Professions and Professionals: Capturing

the Changing Role of Expertise Through

Theoretical Triangulation
By VIOLA BURAU* and LOTTE BØGH ANDERSEN†

Introduction

Experts with a high level of specialized knowledge deliver many

important services, especially in the public sector. New Public Man-
agement 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 institu-
tionalism) and another approach that focuses on the broader institu-
tional 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 pro-
fessional 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.
*viola@ps.au.dk
†lotte@ps.au.dk
American Journal of Economics and Sociology, Vol. 73, No. 1 (January, 2014).
DOI: 10.1111/ajes.12062
© 2014 American Journal of Economics and Sociology, Inc.
 Professions and Professionals 265

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 incom-
plete. 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 perspec-
tives emerge as each others’ blind corners; rational choice institu-
tionalism 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 trian-
gulation 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 con-
cepts are too dissimilar—but we suggest that analyses of how profes-
sional 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 profes-
sionalism and institutions. Following this, we offer empirical illustra-
tions 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
266 The American Journal of Economics and Sociology

approaches. We conclude by discussing how theoretical triangula-

tion in future studies can help us to better understand professions,
professionals, and the changing role of expertise.

Four Ways to Triangulate Different Theoretical Perspectives

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 under-
stand 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 multi-
ple 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 con-
cepts 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). Neverthe-
less, 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
 Professions and Professionals 267

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 pheno-
mena, 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 under-
standing 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 imper-
fect 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 dif-
ferent 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 theo-
retical coherence; however, it demands nonconflicting assumptions
268 The American Journal of Economics and Sociology

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 inves-
tigating 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 over-
come 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 triangu-
lation used to improve our analysis of the same concepts, or is it used
to improve one of the theoretical perspectives? Or does the triangu-
lation offer alternative expectations? Using triangulation to draw atten-
tion 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 assump-
tions. 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
 Professions and Professionals 269

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 rele-
vant 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.
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 theoreti-
cal 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.

Table 1
Overview of requirements for agreement/disagreement in
different types of theoretical triangulation
Relevant Looking at Underlying
for same the same assumptions
research empirical are
question phenomenon nonconflicting

Type 1: Attention to ✓ ✓ ✓
other aspects
Type 2: Seeing from ✓ ✓ not required
different angles
Type 3: Learning ✓ ✓ ex post ✓ ex post
from other theory
Type 4: Testing ✓ not required/✓ not required/✓
competing claims
270 The American Journal of Economics and Sociology

Why Focus on Rational Choice Institutionalism and the

Institutionalist Sociology of Professions?

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 occupa-
tion; 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 profes-
sionals 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
 Professions and Professionals 271

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 investi-
gate 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 illus-
trate 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 con-
stant. These context factors, however, have come to the fore as part
of the more recent emergence of historical and cross-country com-
parative 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 profes-
sional 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
272 The American Journal of Economics and Sociology

affects the actual behavior of individual professionals. In general, the

focus on the broader context and on macro institutions in the insti-
tutionalist 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 assump-
tions. 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 adminis-
tration” version of rational choice institutionalism, which this article
principally draws upon, the main focus is on how micro-level insti-
tutions 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 redis-
covered 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 pro-
fessionals more ungoverned if they work to undermine the role of
professions in regulating individual behavior. At the same time, per-
formance standards, competition, and incentives have a central place
 Professions and Professionals 273

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 profes-
sion 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 diametri-
cally 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 triangu-
late other relevant approaches.
274 The American Journal of Economics and Sociology

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

The concept of “profession” has long been controversial (Freidson

1994; Evetts 2003), and while our two approaches both study pro-
fessional 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 indivi-
dual 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 asymme-
try; 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
 Professions and Professionals 275

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 profes-
sionals 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 indivi-
dualistic) 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 pro-
fession’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, in-
centivized 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 main-
taining a profession’s autonomy over its work and the profession’s
276 The American Journal of Economics and Sociology

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 con-
trast, the institutionalist sociology of professions expects professional
actors to act as collective professions and for the profession’s activ-
ities to be contingent on the interplay among actors who have a
stake in governance or as contingent on the specific organization of
work.
 Professions and Professionals 277

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 bene-
fits 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 con-
cerned 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 practi-
tioners (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 organiza-
tions 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

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
278 The American Journal of Economics and Sociology

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 govern-
ance of a given profession shape how professions are governed.
The institutionalist sociology of professions expects that both regu-
lative and normative institutions impact on how professions are gov-
erned. 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 institu-
tional constraints to maximize personal utilities (Peters 1999: 44) and
are only expected to follow institutional prescriptions if that opti-
mizes 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 understand-
ing of institutions. While the institutionalist sociology of professions
 Professions and Professionals 279

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 assump-
tions (and corresponding expectations) in relation to professional
actors and institutions.

Exploring the Potentials for Theoretical Triangulation

of the Two Approaches

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. Specifi-
cally, 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 ques-
tions 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 institution-
alism also recognizes the existence of the meso level by acknowl-
edging 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
280 The American Journal of Economics and Sociology

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 pri-
marily 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 atten-
tion 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 contrast-
ing 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
 Professions and Professionals 281

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 phe-
nomenon 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 com-
peting 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 insti-
tutions 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 institu-
tions 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
282 The American Journal of Economics and Sociology

formal agreement between the doctors’ professional organization

and the Danish regions (Sygesikringens Forhandlingsudvalg &
Praktiserende Lægers Organisation 2006). Specifically, the GP profes-
sion 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 phe-
nomenon, 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 professional-
ism. 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 defini-
tions, and more radically, the inspiration could come from a theoreti-
cal 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
 Professions and Professionals 283

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 gov-
erning arrangements.
284 The American Journal of Economics and Sociology

In comparison, the strengthening of hierarchy is less extensive in

Germany, for example, and takes the form of subjecting the organi-
zations of the joint self-administration to tighter substantive and pro-
cedural 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 atten-
tion 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 capac-
ities that exist at the micro level that are specifically concerned with
the micro-level context of medical practice and the decisions indivi-
dual 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) con-
tribute 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 behav-
ior of individual professionals. Considering the governing dynamics at
 Professions and Professionals 285

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 differ-
ence, the original claim would be even more credible. This alter-
native 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, respec-
tively. 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 explana-
tory 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 profes-
sions 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)
286 The American Journal of Economics and Sociology

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 institu-
tions is underexposed in both approaches, and theoretical triangula-
tion 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

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 vari-
ations in macro-level governing arrangements on micro-level govern-
ing dynamics.
In rational choice institutionalism, adding the perspective of collec-
tive 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 practi-
tioners, reflecting an explicit strategy used by the professional organi-
zation 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
 Professions and Professionals 287

defining and sanctioning codes of practice by the professional organi-

zation. 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 impor-
tance 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 becom-
ing 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 differ-
ent specialties and between junior and senior doctors. Importantly,
in some cases, the divisions are so severe that groups of indivi-
dual doctors challenge professional organizations. In Germany, for
example, the collective contract negotiated by the organization of
insurance fund doctors has attracted considerable criticism from diver-
gent 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).
288 The American Journal of Economics and Sociology

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 perspec-
tives in the same project demands adequate definitions of frameworks
and concepts due to the risk of conflicting assumptions and incoher-
ence. 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

This article asks how we can triangulate rational choice institutional-

ism 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 indi-
vidual 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
 Professions and Professionals 289

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 chang-
ing role of expertise in contemporary societies.

Note
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).

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