptions are not necessary (applying different angles in the study of the same phenomenon and testing competing expectations) can still be fruitful. Especially, disagreement about the necessity of sanctions for institutions to affect behavior draws attention to the need for a study that can differentiate between situations with sanctioned professional norms and situations where norms rely on a logic of institutional appropriateness in order to shape behavior. For example, it would be interesting to compare dentists' compliance with professional norms in situations where other dentists were unable to assess and sanction their work, to situations where bad dentistry was sanctioned. If these two situations did not differ, the explanation offered by rational choice institutionalism could be rejected, while the logic of appropriateness as an explanation of norm compliance would be equally questioned if the two situations differed greatly.

Although triangulation can be useful in the example above, it is still necessary to consider to what extent drawing together paradigms/theoretical perspectives that have both logically contrasting and at least sometimes incommensurate conceptions of what is important can be done coherently. In other words, how much paradox can we tolerate in a single analysis? In our view, successful triangulation requires that at a minimum the approaches are relevant for the same question. On that basis, the approaches either have compatible core assumptions concerning the empirical phenomenon, or study the same phenomenon or give competing answers to the same question. If assumptions are similar, triangulation is easy, but primarily contributes to include aspects that are neglected in one of the approaches. If the only common ground is that the same phenomenon is studied, triangulation is more difficult, and the focus on avoiding incoherence and eclecticism should be stronger, but the potential gain may also be bigger. If triangulation concerns competing answers to the same question, only one of the approaches should—after the empirical analysis—be presented as being most consistent with the empirical evidence.

With these words of warning, it is time to look at specific examples of how the two approaches can be triangulated. A typical question within rational choice institituionalism is how formal micro-level institutions affect individual behavior. As briefly mentioned, Andersen and Serritzlew (2008) study how incentives and other formal institutions shaped the behavior of 257 Danish general practitioners (GPs) between 1997 and 2006.1

In line with the literature on supplier induced demand (Evans 1974; Richardson and Peacock 2006; Bech et al. 2007), Andersen and Serritzlew (2008) expect that GPs will induce demand for services, meaning that GPs with few patients will give their patients more services. The authors expect this to happen for services with a high level of remuneration that are not subject to professional norms, while the number of patients and level of service utilization is expected not to be related to those services regulated by firm professional norms sanctioned by the relevant occupation. The authors design a study that encompasses individual and small practice GPs and that captures variation between services and over time relating to the level of fees and whether or not the services are regulated firmly by professional norms.

So how can the four types of triangulation be used relative to this study? Firstly, the variation in fees is not unexpected. Macro institutions such as the type of health care system offer important context information. Burau and Vrangbæk (2008) thus characterize the Danish health care system as an entrenched command and control system, and they find that doctors are closely involved in governing health care and take a very active part in negotiations and consensus finding. This helps understanding how Danish GPs are regulated as part of a formal agreement between the doctors' professional organization and the Danish regions (Sygesikringens Forhandlingsudvalg & Praktiserende Lægers Organisation 2006). Specifically, the GP profession has been strongly involved in negotiating fees. Having this in mind helps interpret the findings on how the professionals react to changes in given micro institutions. Another example is that Andersen and Serritzlew (2008) take the professional norms as given, while in the long run, professional norms are dynamic, and the profession as a collective actor plays an important role in shaping professional norms. Both examples relate to the first type of triangulation: the authors could benefit from paying attention to macro institutions (how is GP more generally governed in Denmark?) and to professions as collective actors. Still, the assumptions underlying the understanding of macro institutions and professions cannot be imported directly from the institutionalist sociology of professions without loss of coherence. The triangulation thus contributes by emphasizing a neglected phenomenon, but one that still needs to be theorized so that conflicting assumptions are avoided.

Secondly, GPs are classified as professionals because they have theoretical, specialized knowledge and intraoccupational norms that regulate their conduct. Concerning this classification, it might be beneficial to look at the professional actors through another lens, for example, Evetts's (2003) framework for the analysis of professionalism. She also sees professions as knowledge-based occupations (Evetts 2003: 397), and this allows triangulation of the second type (measuring the same concept from different angles).

Thirdly, triangulation could even contribute to the concept of profession; the authors might be able to learn from other approaches in terms of improving the definition of professions. Noordegraaf and Van der Meulen (2008), for example, analyze whether the professionalization of managers homogenizes occupational definitions, and more radically, the inspiration could come from a theoretical approach with an open definition of professions. This would not necessarily mean that the study adopted an open definition, but this would move the concept of profession in a dynamic direction, for example, by stressing that the degree of specialized, theoretical knowledge should be seen relative to other groups in society and that the perception of this knowledge base is constantly under negotiation. This would be in line with the classical work of Abbott (1988) that focused on open, negotiated boundaries of expertise in a dynamic system of professions.

Finally, triangulation could also formulate rival hypotheses. An example could be the expectation that supplier induced demand would not be seen for any of the services (not even the ones unregulated by firm professional norms) due to the centrality of values concerning equal treatment of patients. Notice here that an alternative hypothesis from the opposite end of the theoretical spectrum (rational choice theory ignoring professional norms) is that the level of supplier induced demand is high for all types of services. Although all four types of triangulation are potentially relevant for the (rational choice institutionalist) study of Andersen and Serritzlew (2008), the goal of the triangulation should still be specified explicitly. The four types thus “rock the boat” very differently and contribute in quite different ways to improve the understanding of how professional actors are governed.

If we take the institutionalist sociology of professions as the point of departure, triangulation also has great potential. Burau and Vrangbæk's (2008) study of governing the medical profession, for example, analyzes the relationship between macro institutions and the substance of reforms concerned with the introduction of clinical standards across four European countries. The main claim is that sector specific institutions help to account for how different countries redefine hierarchy and professional self-regulation. For example, in Britain, the National Institute for Clinical Excellence has become responsible for standard setting, while monitoring and evaluation are in the hands of the Healthcare Commission. The new regulatory agencies all operate at arm's length as quasi government bodies, and their functions are well defined. This gives the government extensive governing capacities; for instance, the Department of Health may use performance reviews conducted by the Healthcare Commission as a basis for more detailed investigations and funding decisions. In terms of institutions, this reflects the combination of an entrenched command and control health care state and highly centralized governing arrangements.

In comparison, the strengthening of hierarchy is less extensive in Germany, for example, and takes the form of subjecting the organizations of the joint self-administration to tighter substantive and procedural regulation. In terms of institutions, this is closely tied to the corporatist health care state where the governing capacities of the state are limited to defining (and re-defining) the overall framework in which the joint self-administration operates. Variations among macro institutions are thus the key explanatory factors in this approach; but focusing on variations of macro institutions comes at the price of leaving the concern for the individual professional to one side. The analysis does not investigate how standard-setting, monitoring and evaluation are implemented at the micro level, and how individual professionals react. The first type of triangulation would direct attention to these other, supplementary concepts and relationships. The rational choice institutionalism would thus be able to open the black box of micro-level institutions and analyze the variety of specific institutions which exist at the micro level as well as the dynamics that occur within such institutions. But similar to the type 1 triangulation discussed above, careful awareness of the potentially conflicting assumptions is required to avoid incoherence.

Triangulation of the second type is also possible in this study, for example in relation to the analysis of governing capacities. Although the study uses an inductive approach, the selection of the research material (primary and secondary written material and interviews with relevant experts) has been guided by theory. Following from this, it would be interesting to analyze the concept of governing capacity from another theoretical angle. Here, the rational choice institutionalist approach, for example, would direct attention to the governing capacities that exist at the micro level that are specifically concerned with the micro-level context of medical practice and the decisions individual medical professionals make on how to deliver high quality health services. Further and related to the last point, a rational choice institutionalist approach might also (third type of triangulation) contribute to a broader conceptualization. The present understanding of governing capacity is linked to the capacity to regulate organizations, but the concept could also include the capacity to change the behavior of individual professionals. Considering the governing dynamics at micro level, individual medical professionals emerge not only as objects but also as agents of governing. This specifically enlarges the understanding of professional self-governance, to include not only professional bodies but also individual professionals.

Finally, Burau and Vrangbæk (2008: 357) expect that “the complex variations in health care states and combinations of different types of sector specific institutions shape the substance of governing medical performance.” An alternative expectation (based on rational choice institutionalism) could be that the actors' interests and resources determine how medical performance is governed. If it turned out that variations in sector-specific institutions at the macro level (rather than variations in actor interests and capacities) explained the difference, the original claim would be even more credible. This alternative expectation is an example of the fourth type of theoretical triangulation.

In sum, the two approaches chosen make for a particularly strong theoretical triangulation, as the approaches are each other's blind corners. There are, in other words, many concepts that one approach focuses on and the other neglects. As a consequence, we know little about the interaction between micro and macro institutions and between the strategic actions of professionals and professions, respectively. For example, Burau's (2005) study of governing community nursing in Germany and Britain highlights both differences in the type of hierarchical relations and variations in relative strength of such relations and makes the macro institutional contexts the key explanatory factor. Yet, the study (and institutionalist sociology of professions in general) does not analyze whether macro institutions moderate the relationships between micro-level institutions and individual behavior. Similarly, studies of individual professionals seldom investigate the effect of macro institutions. For example, when Teodoro (2009: 1) analyzes whether innovations are most likely to diffuse from professions to governments under conditions of job mobility, he holds macro institutions constant. He argues that when an agency head arrives from outside the government, the incentives for innovation are more potent than when an agency head is promoted from within. Teodoro (2009: 9) does mention the reasons why water utility service rates provide an excellent subject for evaluating the (micro-level) theory, but there is no variation in the macro institutional context, and there is little focus on the relevant profession as a collective actor. In other words, the interaction between micro- and macro-level institutions is underexposed in both approaches, and theoretical triangulation draws attention to the importance of designing studies with variation in both types of institutions. The examples above illustrate how the two approaches can mutually strengthen and inspire each other, and, therefore, we argue that the two approaches can often benefit from theoretical triangulation.

The Specific Triangulation of the Two approaches and its Pros and Cons

  1. Top of page
  2. Introduction
  3. Four Ways to Triangulate Different Theoretical Perspectives
  4. Why Focus on Rational Choice Institutionalism and the Institutionalist Sociology of Professions?
  5. Expectations in Relation to Professional Actors
  6. Expectations in Relation to Institutions
  7. Exploring the Potentials for Theoretical Triangulation of the Two Approaches
  8. The Specific Triangulation of the Two approaches and its Pros and Cons
  9. Conclusion
  10. References

Moving beyond individual aspects of theoretical triangulation, we conclude our analysis by discussing the possibilities of a research design that allows identifying both micro-level governing dynamics within the context of macro-level governing and the effect of variations in macro-level governing arrangements on micro-level governing dynamics.

In rational choice institutionalism, adding the perspective of collective actors and macro-level institutions highlights context and offers a springboard for cross-country comparison. The more specific benefits are two-fold. First, the perspective of collective actors helps explain the emergence and design of micro-level institutions. For example, in the case of Danish GPs, we can only understand how the specific incentives in the fee schedule (for example, the combination of fee per capita and fee per item) came about, if we also analyze the professional organization of doctors and its negotiations with the government. The same is true for the macro-level institutions such as the ownership structures characterizing the health system. For example, Danish GP services are produced by self-employed practitioners, reflecting an explicit strategy used by the professional organization during the transition to the national health insurance in 1971. Furthermore, examining professions as collective actors contributes to our understanding of how professional norms come into existence and are sanctioned. Importantly, the latter occurs not only at the level of individual peers, but also at the level of collective actors through defining and sanctioning codes of practice by the professional organization. The professional organization of doctors in Denmark, for example, has introduced a number of clinical guidelines for GPs that are sanctioned both formally in the Patients Complaints Board and informally through peer interaction.

Second, adding the perspective of macro institutional contexts puts rational choice institutionalism in a better position to conduct analyses from a cross-country comparative perspective. Recognizing the importance of the health financing institutions, for example, can lead to interesting comparisons between Danish and Norwegian GPs, whose services differ in relation to the existence of user payments. The same applies to analyzing possibilities of transferring policies/instruments from one country to another. This requires understanding the broader macro institutional context the specific policy/instrument is part of. The Danish GP study, for instance, suggests that the use of services without professional norms can be governed by adjusting fees, but this is obviously only possible in a system where fees are fixed in national agreements.

In relation to the institutionalist sociology of professions, adding the perspective of individual professionals and micro-level institutions allows opening the black box of micro-level governing and offers the possibility of a more fine-grained analysis. The specific benefits are two-fold. First, the focus on individual professionals allows for a more detailed analysis of the interplay among actors who have a stake in governing. Here, individual professionals in particular are becoming more important as continued cost containment in public services increases distributional conflicts within professions and makes the divisions among different groups within a profession more visible. For medical services, this can be manifested as divisions among different specialties and between junior and senior doctors. Importantly, in some cases, the divisions are so severe that groups of individual doctors challenge professional organizations. In Germany, for example, the collective contract negotiated by the organization of insurance fund doctors has attracted considerable criticism from divergent sides in the medical profession. This has led groups of individual doctors to take advantage of the possibility of directly contracting with specific insurance funds at the state level (Kuhlmann 2006).

Second, adding the focus on micro-level institutions allows for the exploration of variations within macro-level institutions. These have specifically come to the forefront following recent public sector reforms across European countries that have had a strong emphasis on promoting market mechanisms. This has entailed a decentralization of and even fragmentation into micro-level institutions. In the case of GPs, for example, the creation of a quasi-market in England, involving regional Primary Care Groups contracting with local hospitals and other health care providers, underlines the more important role micro institutions play in the governance of professional actors (Blank and Burau 2010).

At the same time of course, there are caveats to such a research design and more specifically, to the extent to which it is indeed possible to triangulate the two perspectives. Applying both perspectives in the same project demands adequate definitions of frameworks and concepts due to the risk of conflicting assumptions and incoherence. Researchers also need to watch out for conceptual eclecticism, since the understanding of the central concepts of professional actors and institutions are rather different. In other words, it is important to be explicit about what kinds of theoretical triangulation are used. Still, we find that the benefits of theoretical triangulation are very often more significant than its drawbacks.

Conclusion

  1. Top of page
  2. Introduction
  3. Four Ways to Triangulate Different Theoretical Perspectives
  4. Why Focus on Rational Choice Institutionalism and the Institutionalist Sociology of Professions?
  5. Expectations in Relation to Professional Actors
  6. Expectations in Relation to Institutions
  7. Exploring the Potentials for Theoretical Triangulation of the Two Approaches
  8. The Specific Triangulation of the Two approaches and its Pros and Cons
  9. Conclusion
  10. References

This article asks how we can triangulate rational choice institutionalism and the institutionalist sociology of professions. We identify four types of triangulation: adding more relevant concepts/relationships, triangulating analysis, learning from other theories, and formulating alternative expectations. We argue that the benefits of triangulation are especially strong for rational choice institutionalism and institutionalist sociology of professions because the two approaches constitute each other's blind corners. The latter can gain from also looking at individual professional actors and micro institutions, while the former can gain from also looking at macro institutions and professions as collective actors. Empirically, such a dual focus on macro and micro levels and on individuals and collective actors has also become increasingly important. Public sector reforms have introduced market mechanisms aimed at individual professionals, but professions are still important. Similarly, public sector reforms both strengthen micro-level institutions and highlight the importance of macro-level institutions. Therefore, we suggest that future studies of professionalized services triangulate theories that allow them to include both micro and macro levels and both professions and professionals. Importantly, this will help to overcome the literature's problems with capturing the changing role of expertise in contemporary societies.

Note
  1. 1

    Danish GP services are free of charge for users and are delivered by private GPs. Each GP is only allowed to give daytime services to his own list of patients, and the remuneration system consists of fixed fees per service (approx. 75 percent of the income) and fixed fees per patient (approx. 25 percent of the income).

References

  1. Top of page
  2. Introduction
  3. Four Ways to Triangulate Different Theoretical Perspectives
  4. Why Focus on Rational Choice Institutionalism and the Institutionalist Sociology of Professions?
  5. Expectations in Relation to Professional Actors
  6. Expectations in Relation to Institutions
  7. Exploring the Potentials for Theoretical Triangulation of the Two Approaches
  8. The Specific Triangulation of the Two approaches and its Pros and Cons
  9. Conclusion
  10. References
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