Embedding the Examination of Multilevel Factors in an Organization Field Context

In our increasingly specialized and professionalized service sectors, the days of dedicated continuing contact between a single provider and his/her clients has become a distant memory. Service provision in domains such as medical, legal, or financial arenas has become multilevel and multiplex, involving many layers of providers and their systems. Moreover, in contexts entailing long-term relations, such as cancer care, the participants enter and exit over time, varying in their identities, interests, relative salience, and influence as the stage of disease progresses. All the contributors to this volume share a set of basic premises. They: take seriously the importance of social context in explaining behavior; recognize the complexity of the cancer care context, with its multiple levels, interdependencies, and interactions; acknowledge the multiple types of variables which operate, reflecting the varied facets of actors (individuals, organizations, associations) and their component systems (biological, psychological, sociological). I want to suggest the value of embedding these complex processes within a larger conceptual framework—an “organization field.” This approach calls attention to the fact that most behavior in modern societies takes place in circumscribed arenas dominated by a set of relatively specialized, independent, but interdependent organizations (1). “The notion of field connotes the existence of a community of organizations that partakes of a common meaning system and whose participants interact more frequently and fatefully with one another than with actors outside the field” (2). An organization field comprises three components: actors—both individuals (eg, patients and their families, physicians), and organizations (eg, hospitals, clinics, professional associations); institutional logics—the values and norms, ideas, beliefs, and meaning systems that guide the behavior of actors (eg, medical specialties; legal frameworks; kinship systems; research cultures, nonprofit, for-profit, and public contexts); “governance structures”—the regulative and normative frameworks that exercise control both within individual organizations and at the wider field level (eg, legislative and regulatory controls, collegial professional norms, family and status systems) (3). An organization field approach encourages attention to the dynamics of the components and their interrelations: changes in the types, number, relative power of individual and collective actors over time; changes in the prevailing logics as the influence of varying types of actors, and arguments, and assumptions wax and wane; and changes in nature and impact of varying attempts to exercise control over field participants (4). Organization fields are arenas of conflict as well as cooperation. Organizations and individuals hold varying interests, operate under differing institutional logics. For example, differences among the professional norms of doctors, the bureaucratic standards of administrators, the legal concerns of lawyers, and the beliefs and cultural values of patients and their families can lead to misunderstandings and conflicts (5). In addition, organization fields are always themselves subsystems of wider societal and even trans-societal fields. Thus, the United States provides a distinctive context within which health-care fields operate with its highly federalized systems (and great variations among component state systems), fragmentation of authority and power, strong belief in market solutions, and high regard for individual freedom and autonomy of action. It should be clear that multilevel processes are central to understanding field phenomena. Specialized organization fields are embedded within and affected by wider societal structures and forces. Field-level relations among organizations and individuals are configured into distinctive networks—each network has a structure which influences the behavior of its members, and individuals and organizations occupy specific locations within the field that shapes their interests and identities. Individuals—patients, doctors, research scientists—operate within and move among and across organizational contexts—contexts that provide both resources for and constraints on their actions. The examination of such processes is at the heart of field-level analysis. On the other hand, the organization field framework provides several advantages to those interested in multilevel processes: it recognizes the centrality of organizations in modern societal systems; it is supportive of a dynamic analysis that recognizes that fields evolve over time, moving from lesser degrees of structure and coherence to higher levels—or the reverse, shifting from structuration to destructuration processes; it emphasizes the importance of cultural and cognitive frameworks (values, norms, beliefs) as well as structural (relational, network) factors and attends to their interdependence; it accommodates the tension between structures—which are both the context and the product of action—and actors—who are constrained by but also reproduce and change the structures in which they are embedded; it carves the complex social world into intellectually manageable chunks: multilevel processes are seen to occur within specific structural and culturally bounded systems. Finally, the organization field framework is heuristic: Field boundaries can be drawn to suit and incorporate those aspects of the situation of interest to investigators. In more conventional approaches, fields are constructed around a particular product or service market. In more public arenas, they can be crafted to bind a specific policy arena. And they can be designed to encompass a specific issue or type of intervention. Salient issues or specific types of clinical interventions become a vortex bringing together multiple types of players, logics, and governance claimants each struggling to pursue their interests and maintain their identities as they seek to recognize/accommodate the needs of others and to make sense of their social worlds.