Multidisciplinary Collaboration in Hospitals via Patient- and Process-Oriented Units: A Longitudinal Study

Introduction

The complexity of healthcare is increasing, mainly due to the prevalence of multimorbidity in an ageing population. Complex care for patients with multimorbidity requires a multidisciplinary approach. Traditional physician-centered hospital structures do not facilitate the necessary multidisciplinary collaboration. European hospitals are implementing process-based hospital designs with patient- and process-oriented units to stimulate multidisciplinary collaboration. Patient-oriented units are formed based on shared patient groups and focus on care trajectories, while process-oriented units are formed based on having similar processes and focus on efficiency.

Purpose

This study has two aims. First, to study the effect of introduction of these units on multidisciplinary collaboration and perceived impact (efficiency, innovation, and effectiveness). Second, to study whether there are differences between patient- and process-oriented units.

Methods

A survey-based longitudinal evaluation study was conducted in 2020 and 2022 among physicians in a Dutch hospital to measure multidisciplinary collaboration (relational coordination) and perceived impact (efficiency, innovation, and effectiveness). In addition, open questions were used to enrich the data.

Results

Quantitative and qualitative data together suggest that physicians in patient-oriented units notice benefits from the redesign to multidisciplinary units, they perceive higher impact over time. Physicians in process-oriented units achieve a better relationship with the physicians in their unit over time, but they do not perceive impact as high as physicians in patient-oriented units.

Conclusion

A process-based design with patient- and process-oriented units is supportive of multidisciplinary collaboration and perceived impact, especially for physicians in patient-oriented units. Physicians in patient-oriented units are positive about the introduction of these units as they feel it contributes to better multidisciplinary patient care. As the results for physicians in process-oriented units may be less directly visible in terms of quality of care, they are less likely to see positive effects, even though their relationships are improving.

Hybridity enabled: A research synthesis of the enabling conditions for hybrid professionalism in healthcare

Hybrid professionals in healthcare organizations play a critical role, the characteristics, processes and implications of which have been thoroughly studied by scholars in the field. However, not as much attention has been paid to the conditions under which such roles might be taken by professionals entering the ground of management. This gap results into a lack of conceptual clarity and eventually ends being an obstacle in framing and ameliorating the tools needed to act such a role in its different phases. This is a research area worthy of a finer-grained understanding: the ability of organizations to effectively support role hybridization, in fact, is a requisite for professionals-managers' willingness to stay in the role and cope with the complexity that such a two-fold position entails, no matter what. Based on the results of a scoping literature review, this paper presents the enabling conditions for hybrid professionalism in healthcare, and proposes a classification of them into categories corresponding to different facets of hybrid role-taking: opportunities for interaction with management, tools supporting sense-making, and provision of delegation and autonomy. For each of these categories, organizational and management tools discussed in the literature are presented. The results of the study provide a road-map of the enabling conditions for hybrid professionalism that aims to be of practical convenience for managers and policy-makers in health care. Eventually, suggestions for organizational design and personnel management, as well as directions for further research, are highlighted.

Medical professionals' agency and pharmaceuticalization: Physician-industry relations in Russia

In the contemporary world pharmaceuticals have become a go-to answer to a growing number of questions. This process of pharmaceuticalization gives rise to a concern with the increasing influence of the pharmaceutical industry on physicians' decision-making. Critics suggest that companies' for-profit-interests might compromise the integrity of medical practice. This article employs qualitative research methodology to explore how Russian physicians deal with the industry's efforts to expand and shape the use of pharmaceuticals. By bridging perspectives of social studies of science and sociology of professions, we offer a contextualized account of physicians' daily practices and interpretations related to pharmaceuticalization. The findings question conventional assumptions of physician-industry relations and allow to delineate a new form of medical professionalism that emerges in the context of pharmaceuticalization and cannot be reduced to either "resisting" industry marketing activities or "giving in" to them and thus corrupting biomedical expertise. Instead, the ways in which physicians navigate abundant sources of knowledge and use industry resources to overcome constraints of their organizational environment attest to mundane forms of agency exercised by physicians in their relations with industry.

Capturing dynamics in nursing: a diary study of nurses' job characteristics and ability and willingness to continue working

Objectives

This study aimed to gain insight into (1) the dynamics of job characteristics (demands and resources) of nurses and (2) how job characteristics relate to nurses' ability and willingness to continue working (understood as employability). Job characteristics are profession-specific and vary over time, but studies often overlook these dynamics. Moreover, job characteristics relate to nurses' employability, which is under pressure due to a rapidly changing work environment. It is necessary to gain insight into the dynamic job characteristics of nurses to develop targeted workplace interventions that help nurses remain employable.

Methods

This study adopted a mixed methods diary approach, with a strong emphasis on qualitative analysis. 46 Nurses from two hospitals in a large Dutch city completed a structured diary at six points over 3 weeks, resulting in 225 diary entries in total. The nurses used a custom-made application on their mobile devices to describe in their own words what they experienced as demanding and resourceful throughout the shifts and how they experienced their employability. Prior to the diaries, nurses completed an intake survey.

Results

A within-person analysis highlighted the day-to-day dynamics in the nursing profession. The job characteristics a nurse mentioned in the first diary entry often were completely different from the job characteristics the same nurse mentioned in the other diary entries. This analysis also showed variety within nurses' employability, demonstrating that perceptions of employability vary over time. A between-person analysis highlighted links between job characteristics and nurses' employability: social interactions strengthen a nurse's employability, a strict task approach threatens it, and aspects such as a strong drive to care, professional development, and autonomy (clustered as aspects that enable to "act professionally") create opportunities to enhance employability.

Conclusion

Insights from this study show that job characteristics typical to the nursing profession can be linked to nurses' perceptions of employability. Also, it stems from this research that not only job characteristics but also employability are dynamic in the short run. Understanding and enhancing employability in a nursing context requires capturing these dynamics, for instance by collecting data at several points in time or by using mixed-method studies to understand employability scores within their context.

Connective and Tactfully Tactical: Connective Tactics and Professional Authority in Doctor-Patient Relationships

Medical authority is often thought to be threatened by lay access to information, but how does professional authority work when citizens have more knowledge and choices? We seek to understand how professional authority works in doctor-patient relationships and what each side does to navigate medical encounters. Our abductive study is relational as it builds on qualitative interviews with both doctors and patients. While doctors and patients each try to steer the encounter towards their desired outcomes, they also employ a series of 'connective tactics' to maintain a good, professional relationship. These connective tactics are often draped in a 'tactful' and informal manner so as not to threaten the continuous authority relationship between professionals and citizens. Both sides have a repertoire of how to act on authority relations, often supported by courteous attempts to not insist on formal superiority or patient rights. Each side shifts between what may seem like traditional and connective ways to perform medical authority. Doctors can continue to act as knowledge authorities if they also at least appear to be equals with patients; and patients can use internet findings to get involved in medical decisions as long as they pretend to still respect medical authority.

International alliance structure and effectiveness: evidence from law firms

International alliances are important strategic vehicles to build geographic scope and enter foreign markets, especially for firms lacking the resources or facing limitations to direct foreign expansion. Addressing recent calls to study alliance structure, we investigate the design parameters of nonequity international alliances and their performance implications. Building on the resource-based view of the firm, we theorize the effect of three key structural dimensions – formalization, interface, and specialization – on firm effectiveness. Our empirical work focusses on the legal service industry where international interfirm alliances are common, and resources like expert workers and knowledge are essential. We study 121 French, German, Italian, and Spanish law firms; and our data include the structural features of the alliances to which they belong, as well as various measures of firm effectiveness. Our analyses via structural equation modelling point toward the importance of informality and strong interface for effectiveness in these contexts. This study contributes to a finer understanding of international alliances by directly addressing the structural variation among nonequity international alliances, and analyzes their implications for firms. We thus respond to calls to investigate structural dimensions of alliances, operationalizing relevant dimensions of alliance organizational structure. Second, we add to understanding of the performance effects of international alliances, showing the benefits of individual structural parameters for firm effectiveness. Finally, we extend research on the use of international alliances as a strategic vehicle to enter foreign markets, capturing essential aspects of the internal arrangements of these interorganizational collaborative relationships, and thus adding to understanding of this strategic entry mode.

Working on connective professionalism: What cross-sector strategists in Swedish public organizations do to develop connectivity in addressing ‘wicked’ policy problems

In light of current debates on ‘protective’ and ‘connective’ professionalism, this article explores a new type of occupational position that is emerging within the Swedish public sector: the cross-sector strategist. The growing presence of this intermediary occupational position is seen as attempts to formalize and institutionalize the imprecise roles and governance of ‘wicked’ policy problems, and the job of these strategists is focused on supporting other jurisdictions to meet and act. By pursuing connective strategies in the form of triggering, selling, bridging, brokering, and forming accountabilities, cross-sector strategists seek to establish embedded workspaces where strategic action and decisions can be produced jointly and across jurisdictional boundaries. The study illustrates how calls for changes in professional action towards connectivity are now part of the formal organizational structure of public sector organizations, confirming the incapability of professional actors to connect in the absence of intermediary support functions. In the concluding discussion, we consider the relevance of ‘connective professionalism’ as a descriptive theoretical device applied to work settings understood as increasingly complex and interdependent, with calls for inter-professional collaboration and intensifying engagement in preventing problems rather than simply treating them.

Reflection Machines: Supporting Effective Human Oversight Over Medical Decision Support Systems

Human decisions are increasingly supported by decision support systems (DSS). Humans are required to remain "on the loop," by monitoring and approving/rejecting machine recommendations. However, use of DSS can lead to overreliance on machines, reducing human oversight. This paper proposes "reflection machines" (RM) to increase meaningful human control. An RM provides a medical expert not with suggestions for a decision, but with questions that stimulate reflection about decisions. It can refer to data points or suggest counterarguments that are less compatible with the planned decision. RMs think against the proposed decision in order to increase human resistance against automation complacency. Building on preliminary research, this paper will (1) make a case for deriving a set of design requirements for RMs from EU regulations, (2) suggest a way how RMs could support decision-making, (3) describe the possibility of how a prototype of an RM could apply to the medical domain of chronic low back pain, and (4) highlight the importance of exploring an RM's functionality and the experiences of users working with it.

When performance is not enough-A multidisciplinary view on clinical decision support

Scientific publications about the application of machine learning models in healthcare often focus on improving performance metrics. However, beyond often short-lived improvements, many additional aspects need to be taken into consideration to make sustainable progress. What does it take to implement a clinical decision support system, what makes it usable for the domain experts, and what brings it eventually into practical usage? So far, there has been little research to answer these questions. This work presents a multidisciplinary view of machine learning in medical decision support systems and covers information technology, medical, as well as ethical aspects. The target audience is computer scientists, who plan to do research in a clinical context. The paper starts from a relatively straightforward risk prediction system in the subspecialty nephrology that was evaluated on historic patient data both intrinsically and based on a reader study with medical doctors. Although the results were quite promising, the focus of this article is not on the model itself or potential performance improvements. Instead, we want to let other researchers participate in the lessons we have learned and the insights we have gained when implementing and evaluating our system in a clinical setting within a highly interdisciplinary pilot project in the cooperation of computer scientists, medical doctors, ethicists, and legal experts.

"Nothing works without the doctor:" Physicians' perception of clinical decision-making and artificial intelligence

Introduction

Artificial intelligence-driven decision support systems (AI-DSS) have the potential to help physicians analyze data and facilitate the search for a correct diagnosis or suitable intervention. The potential of such systems is often emphasized. However, implementation in clinical practice deserves continuous attention. This article aims to shed light on the needs and challenges arising from the use of AI-DSS from physicians' perspectives.

Methods

The basis for this study is a qualitative content analysis of expert interviews with experienced nephrologists after testing an AI-DSS in a straightforward usage scenario.

Results

The results provide insights on the basics of clinical decision-making, expected challenges when using AI-DSS as well as a reflection on the test run.

Discussion

While we can confirm the somewhat expectable demand for better explainability and control, other insights highlight the need to uphold classical strengths of the medical profession when using AI-DSS as well as the importance of broadening the view of AI-related challenges to the clinical environment, especially during treatment. Our results stress the necessity for adjusting AI-DSS to shared decision-making. We conclude that explainability must be context-specific while fostering meaningful interaction with the systems available.

Knowing, relating and the absence of conflict: relational leadership processes between hospital boards and chairs of nurse councils

Purpose

This study aims to enhance understanding of the collaboration between chairs of nurse councils (CNCs) and members of executive hospital boards (BM) from a relational leadership perspective.

Design/methodology/approach

The authors used a qualitative and interpretive methodology. The authors study the daily interactions of BM and CNCs of seven Dutch hospitals through a relational leadership lens. The authors used a combination of observations, interviews and document analysis. The author’s qualitative analysis was used to grasp the process of collaborating between BM and CNCs.

Findings

Knowing each other, relating with and relating to are distinct but intertwined processes that influence the collaboration between BM and CNC. The absence of conflict is also regarded as a finding in this paper. Combined together, they show the importance of a relational process perspective to understand the complexity of collaboration in hospitals.

Originality/value

Collaboration between professional groups in hospitals is becoming more important due to increasing interdependence. This is a consequence of the complexity in organizing qualitative care. Nevertheless, research on the process of collaborating between nurse councils (NCs) and executive hospital boards is scarce. Furthermore, the understanding of the workings of boards, in general, is limited. The relational process perspective and the combination of observations, interviewing and document analysis proved valuable in this study and is underrepresented in leadership research. This process perspective is a valuable addition to skills- and competencies-focused leadership literature.

Clinicians' psychological empowerment to engage in management as part of their daily work

PURPOSE

The purpose of the article is to analyze how physicians and nurses, as the two major health care professions, experience psychological empowerment for managerial work.

DESIGN/METHODOLOGY/APPROACH

The study was designed as a qualitative interview study at four primary care centers (PCCs) in Sweden. In total, 47 interviews were conducted, mainly with physicians and nurses. The first inductive analysis led us to the concept of psychological empowerment, which was used in the next deductive step of the analysis.

FINDINGS

The study showed that both professions experienced self-determination for managerial work, but that nurses were more dependent on structural empowerment. Nurses experienced that they had competence for managerial work, whereas physicians were more ignorant of such competence. Nurses used managerial work to create impact on the conditions for their clinical work, whereas physicians experienced impact independently. Both nurses and physicians experienced managerial work as meaningful, but less meaningful than nurses and physicians' clinical work.

PRACTICAL IMPLICATIONS

For an effective health care system, structural changes in terms of positions, roles, and responsibilities can be an important route for especially nurses' psychological empowerment.

ORIGINALITY/VALUE

The qualitative method provided a complementary understanding of psychological empowerment on how psychological empowerment interacted with other factors. One such aspect was nurses' higher dependence on structural empowerment, but the most important aspect was that both physicians and nurses experienced that managerial work was less meaningful than clinical work. This implies that psychological empowerment for managerial work may only make a difference if psychological empowerment does not compete with physicians' and nurses' clinical work.

Emotional labour as a vehicle of organisational change in maternity care: The case of Russian doulas' institutional work

Sociological scholars of healthcare professions are becoming increasingly aware of the organisational dimension of professionalism, including how professionals as institutional actors are exposed to and influence organisational transformation. By tracing the ground-level professional efforts of Russian doulas-a caring profession that has been plunged into a reforming health system-in this article I explore how meaning-making activities and professionals' emotional labour build into and advance institutional changes in post-socialist maternity care. Drawing on qualitative research materials, I define three ways through which doulas' institutional efforts engage with emotions in clinical settings: (1) redefining emotional labour as a compound of maternity care; (2) grounding emotional labour in the context of reforming institutions; (3) using emotional labour to bridge discrepancies within organisational arrangements in healthcare. My research findings provide new insights into how marketisation influences professional care, as well as about caring professionalism in post-socialist maternity care. Attention to doulas' professional efforts allows for the affective transformation and inequality in the context of healthcare reforms to be analytically grasped. In particular, I trace how doulas' institutional agency embodied in emotional labour constructs the neo-liberal patient's identity.

Organisational learning in complex epistemic environments: reflections from studies of professional work in Norway

Purpose

The aim of this invited paper is to explore how more complex epistemic environments generate opportunities and challenges for organizational learning in professional realms. Based on these explorations, a second aim is to discuss whether there are specific conditions in Nordic working life that facilitates or restricts such learning opportunities.

Design/methodology/approach

The paper discusses conditions for organizational learning in terms of changing knowledge practices and relations. Examples from studies of knowledge work in the Norwegian education and health sectors are provided to illustrate how professionals become involved in epistemic practices as part of their work and how these practices are changing in relation to evolving knowledge cultures.

Findings

The paper conceptualises and discusses how knowledge practices are changing in relation to specific and increasingly complex epistemic environments. It is argued that features such as low power distance, high levels of higher education participation, well-developed digital infrastructures and a general trust in professionals are conducive to learning. At the same time, taking advantage of learning opportunities are increasingly depending on individuals’ agency and capacities to cope with new demands.

Originality/value

To better account for the complexity of epistemic environments, organisational learning can be seen as a matter of connecting epistemic practices in the local work organisation to wider knowledge circuits.

Professions, work, and digitalization: Technology as means to connective professionalism

Developments within digital technology are often seen as an enabler, allowing professions to connect to outside players for competence and new ways of performing their professional work. At the same time, it is often seen as a threat, challenging professional claims to competence and status. This article explores how the implementation of new digital technology affects a profession. The empirical data are from a case study from the maritime industry that focuses on ship engineers and the implementation of an advanced sustainable fuel system and a subsequent new business model to enable its operationalization. Our findings indicate that digital technology created pressure on the profession when their existing competencies did not cover the maintenance of this new technology. The solution for the shipowner to mend the competency gap was more digital technology, specifically technology that enabled more connectivity toward the outside world. This article shows how the profession of the ship engineer was able to connect to outside partners so they could gain competence and incorporate the new digital technology in their professional work. These relations shape the professional work of the ship engineers and move the profession toward connective professionalism. The contribution of this paper is the identification of mechanisms like the pressure to connect to outside actors, removal of barriers, and the observed value of the professional work. These mechanisms are essential to understanding connective professionalism.

Approaching Trust: Case Studies for Developing Global Research Infrastructures

Trust is a core component of collaboration. Trust is a local phenomenon, and scientific research is a global collaborative, its impact multiplied through open exchange, communication and mobility of people and information. Given the diversity of participants, local policies and cultures, how can trust be established in and between research communities? You need transparent governance processes, thoughtful engagement of stakeholder groups, and open and durable information sharing to build the “stickiness” needed. In this paper we illustrate these concepts through three trust building use cases: ORCID, Global Alliance for Genomics and Health, and SeamlessAccess, platforms sharing an identity and access technical service core, painstaking community building, and transparent governance frameworks.

Research on professional organizations: A review of theoretical traditions, themes, methods and locations

This research note presents an overview of the contemporary "professional organization" research area. We begin with the historical roots and evolution of research into professionals and the organizations in which they work, identifying five theoretical traditions-namely sociology of organization, sociology of the professions, professional organization, professional service firms, and public professionalism. Reviewing recent research in these areas allows us to identify important research phenomena-such as hybridity, institutional work, internationalization, and professional identity-and to understand how the institutional view within the "sociology of the professions" tradition has become a dominant paradigm for this research. This review also reveals the extent to which various occupations, methodological approaches, and academic fields, and locations have assumed positions of importance in recent years. Finally, future directions relevant to sociology researchers are discussed.

Getting on track for digital work: Digital transformation in an administrative court before and during COVID-19

This article analyses organizational change and new ways of working in one of our most institutionalized and professionalized contexts—the courts. Here, digital technologies and the implementation of digital work practices carry great promise as they enable more accessible and qualitative services to be produced more efficiently and effectively. While prior studies have shown that institutionalized and professionalized actors are reluctant to respond to change, attempts to change work practices through digital technologies remain understudied. In particular, we do not know how COVID-19 has influenced the motivation and implementation of digitalized work. This article draws on a large Swedish administrative court and its attempts to digitalize its work starting in 2018. We find that several barriers first inhibited a successful transformation of work practices. These barriers were connected to the institution of the court and the institutionalized profession of judges, which worked together in preventing organizational change. However, COVID-19 radically accelerated the digital implementation of work practices and gave rise to two separate re-assessment processes. The first established new motivations for digitalized work, and the second allowed for a new perception of value in digital work. These processes effectively broke down perceived barriers and substantially facilitated a more successful digital transformation of working practices.

Counter-professionalization as an occupational status strategy: The production of professionalism in Israeli child-care workers’ identity work

Recent approaches to professions and professional identity question the premise that professionalization is the ultimate generator of status, showing that the classical model of professionalization does not always coincide with workers’ creative construction of professionalism and professional dignity. Extending these approaches, and focusing on workers’ identity discourse, this study examines how private child-care workers in Israel claim professional status precisely by avoiding formal professionalization and promoting a counter-professionalization ethos. Drawing on field observations and interviews, we analyze nannies’ tacit occupational community dynamics, by which they establish professional rules and boundaries and discursively construct a respected professional self. Their identity-talk reveals a vocational self-imaging based on personal charisma, one that resists training and credentials. This vocational self-imaging allows rebuttal of the nanny stereotype as a low-class uneducated workforce, associated with their ethnicized backgrounds, by symbolically transforming it and using it as a high-value identity resource. This counter-professionalized identity-talk prevails despite the social distinction between senior and junior nannies. Thereby, nannies gain professional status while the professionalization of child care is rejected. The analysis of these cultural dynamics provides a stronger perspective on professions as spheres of identity construction—specifically those ranked lower as unskilled labor—and on workers’ agency behind their ostensibly passive compliance with under-professionalization.

How professional actions connect and protect

Below we provide responses to the ongoing debate sparked by Mirko Noordegraaf’s intervention in suggesting that we are moving toward forms of ‘connective professionalism’. Critics in this debate have objected to Noordegraaf in a number of ways. Some object to a conflation of ideal types and empirical description. Others assert that Noordegraaf suggests a staged process of moving from protective to connective types of professionalism does not ring true; that we can finds forms of connection and protection in contemporary professionalism and in professional action. Our companions in this issue (Alvehus, Avnoon, and Oliver) suggest that greater connectiveness also permits new forms of protection as part of professionalism. Our short essays contribute to the Noordegraaf debate by focusing less on professionalism and more on how forms of professional action lead to mechanisms of connection and protection.

Protective and connective professionalism: What we have learned and what we still would like to learn

This essay begins with a contribution from Mirko Noordegraaf, author of the 2020 ‘From Protective to Connective Professionalism’ article that initiated this series of exchanges in the Journal of Professions and Organization (JPO). Then, wrapping up this series, David Brock, JPO Editor-in-Chief, looks back at protective and connective constructs in our literature, and suggests several research directions. Our aim is not to close the debate, but to open it up and connect it to promising research avenues, newly arising research strands and promising publications.

‘It’s complicated’: Professional opacity, duality, and ambiguity—A response to Noordegraaf (2020)

In this comment to Noordegraaf’s ‘Protective or connective professionalism? How connected professionals can (still) act as autonomous and authoritative experts’, we argue that Noordegraaf has contributed significant insights into the development of contemporary professionalism. However, we argue for a less binary and more complex view of forms of professionalism, and for finding ways of understanding professionalism grounded in a relational view of everyday professional work. The first section (by Johan Alvehus) suggests that Noordegraaf’s ‘connective professionalism’ is primarily about new ways of strengthening professionalism’s protective shields by maintaining functional ambiguity and transparent opacity around professional jurisdictions. The second section (by Amalya Oliver and Netta Avnoon) argues for viewing professionalism on a range of protection–connection and offers an approach for understanding how connective and protective models co-occur. Both commentaries thus take a relational, dynamic, and somewhat skeptical view on the reproduction and maintenance of professionalism.

Red tape and psychological capital: a counterbalancing act for professionals in street-level bureaucracies

Assuming that red tape is inevitable in institutions, and drawing on positive organizational behavior, we compare the impact of individual psychological capital on the ability of street-level bureaucrats (SLBs) with different professional backgrounds to work within the confines of red tape. The two SLB professions investigated here are nurses and local government employees; and the work outcomes of interest to this study are well-being and engagement. The findings show that red tape has a different impact on each professional group but, encouragingly, they also indicate that psychological capital has a compensatory effect. Implications include nurses requiring more psychological resources than local government employees to counteract the negative impact of red tape. A practical implication for managers is that, if perception of red tape in organizations is set to increase or to stay constant, enhancing the psychological capital of professionals in SLB roles, through specific interventions, may be beneficial to professionals and organizations alike.

Connective professionalism: Towards (yet another) ideal type

In this essay, four leading scholars provide critical commentary on an article entitled ‘Protective or Connective Professionalism? How Connected Professionals Can (Still) Act as Autonomous and Authoritative Experts’ (Noordegraaf, 2020, Journal of Professions and Organization, 7/2). Of central concern to all four commentators is Noordegraaf’s use of ideal types as a heuristic device to make his case and capture historical change over time. While some question the usefulness of ideal types, others question Noordegraaf’s use of them. The commentators raise additional concerns, especially the limited attention to variations across professions, geographic regions, and limited attention to social–historical contexts.