I.E.C. Thylefors & O.

Persson

The more, the better? Exploring vertical and

horizontal leadership in cross-professional health
care teams
In: Leadership in Health Services, 2014
 Thylefors & Persson (2014)
The current issue and full text archive of this journal is available at
www.emeraldinsight.com/1751-1879.htm

The
The more, the better? the
Exploring vertical and horizontal leadership in
cross-professional health care teams
Ingela Emma Christine Thylefors and Olle Persson
Department of Psychology, Göteborg University, Gothenburg, Sweden
Received 20 Sept
Revised 14
Accepted 22
Abstract
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Purpose – This paper seeks to explore vertical and horizontal leadership and the relationship of the
form of leadership to effectiveness in Swedish cross-professional health care teams.
Design/methodology/approach – Questionnaire data were collected from a sample of 47 teams
and observation data from a sub-sample of 38 teams. Data on leadership were condensed to indices:
directive and participative leadership (vertical leadership) and functional influence and self-regulation
(horizontal leadership). Effectiveness was estimated using five measures: team climate, self-assessed
effectiveness, teamwork organisation, assessments of results from a simulated case conference (case
quality) and manager-rated effectiveness.
Findings – Positive relationships were found between leadership and effectiveness with one
exception: case quality was negatively associated with vertical leadership though positively to
functional influence. When controlled for team climate the correlations between self-assessed
effectiveness and leadership disappeared. However, it remained between vertical leadership and the
assessment of teamwork organisation. The results suggest that hierarchical and horizontal/shared
leadership are complementary forms.
Research limitations/implications – The small number of teams together with the problem of
causality in this cross-sectional study are the main limitations.
Practical implications – One implication for practice is the need for clarification of how leadership
and influence should be distributed from a contingency perspective.
Originality/value – This study takes both horizontal and vertical leadership into account compared
with previous studies often focusing on one facet. In addition, cross-professional health care teams
with their special characteristics are underrepresented within research on team leadership.
Keywords Team effectiveness, Shared leadership, Cross-professional health care teams,
Horizontal leadership, Team leadership, Vertical leadership
Paper type Research paper

Introduction
There are many good arguments behind the introduction of team-based work
organisations. One is the fact that solutions to complicated problems demand a range
of knowledge and competence and, hence, collaboration between specialists from
different areas has become a necessity (Reeves et al., 2010a, b). Another is the need to
break the dominating hierarchical or vertical authority pattern and make better use of
employee skills, also in terms of influence and leadership (Rubenowitz, 2004). These
arguments behind the growing number of teams in work life have increased the
Leadership in
Vol
This study has been funded by the Swedish Council for Working Life and Social Research. The
q Emerald Group Pub
role of the research council is to review the applicants’research plans (peer reviews) prior to the
granting of funds. The funding council has no active part in the research process. DOI 10.1108/LH

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Open Universiteit Organiseren en veranderen - Advanced studies in management 2

LHS interest in team coordination and leadership: leadership is considered crucial for team
27,2 performance and effectiveness, even in the absence of consensus on the exact nature of
the role (Morgeson et al., 2010; Zaccaro et al., 2001). This paper explores leadership in
cross-professional health care teams.
In the literature, team leadership is approached from two directions. It may be a
formal role connected to decision-making authority, legitimate power and certain
136 responsibilities: hierarchical or vertical leadership. It may also be defined as all
behaviour, independent of hierarchical roles, that facilitates goal attainment: shared or
horizontal leadership (Day, 2001). Pearce and Sims (2002) describe this shared
leadership as a “serial emergence” of leaders (p. 176). Thus, team leadership has both a
vertical dimension represented by formal leaders as a part of the organisation’s
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hierarchical structure, and a horizontal dimension comprising a shared leadership with

altering leadership roles.
In discussions of team leadership, vertical leadership usually is regarded as a
“one-man show” and referred to as traditional. Moreover, it is often described in
authoritarian terms and the existence of a democratic leadership is relatively ignored
(Ensley et al., 2006; Jackson, 2000). This might reflect a difference between different
industries as well as between countries. Scandinavia has a long tradition of a relatively
democratic and participative work life (Brodbeck et al., 2000), even more pronounced in
knowledge intensive organisations such as health and social care (Statistics Sweden,
2012). With a few exceptions (e.g. Konu and Viitanen, 2008), the extensive research on
participation and empowerment at work is rarely explicitly referred to in the case of
shared leadership, despite having many common features. It should be noted that both
vertical and horizontal leadership may be carried out by single individuals as well as
taking the form of a collaborative process.
Several terms are in use to describe teams with some kind of shared leadership, for
example self-managed (Solansky, 2008), self-directed (Fisher, 2000), bossless (Barry,
1991), autonomous (Fiorelli, 1988), and self-governed (Kooiman, 2003). Although the
terms are sometimes used synonymously, they comprise somewhat different ideas:
some stress the authority to make essential decisions (Katzenbach and Smith, 2003)
while others also include taking over traditional leadership tasks and responsibilities
(Burke et al., 2006) and yet others emphasise the ability to make one’s own decisions
and direct one’s own activity (Rubenowitz, 2004) or the capacity to take on a
“leader-member role” (McCallin, 2003). In spite of these differences, the ideas of shared
leadership have one factor in common: they state the importance of involving team
members in both informal and formal leadership activities to replace or to complete
hierarchical leadership.
Leadership constitutes a dimension in the threefold typology with respect to
cross-professional team structure with dependence, role differentiation and
leadership/coordination as cornerstones (Hall and Weaver, 2001; Thylefors et al.,
2005). In this typology leadership is understood as one-dimensional, from centralised
coordination/leadership to self-regulation. However, Thylefors et al. (2005) showed that
manager-coordination and self-regulation are not endpoints on a single continuum but
form two factors or dimensions.
Several studies note a strong linkage between leadership and team effectiveness.
For example a review by Lemieux-Charles and McGuire (2006) identifies leadership in
health care teams as significantly related to both objective and subjective outcomes but

136
 Thylefors & Persson (2014)

the kind of leadership referred to is not clear. Burke et al. (2006), paying attention to Th
team leadership functions in their meta-analytic study, conclude that leadership does the
matter with respect to team performance outcomes, regardless of whether the functions
are shared or held by an individual. However, the responsibility to ensure that all
functions are accomplished rests on the formal team leader. In the case of vertical team
leadership, most studies have tried to identify effective leadership qualities relative to
team performance. In general, a democratic or participative leadership is usually
preferred (Borrill et al., 2000; Rubenowitz, 2004), i.e. leadership encouraging a shared
leadership.
Shared or horizontal team leadership is reported to be a better predictor of outcomes
than vertical leadership in some contexts (Pearce et al., 2008a) and Pearce (2004)
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argues, “research indicates that poor-performing teams tend to be dominated by the

team leader” (p. 47). Unequivocal positive connections between objective output
measures and shared team leadership in health and social care are hard to find. There
are, however, reports on positive relationships between team types with a high degree
of shared leadership, i.e. inter- and transprofessional teams, and subjective
effectiveness measures (Hall and Weaver, 2001; Thylefors et al., 2005).
Some studies suggest that the two leadership dimensions facilitate and support
different aspects of team effectiveness and performance and hence recommend a
contingency approach to team leadership (e.g. Yun et al., 2005). The dominating view
nowadays is that understanding team leadership must encompass both vertical and
horizontal aspects (Pearce et al., 2008b). Also strong advocates for autonomous and
self-managed team conclude that shared leadership needs support and maintenance
from the vertical leader in order to succeed (Barry, 1991; Pearce, 2004). Although
vertical and horizontal leadership are regarded as complementary, few studies take
both perspectives into account simultaneously (Morgeson et al., 2010). The theme is
approached, however, in discussions of the balance between “managerial” and
professional authority (e.g. Martin, 2000).
Cross-professional teams in health and social care have a number of characteristics
that distinguish them from other teams, although they have similarities with
cross-functional teams in knowledge intensive businesses. The majority of team
members are practitioners belonging to the professions, meaning a high degree of
autonomy partly protected by their professional authorisation. This autonomy and
built-in heterogeneity place high demands on coordinating efforts by a formal leader
(Ghobadi and D’Ambra, 2012). Cross-professional team collaboration means some kind
of mutual influence based on specific competences relative to the issue in focus. The
distribution of influence or leadership within a team is accepted as a key factor for
successful teamwork (Bell, 2001; Atwal and Caldwell, 2005). The importance of vertical
team leadership is, however, less recognised and, for example, both Reeves et al.
(2010a) and Martin and Rogers (2004) note tensions and problems in the formal team
leadership.
Independent of source, leadership is a means to promote effectiveness. However, in
health and social care there are multiple legitimate stakeholders with different
objectives and views on effectiveness. Consequently, several authors address the need
to use a multidimensional approach when evaluating teamwork (Delgado Piña et al.,
2008; Lemieux-Charles and McGuire, 2006).

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Open Universiteit Organiseren en veranderen - Advanced studies in management 2

LHS To sum up, the literature considers two types of team leadership, vertical and
27,2 horizontal. Within some contexts, defiance with respect to shared/horizontal leadership
receives attention and many authors advocate strengthening shared leadership,
especially in knowledge-intensive teamwork. In other contexts, such as health and
social services, the situation is the opposite: an underestimation of the importance of
vertical, formal team leadership is observed. Vertical team leadership is reported both
138 as an obstacle and as an enabler for shared leadership and both vertical and horizontal
team leadership have separately demonstrated a positive connection to one or several
measures of effectiveness. Many studies on team leadership seem to focus on teams
without designated internal team leaders but this is seldom made explicit.
The aim of this study was to explore vertical and horizontal leadership in
cross-professional health care teams, and the relationship between team leadership and
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effectiveness. In addition a specific question was addressed: are teams characterised by

a high degree of both vertical and horizontal leadership more effective than those with
a lower degree?

Method
This study is part of a research project focusing on cross-professional team
organisation and effectiveness and make use of data collected within that project, both
questionnaire data and data from a simulated consultation conference. Initially, a
reference group comprising senior practitioners and managers was assigned to
participate in the design of the project.

Sample
Teams from four care sectors were included in the project: occupational health service,
psychiatric care, rehabilitation and school health care. These sectors were chosen
because they have a well-established team organisation and a similar organisational
context: every individual team was collocated and all members of a team had the same
employer. The teams also had similar working conditions: they delivered outpatient
care, were mostly working with continuous, elective interventions and were taking
relatively reversible decisions in relation to their clients. An invitation to participate in
the project was distributed to teams in the western part of Sweden. All teams and
individual members participated on an entirely voluntary basis.
The sample in this study included only teams with an internal designated leader (73
per cent of the total sample) and consisted of 380 members from 47 teams (sample I)
who responded to a questionnaire: subsequently 38 of those teams took part in an
observation event (sample II). Sample distribution over professions and teams is
presented in Table I. The response rate to the questionnaire was 83 per cent.
In addition, senior managers, one or two levels above the internal team leader, were
asked to assess the effectiveness of the subordinate teams. However, the response rate
was low, with only 22 of the 46/38 teams being rated by their manager: five
occupational health service teams, seven rehabilitation teams and ten psychiatric
teams.
The teams had a predominance of females (78.5 per cent) and an average size of 8.71
members (SD ¼ 3.81). Diversity in terms of the number of professions represented in
the teams varied, ranging from two to eight with an average number of five.

138
 Thylefors & Persson (2014)

The more, Th
Sample II Number of individuals/teams Sample I Sample II
the better? the
Professions
6 Audiologist 6 6
23 Medical secretary 33 23
52 Nurse 90 52
26 139 Occupational therapist 34 26
18 Physician 28 18
25 Physiotherapist 34 25
40 Psychologist 52 40
41 Social worker 53 41
33 Special education teacher 36 33
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5 Speech therapist 7 5
3 Technician/engineer 3 3
2 Other 4 2
294 Total number of individuals 380 294

Care sectors
5 Occupational health service 5 5
10 Table I. Psychiatry 17 10
17 Samples distributed over Rehabilitation 19 17 Samples distr
6 professions and care School health care 6 6 profession
38 sectors, frequencies Total number of teams 47 38 sectors,

Measures
nnaire comprising 12 Team leadership/coordination was explored by a questionnaire comprising 12
was a literature review. items/statements (Table II). The basis for the questionnaire was a literature review.
synonymies are well The constructs hierarchical and shared leadership and their synonymies are well
2006; Yukl, 2001). The established in the team literature (e.g. Day, 2001; Ensley et al., 2006; Yukl, 2001). The
tems. After consulting content of this literature was operationalized into a number of items. After consulting
ty of both vertical and the reference group in the project 12 items, reflecting the variety of both vertical and
med a two-dimensional horizontal leadership, were chosen. A factor analysis confirmed a two-dimensional
onbach’s a, was also solution (Table II). Internal consistency, estimated by Cronbach’s a, was also
ectively). The 12 items satisfying relative to the number of items (0.84 and 0.60, respectively). The 12 items
nctional influence, both were reduced to four mean indices: directive leadership and functional influence, both
articipative leadership reflecting a leadership mainly carried out by individuals, and participative leadership
rship. These indices, in and self-regulation reflecting a collective or collaborative leadership. These indices, in
ship/coordination. The turn, were reduced to two indices: vertical and horizontal leadership/coordination. The
e to how characteristic respondents could agree or disagree on a five-point Likert scale to how characteristic
the statement was for their own team (1 ¼ not at all).
ur of them were mean Team effectiveness was estimated using five measures; four of them were mean
efficiency), teamwork indices (Table III). Three of these, team climate (process efficiency), teamwork
om the questionnaire organisation and self-assessed effectiveness, were drawn from the questionnaire
nd one, manager-rated completed by the team members participating in the project, and one, manager-rated
managers. Data from a effectiveness, from a questionnaire completed by the senior managers. Data from a
ase quality. The team simulated consultation conference gave the fifth measure, case quality. The team
the respondents could climate scale (Thylefors, 2012) included 20 statements. Again the respondents could
le in relation to how agree or disagree with the statements on a five-point scale in relation to how

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Open Universiteit Organiseren en veranderen - Advanced studies in management 2

LHS
Factor loadings1
27,2 Indeces/items a ICC(1,k) Vertical Horizontal

Directive leadership 0.82 0.78

Our manager/team leader or equivalent controls
actively the work within the team 0.84
140 The coordination of our efforts is done by our
manager/team leader or by standardized routines 0.73
Our work is coordinated mainly by a manager, team
leader or equivalent 0.85

Participative leadership 0.72 0.73

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Our team leader coordinates work in cooperation

with us, the team members 0.82
The work in our team is coordinated by us together
with our team leader 0.74
Our manager/team leader shares the leadership with
the team 0.53 0.44

Functional influence 0.62 0.62

The dominance of a profession depends entirely on
the situation 0.56
Depending on the character of the issue/task the
amount of influence varies among the members 0.54
The most suitable person at the time takes on
leadership 0.66
Table II. Self-regulation 0.50 0.78
Description of team Everyone takes responsibility for coordinating their
leadership/coordination activities with others 0.49
indeces; items, In practice, we share the management
Cronbach’s a, intra-class responsibilities in the team 0.66
correlations ICC(1,k) and We govern ourselves in our teamwork, that is, the
factor loadings (principal team is self-regulated 0.47
component analysis with
1
Varimax rotation) Notes: Factor loadings . 0.25; The two-factor solution explained 55.10 percent of the variance

characteristic they were of their own team. The items on self-assessed and
manager-rated effectiveness were formulated as questions with five response
alternatives (1 ¼ to a very low degree).
For the mean indices, the reliability/internal consistency was estimated
using Cronbach’s a. As the number of items within each index was limited a rather
low alpha value was accepted. As the data were treated at a team level, the intraclass
correlation, ICC(1,k), was calculated and all values justified the use of aggregated
measures.
The fifth effectiveness measure, case quality, consists of results from a simulated
consultation conference with three cases on the agenda. The three cases had a
multifaceted problem image with elements relevant to all teams and professions. The
team task was to generate and summarise in writing possible hypotheses about the
patient’s/client’s problems as well as recommendations.

140
 Thylefors & Persson (2014)

The more, Th
a ICC(1,k) Indeces/items a ICC(1,k)
the better? the
0.95 0.72 Team climate 0.95 0.72
Our meetings are characterised by the fact that all have their say
Our meetings have a positive “keynote” We pay interest and
attention to each other
141 Our work is focused and everybody knows what has to be done,
by whom and when
We are good at expressing ourselves clearly
We deal with controversies that occur in our team in a
constructive way
We are good at listening to each other
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Our meetings are characterised by a free exchange of views

We get along very well in the team
We strive for decisions in consensus
Now and then the team takes a break to evaluate the work process
We all take an active part in our team discussions
Our differing opinions are respected
We share opinions, knowledge and experiences within the team
Individual contributions are encouraged in the team
We are open to new ideas in our team
Suggestions on how we can make things in a different way are
welcomed
We help each other to achieve great results
We will not give up until an issue is resolved
Criticism within the team is given in a constructive and positive
manner

Teamwork organisation
– 0.79 To what degree is the teamwork efficiently organised? – 0.79

0.83 0.82 Self-assessed effectiveness 0.83 0.82

To what degree do you consider all team members working
towards the same goal?
To what degree do the efforts within the team reach a high
quality?
To what degree does the work of the team meet the users/clients/
patients/pupils needs?
To what degree does your team fulfil its goals?
To what degree do you have a high level of expertise within the
team?

0.80 – Manager-rated effectiveness 0.80 –

Items as above with minor adjustments and the question “Taking
all your information about the team into account (client
satisfaction, cost effectiveness, work satisfaction, productivity,
quality etc.), were on the following effectiveness scale would you
Table III. place the team?”
Description of De
_ _ effectiveness indices; Case quality _ _ effectiven
items, Cronbach’s a, Expert evaluations of hypothesis and recommendations with items, Cr
intra-class correlations respect to three cases dealt with on a simulated consultation intra-class
ICC(1,k) conference

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Open Universiteit Organiseren en veranderen - Advanced studies in management 2

LHS The conference lasted 45 minutes and was followed by two observers. For this study,
27,2 only the suggestions from the consultation conference were considered. They were
evaluated on a five-point scale, where 1 stood for a contraindicated suggestion
(harming the client) and 5 for correct hypotheses and suggestions of adequate
measures. Case quality was made up of these evaluations (min. ¼ 3; max. ¼ 15). The
evaluations were determined in consensus by two senior psychologists in cooperation
142 with a senior physician, all with relevant clinical experience.

Data analysis
The data were analysed statistically using SPSS 11 for Mac OS X. Correlations were
calculated using Pearson’s product moment correlation or partial correlation. One-way
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analysis of variance, ANOVA (Tukey’s post hoc test), was used to compare mean
scores of subgroups.

Results
Table IV shows descriptive statistics and inter-correlations for study variables. Four of
the five effectiveness measures are strongly correlated to each other (r $ 0.55): team
climate, teamwork organisation and self-assessed effectiveness as well as
manager-rated effectiveness. The fifth measure, case quality, appears to be
unrelated to the other measures (r ¼ 2 0.11 to 0.10). Four of the leadership indices
are positively related to the effectiveness measures with varying strength (r ¼ 0.24 to
0.73), but again with the exception of case quality. Instead the correlations demonstrate
a negative relationship between vertical leadership and case quality (r ¼ 2 0.34). Case
quality is, on the other hand, positively correlated with functional influence (r ¼ 0.34).
What is noteworthy is that vertical leadership is somewhat more strongly associated
than horizontal leadership with the member-assessed effectiveness measures,
especially in the case of teamwork organisation, i.e. assessments of the
appropriateness of the organisation of the teamwork (r ¼ 0.75 and 0.31, respectively).
A partial correlation was used to explore the relationship between team leadership
and effectiveness further while controlling for team climate (Table IV) since team
climate has been recognised as an intervening or mediating variable between
leadership and effectiveness (Hogan and Kaiser, 2005). An inspection of the correlation
pattern suggests that team climate affects the strength of associations between some
independent and dependent variables. The strong positive correlation between vertical
leadership, directive and participative, and the assessment of the appropriateness of
work organisation remains when controlled for team climate, albeit slightly weakened.
Also the moderate negative correlation between vertical leadership and case quality
remain in the partial correlation analysis. In contrast, the correlations between, on the
one hand, the two aspects of the vertical leadership, and, on the other hand, self- and
manager-assessed effectiveness almost disappear in the partial correlation analysis.
Team climate also affects horizontal leadership made up of functional influence and
self-regulation. Comparing zero order and partial correlations suggests an effect of
team climate on both self-assessed effectiveness and teamwork organisation: the rather
weak but positive zero order correlations were erased in the partial correlation analysis
(from 0.31 to 2 0.18 and from 0.26 to 2 0.15, respectively). In the case of functional
influence, the positive correlations with manager-rated effectiveness as well as case
quality remain in this analysis.

142
 influence1 20.06 20.33* 0.01 20.29þ 1
Self-
*
regulation1 20.02 20.35 0.11 20.22 0.64*** 0.56*** 1
Vertical
leadership1 0.95*** 0.93*** 0.94*** 0.91*** 20.03 20.34* 0.05 20.32* 1
Horizontal
** * *** ***
leadership1 20.07 20.42 0.07 20.29 0.91*** 0.90 0.90*** 0.88 20.01 20.39** 1
** **
Team climate1 0.53*** 0.58*** 0.38 0.47 0.58*** 0.47** 1
Teamwork
*** *** *** ** * *** *** *
organisation1 0.73 0.61 0.70 0.46 0.24 20.16 0.32 20.16 0.75 0.58 0.31 20.18 0.84*** 1
Self-assessed
** * þ * ** þ
effectiveness1 0.43 0.08 0.34 20.16 0.29 0.01 0.35 0.01 0.41 20.03 0.26 20.15 0.73*** 0.73*** 0.30* 1
Manager-
assessed
effectiveness2 0.38 0.06 0.30 20.11 0.55* 0.43þ 0.30 0.01 0.36 20.01 0.47þ 0.25 0.63** 0.55* 0.03 0.59* 0.25 1
Case quality3 20.33* 20.32þ 20.31þ 20.30þ 0.34* 0.42* 0.10 0.17 20.34* 20.34* 0.27þ 0.37* 20.11 20.10 20.02 20.02 0.10 20.01 0.08 1

+ * ** *** 1 2 3 a
Notes: , 0.10, p , 0.05; p , 0.01; p , 0.001; n=46; n=22; n=38; PCC=Partial correlation coefficients

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143
Means, standard
the better?
The more,

variables
deviations and
inter-correlations of study
143

Table IV.
Thylefors & Persson (2014)

Manager-
Participative Horizontal Teamwork Self-assessed rated
Directive leadership leadership Functional influence Self- regulation Vertical leadership leadership Team climate organisation effectiveness effectiveness
Case
n PCCa n PCCa n PCCa n PCCa n PCCa n PCCa n PCCa n PCCa n PCCa n PCCa quality

Mean 3.06 3.07 3.23 3.03 3.07 3.14 3.68 3.35 3.84 4.01 8.76
Standard
deviation 0.58 0.51 0.31 0.30 0.52 0.28 0.40 0.64 0.43 0.58 2.30
Directive
leadership1 1
Participative
leadership1 0.79*** 0.70*** 1
Functional
influence1 20.06 20.33* 0.01 20.29þ 1
Self-
* ***
regulation1 20.02 20.35 0.11 20.22 0.64 0.56*** 1
Vertical
*** *** *** ***
leadership1 0.95 0.93 0.94 0.91 20.03 20.34* 0.05 20.32* 1
Horizontal
leadership1 20.07 20.42** 0.07 20.29* 0.91*** 0.90*** 0.90*** 0.88*** 20.01 20.39** 1
Team climate1 0.53*** 0.58*** 0.38** 0.47** 0.58*** 0.47** 1
Teamwork
organisation1 0.73*** 0.61*** 0.70*** 0.46** 0.24 20.16 0.32* 20.16 0.75*** 0.58*** 0.31* 20.18 0.84*** 1
Self-assessed
effectiveness1 0.43** 0.08 0.34* 20.16 0.29þ 0.01 0.35* 0.01 0.41** 20.03 0.26þ 20.15 0.73*** 0.73*** 0.30* 1
Manager-
assessed
effectiveness2 0.38 0.06 0.30 20.11 0.55* 0.43þ 0.30 0.01 0.36 20.01 0.47þ 0.25 0.63** 0.55* 0.03 0.59* 0.25 1
Case quality3 20.33* 20.32þ 20.31þ 20.30þ 0.34* 0.42* 0.10 0.17 20.34* 20.34* 0.27þ 0.37* 20.11 20.10 20.02 20.02 0.10 20.01 0.08 1

+ * ** *** 1 2 3 a
Notes: , 0.10, p , 0.05; p , 0.01; p , 0.001; n=46; n=22; n=38; PCC=Partial correlation coefficients
Open Universiteit Organiseren en veranderen - Advanced studies in management 2

LHS To test whether teams with different leadership patterns also differ from each other in
27,2 terms of effectiveness, the teams were categorised into four groups, split by mean
along vertical and horizontal leadership. The groups were: “combined” (high on both
vertical and horizontal leadership), “manager-coordinated” (high on vertical and low on
horizontal leadership), “self-managed” (low on vertical and high on horizontal
leadership) and “leaderless” (low on both vertical and horizontal leadership). Using
144 ANOVA these four groups were compared to each other on all effectiveness measures
(Figure 1).
When it comes to team climate, “combined”, “self-managed” and
“manager-coordinated” teams assessed their climate as better than the “leaderless”
teams did (F ¼ 13.12, 3(44), p , 0.01; M ¼ 4.03, SD ¼ 0.23; M ¼ 3.80, SD ¼ 0.34;
M ¼ 3.78, SD ¼ 0.22; M ¼ 3.33, SD ¼ 0.38). The “combined” teams also assessed their
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work organisation as more appropriate compared to the “leaderless” and the

“self-regulated” teams (F ¼ 19.49, 3(44), p , 0.001; M ¼ 3.99, SD ¼ 0.43; M ¼ 2.82,
SD ¼ 0.47; M ¼ 2.99, SD ¼ 0.43). The “manager-coordinated” teams (M ¼ 3.55,
SD ¼ 0.37), in turn, were more satisfied with the organisation of their teamwork than
the “leaderless” teams ( p , 0.001). Only one difference appears with respect to
self-assessed effectiveness in that the “combined” teams score higher than the
“leaderless” teams (F ¼ 4.54, 3(44), p , 0.01; M ¼ 4.14, SD ¼ 0.29; M ¼ 3.60,

Figure 1.
Leadership patterns and
effectiveness measures
(mean values)

144
 Thylefors & Persson (2014)

SD ¼ 0.39). Similarly, manager-assessed effectiveness is higher in the “combined” Th

teams than in the “leaderless” teams (F ¼ 3.08, 3(13), p , 0.05; M ¼ 4.52, SD ¼ 0.49; the
M ¼ 3.39, SD ¼ 0.54). The differences between the four groups in terms of case quality
were insignificant ( p . 0.10).

Discussion
Taken altogether, the correlation analyses suggest that both vertical and horizontal
leadership covariate in a positive way with team effectiveness, except for vertical
leadership relative to case quality, i.e. the results of the simulated team conference.
Thus, our results gain support both from those authors advocating that teams in
general will be most effective when in charge of their own internal processes and from
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those voices arguing the necessity of a hierarchical team leadership.

In this study, team climate has primarily been considered as a dependent variable
with a value in itself as a part of a satisfying work environment and, in this context, as
a variable that directly affects the care atmosphere for the benefit of the patients. Team
climate has also been noted in previous research as an intervening or mediating
variable (Hogan and Kaiser, 2005) and our data suggest that this is the case as regards
the relationship between certain independent and dependent variables. Most obvious is
that team climate affects the positive relationship between leadership, vertical as well
as horizontal, and self-assessed effectiveness. When controlling for team climate the
correlations disappear. On the other hand, the positive linkage between vertical
leadership and teamwork organisation is relatively unaffected by the team climate.
Also, the negative correlation between case quality and vertical leadership remains. As
for horizontal leadership, the positive relationships remain both with case quality and
with manager-rated effectiveness, mainly explained by the degree of functional
influence.
The relationships between team climate and both self- and manager-assessed
effectiveness raise a question: do these effectiveness measures mainly reflect a
satisfying team climate or are they well-informed views from practitioners and senior
managers with a solid insight into the situation – an insight which takes into account
more aspects of effectiveness than our measures? The self-assessed effectiveness index
may well be considered a measure of team efficacy, i.e. a shared belief in the general
capacity of the team (Zaccaro et al., 2001). Still the index may indicate team
effectiveness as Gully et al. (2002), for example, found support for a positive
relationship between efficacy and performance, most pronounced in interdependent
teamwork.
In a cross-sectional study such as this and with seven out of nine measures obtained
from a single source, a questionnaire, directions of causality cannot be determined in
most cases. Only alternative interpretations may be given. It is reasonable to assume a
reciprocal interaction between most of the variables in the study. For example, both
vertical and horizontal leadership may affect the team climate and, at the same time,
leadership is facilitated and encouraged by a climate characterised by effective and
beneficial communication as well as smooth goal-directed work processes. At the same
time, a collaborative leadership, whether vertical or horizontal, offers both
opportunities and motivation for improving communication and work processes.
Neither can reciprocity be ruled out in the case of effectiveness. For example, Ilgen et al.
(2005) propose that output is likely to feed back into the team process. Nevertheless,

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Open Universiteit Organiseren en veranderen - Advanced studies in management 2

LHS some relations are probably mainly unidirectional; for example, directive leadership
27,2 may influence the climate more than the other way around (Hogan and Kaiser, 2005).
Additionally, it is reasonable to assume that the relationship between leadership and
the more objective effectiveness measure, case quality, is unidirectional. That is, a
vertical leadership impairs the team’s ability to handle patient/client problems while
the presence of functional influence has the opposite effect.
146 Then, are cross-professional teams with a high degree of both vertical and
horizontal leadership more effective than others? Our results suggest that the answer is
yes, but on the condition that team leaders and members are aware of what type of
leadership the pre-existing situation requires. Teams need a blend of leadership
sources, both formal, vertical leadership and a leadership distributed among the team
members, but not at the same time. Teams have a variety of tasks to manage in
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collaboration within an organisational framework. Some will benefit from a relatively

centralised leadership and others from a shared or distributed leadership. The main
task, to help clients/patients, is disadvantaged by a vertical leadership, also when it
has a participatory character, but is favoured by a functional influence. This functional
influence is also the main rationale for cross-professional teams. Other tasks, such as
organising teamwork, will benefit from a democratic vertical leadership in which the
team leader has the option of using a legitimate power when consensus is neither
possible nor reasonable. Thus, effective team leadership requires sensitivity to the task
or issue in question.

Limitations
A number of limitations of the study have to be acknowledged. The study shares a
weakness with many team studies, namely the limited number of cases in spite of the
number of individuals in the sample. This affects both the statistical analysis and the
generalisability of the results. Also, the use of self-assessment complicates the
interpretation of the findings as individual perceptions do not necessarily reflect actual
conditions. Another shortcoming is the aforementioned issue of causality and a
possibility of common-method bias that may inflate or deflate the correlations.
However, as no single factor accounted for the majority of the variance, a common
factor bias (Podsakoff and Organ, 1986).

Implications for practice

Our study explored leadership in teams with internal formal leaders. The majority of
the leaders also take some part in operative work and thus have a double and complex
role in relation to other team members. The role is further complicated by the fact that
one decisive factor for team effectiveness is how leadership or influence is distributed
in a given situation. Consequently, a clarification of the distribution of power, decision
latitude and responsibilities in the team from a contingency perspective seems a
promising way to improve team effectiveness. For example, Øvretveit’s (1995)
discussion of formal decision-making procedures may be a helpful device in such a
clarification process. A factor to be considered in a contingency approach is task
structure or complexity. Complex tasks, such as patient and client problems in
specialist care, seems to be facilitated by collective efforts, i.e. a shared leadership,
while well-structured tasks may limit the need for discussion and information
exchange.

146
 Thylefors & Persson (2014)

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 and social care and as a senior lecturer at the university. Besides her academic career, she works

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as an organisational consultant with a special focus on human service. Her research interests are
reflected in papers and books on leadership, group psychology, conflict management and work
Thylefors
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Ingela Emma (2014)
Christine Thylefors is the corresponding author and can be contacted
at: ingela.thylefors@psy.gu.se
Olle Persson is a Senior Lecturer at the Department of Psychology, Göteborg University,
Sweden and an authorised psychologist with working experiences from psychiatric and
occupational health care. His professional interests include leadership development, executive
coaching and team collaboration. He has participated in a number of research studies on stress
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About the authors

Downloaded by OPEN UNIVERSITEIT NEDERLAND At 05:21 17 JulyDownloaded

Ingela Thylefors is an authorised Psychologist and Associate Professor at the Department of

Psychology, Göteborg University, Sweden. She has a background as a practitioner within health
and social care and as a senior lecturer at the university. Besides her academic career, she works
as an organisational consultant with a special focus on human service. Her research interests are
reflected in papers and books on leadership, group psychology, conflict management and work
life bullying. Ingela Emma Christine Thylefors is the corresponding author and can be contacted
at: ingela.thylefors@psy.gu.se
Olle Persson is a Senior Lecturer at the Department of Psychology, Göteborg University,
Sweden and an authorised psychologist with working experiences from psychiatric and
occupational health care. His professional interests include leadership development, executive
coaching and team collaboration. He has participated in a number of research studies on stress
management, leadership and teamwork.

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leadership in cross-professional health care teams. Leadership in Health Services, 27(2), 135–149.
https://doi.org/10.1108/LHS-09-2012-0031.

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