Co-worker dialogue – a tool for health, personal development, and an empowering development culture in the workplace

ABSTRACT This study explores managers’ perspective on how co-worker dialogue [CWD] can foster co-worker health and personal development, and contribute to an empowering development culture in the workplace. The interview study was performed at a hospital in Sweden. Seventeen hospital managers participated. The managers, both men and women, worked in different areas, and a majority had 30–40 co-workers. To uncover underlying pattern phenomena in the interview data, a six-step inductive qualitative thematic analysis was conducted. The findings present three themes, each highlighting different prerequisites for CWD to function as a resource for the co-workers and the workplace: (1) Utility; (2) Content, and (3) Implementation. The study provides suggestions for and problems of practical implications from the findings. To make the findings useful in other organizations, practical implications are presented and discussed in the light of workplace health promotion [WHP]. The CWD is not focusing on performance the way traditional PA does. The CWD is therefore an important complement to PA in annual co-worker meetings, to also highlight the co-worker perspective. If managers realize the value of working with both PA and CWD, opportunities for health, personal development, and an empowering development culture are created.


Introduction
There are many challenges in the work life to preserve and improve employee health and personal development, thereby also promoting organizational development for efficiency and productivity. For a sustainable work life, a good and structured work organization is required to create conditions in the workplace that foster prerequisites which continuously regenerate energy among the employees (Kira & Forslin, 2008). In most organizations, major and minor processes are ongoing to improve employee health and performance, as well as to develop the organization and to reach set goals, but in different ways (Nilsson, 2010). Workplace Health Promotion [WHP] focuses on the co-workers' work-related health and well-being as a means to reach organizational goals. Quality criteria for WHP are focusing on three parts; improvement of the organization and the work environment, promoting active participation, and encouraging personal development and empowerment (European Network for Workplace Health Promotion [ENWHP], 1999). Performance Management [PM], on the other hand, focuses on co-worker performance from various aspects in order to reach organizational goals. Bae (2006) specifies three parts of PM: defining co-worker performance, evaluating co-worker performance, and providing feedback on co-worker performance. Managers have annual co-worker performance appraisals [PA] about these parts. This type of meeting has several names in the literature, such as: performance appraisal, performance evaluation, employee review, performance review, employee appraisal or others (Asmuss, 2008). In Western research, there seems to be more focus on the effectiveness of PA (DeNisi & Murphy, 2017) and less focus on complementary models like co-worker dialogue [CWD]. CWD is also an annual individual dialogue but more about how the manager and the co-worker together can create prerequisites for the co-worker to do a good job, achieve personal development, and feel well at work (Sandlund, Olin-Scheller, Nyroos, Jakobsen, & Nahnfeldt, 2011). To empower co-workers' health promoting self-management and encourage health promoting work processes (Dietscher, Winter, & Pelikan, 2017;Pelikan, Dietscher, Krajic, & Nowak, 2005), work-related resources and solutions should be focused on a participatory and continuous process at the workplace, and annual CWDs could be used as a practical tool as it contributes to shed light on coworker health and personal development, as well as workplace improvements. Due to all the negative criticism of being ineffective and not developing for the coworkers (Bouskila-Yam & Kluger, 2011;Gordon & Stewart, 2009;Roberts, 2003;Spence & Wood, 2007), some attempts have been made over the years to conduct PAs according to more employee-centred models (e.g. Bouskila-Yam & Kluger, 2011;Gordon & Stewart, 2009;Kluger & Nir, 2009;Lee, 2006;Mikkelsen, Ogaard and Lovrich, 1997;Roberts, 2003) . Such PA models are a development of PAs, but performance from the organizations perspective is still in the foreground. This contrasts to the CWD, that places the coworker in the foreground to discuss which prerequisites are needed to feel well at work, how to develop personally, and manage to do a good job.
The CWD between managers and co-workers is considered a unique part of Swedish work life. For all co-workers in Sweden, annual co-worker meetings are in general divided into three parts: (1) a monetary-based performance appraisal [PA]; (2) a dialogue about the co-workers health and personal development [CWD]; and (3) a meeting with notice of the new salary. The second part of the CWD is sometimes also called Staff development dialogue/talk, and as the names indicate, the dialogue between coworker and manager is intended to be more equal. Some organizations have three annual meetings with each co-worker, others have PA and CWD at the same meeting, followed by a salary notice meeting later. The structure and conversation focus depends on the nature of the context, for example in health care organizations the co-worker performance does not have the same focus as in a profit-making company. The CWD differs from the traditional PA because CWD focuses on the individual work experience and personal development, and not the individual in relation to performance the way the PA does.
However, it is also important to consider system and collective factors, and not only individual factors in a CWD, as they are also prerequisites and resources for individual well-being and personal development. Thus, WHP is seen as more system-oriented, and the traditional PM has a more outcome-or process-oriented approach because of its performance component. A system-oriented WHP is described by Eriksson, Orvik, Strandmark, Nordsteien, and Torp (2017) and by Sirola-Karvinen, Jurvansuu, Rautio, and Husman (2010) as a salutogenic approach with focus on health resources, participation, empowerment, and commitment. It also highlights interrelated factors as important to sustainability of co-workers health and personal development, as well as to the efficiency at the workplace.
Thus, there is a need to primarily explore and get a deeper understanding of the phenomenon of CWD and its relationship to work-related health and personal development, but also to explore if CWD contributes to collective commitment to the workplace. However, there is a lack of studies that investigate how CWD actually works and how it is experienced by co-workers and managers (Sandlund et al., 2011). Starting with the mangers' perspective, the aim of this study was to explore how co-worker dialogue [CWD] may foster co-workers' health and personal development, and contribute to an empowering development culture in the workplace.

Setting and participants
Sweden has a regulation, which requires that all employers should have some kind of annual meeting between co-worker and manager. This is one part of the Systematic work environment management, which all Swedish employers are obliged to adopt. It involves investigating, implementing and following up on activities to prevent accidents, hazards and poor health at work (AFS 2001:1). Sweden also has a work environment strategy (AFS 2015:4), which is implemented for the years of 2016-2020. It has three priority areas: (1) prevention of accidents and zero tolerance of fatal accidents; (2) a sustainable work life; and (3) a healthy psychosocial work environment. In particular, the third area relates to the Swedish provisions for the organizational and social work environment, which regulate questions about knowledge requirements, goals, work load, work hours and victimization that employers must follow (AFS 2015:4). The third area can be directly connected to CWD, and is therefore attributed to Swedish work life legislation.
To explore how co-worker dialogue [CWD] could foster co-worker health and personal development, and contribute to an empowering development culture in the workplace, a qualitative study was performed among managers in 2014 at a hospital in the south of Sweden. The hospital has about 1,500 coworkers with a focus on primary health care and specialized planned care. Information from the hospital management stated that the managers were obliged to have annual individual meetings with their co-workers, but there was no overall expressed strategy on how to implement the co-worker meetings within the hospital organization. The managers were free to implement co-worker meetings as they wanted. It was only recommended that three annual meetings per co-worker were held: (1) a monetarybased performance appraisal [PA]; (2) a co-worker dialogue [CWD]; and (3) a meeting with notice of the new salary. A few months before this study was carried out, the hospital management had developed a draft template comprising both PA (a monetarybased performance appraisal) and CWD (a dialogue about the co-workers health and personal development.) But it had not been launched yet throughout the organization, so only a few managers had tested the template, and some knew it existed but had not tested it. The hospital management had not yet done any follow-up on the co-worker meetings, neither on progress nor results.
All hospital managers (n = 19) in one of the hospital´s collective administrations, with approximately 700 coworkers, were asked to participate in an interview study. Seventeen of the managers agreed to participate voluntarily, see Table 1 for characteristics of the participants. The managers work in different areas of the hospital, e.g. internal medicine, orthopaedics, emergency, administration, and surgery. The managers have 5 to 58 co-workers, and those at each end of the span were a female financial manager with five co-workers and a male operations managers with 58 co-workers. Most of the other managers had around 30-45 co-workers each. In the position as operations manager (overall responsibility for multiple units) were one male and one female manager. Among the unit managers (responsible for one unit), there were both men and women and they had a fairly even distribution of employees.

Procedure
This study was part of a post doc-project, and most of the participants were therefore already familiar with the interviewer from previous studies. The relationship facilitated the implementation of this study and contributed to the participants daring to open up and give comprehensive and honest answers to the interviewer's questions. In the study, the managers' perspective was examined, and in another study the co-workers were interviewed, but that result is not presented in this article. The interviewer (P.N.L) has vast experience of conducting both individual interviews and focus group interviews. The first author (P. N.L) planned all the interviews and agreed on meetings with each manager. The interview took place at the manager's own office or in a meeting room at the hospital. An information letter on the study and how the ethical aspects were taken into account was sent by e-mail to each of the participants before the interview. The interviewer (P.N.L) followed a semi-structured interview guide, with openness to ask the questions in a different order and ask additional questions depending on each interview. The interview guide contained questions on how the manager implements and experiences co-worker dialogues, e.g. frequency, formality, location, structure, and social process. Interviews lasted 45-90 min and all interviews were recorded and transcribed verbatim.

Ethical considerations
This study was performed in accordance with the ethical guidelines of the Helsinki Declaration (World Medical Association, 2013). The participants were informed about the aim of the study, the preservation of confidentiality, their voluntary participation, and their ability to withdraw at any time. Information was also given prior the interview. Informed consent was obtained from all study participants before the interview. As the interview study was not based on an experimental design, or involved sensitive personal information, there was no need for ethical approval according to the Swedish Law of Research Ethics, SFS 2003:460.

Analysis
The focus of this study was to explore the managers' perspective on how co-worker dialogue [CWD] promotes co-worker health and personal development, and also how CWD can contribute to an empowering development culture in the workplace. Therefore, an inductive approach was chosen in the analysis, in order to catch various details (Vaismoradi, Turunen, & Bondas, 2013). To uncover underlying pattern phenomena in the interview data, a thematic analysis was chosen. Thematic analysis is a method for identifying, analyzing, and reporting themes in six phases (Braun & Clarke, 2006), and our analysis followed these six phases by P.N.L performing all steps in the analysis and Å.B functioning as a discussion partner during the analysis. The analysis was followed by a final discussion about the findings. Phase 1 was to become familiar with the data by listening to all the interviews and reading all transcripts to get a comprehensive picture of the material. Phase 2: initial codes were generated throughout the data to mark the content areas of interest (meaning units) based on the stated aim. Phase 3 involved searching for themes, and all codes were read and themes emerged from answers to the question: "What does this expression exemplify?" (Ryan & Bernard, 2003, p. 87). Two candidate themes were identified in the data: Utility, and Implementation. Phase 4: themes were reviewed in relation to the aim and the themes were refined as to their content. During this phase, it became evident that one candidate theme needed to be divided into two separate themes, because the theme "Implementation" was more about "how" while there were also lots of other things in this theme that were about "what". Phase 5: defining and naming themes by identifying the essence of what each theme was about, and describing what aspect of the data the themes captured. The themes were labeled: 1) Utility, 2) Content, and 3) Implementation. For each of the three themes, the analysis identified various resources for and perspectives on CWD. Phase 6: presenting the data, and this was done in this article's findings section and further discussed (Braun & Clarke, 2006). Each theme was illustrated with quotes from the interviews, and the number in brackets after each quote shows the interview number.

Findings
The findings show different descriptions of how Swedish healthcare managers implement and experience coworker dialogue [CWD]. Initially, the participants were asked what they called the dialogue with their co-workers, and they mostly used the term CWD. A few said they used both CWD and staff development dialogue/talks, while other participants completely disregarded staff development dialogue/talks because they felt that it brought the concept into a school setting where parents and children have development talks with the teacher. The findings show three themes that in combination highlight different aspects of CWD: (1) Utility; (2) Content; and (3) Implementation.

Utility
The participants described the benefits of CWD based on different levels and functions. They believed that CWD was of mutual benefit to co-workers, managers, work group as well as the organization, but in different ways.
[. . .] once a year, it's almost a year to summarize, even if you have dialogues along the way but not as thorough as the CWD, it's still a way to summarize how it works for the co-worker. The total of both the unit activity and how it works, as well as about the co-worker, so in many ways it is a nice forum during the time you have together to talk about everything in the CWD. I think it's nice and I think the coworker expects that too (15).
For the individual co-worker, the manager perceived the CWD as an opportunity to get individual time with the manager and create better contact (i.e. speak both about private and work issues) and to reflect on experiences of the work environment and the work situation.
The dialogue included what and how the co-worker wanted to develop in his/her work, e.g. current areas of responsibility, or further education. The dialogue also provided an opportunity for the co-worker to talk about things that may be difficult to address at meetings where the entire work group is present, and it was also to clarify expectations between manager and coworker.
[. . .] it's a mutual dialogue where we can talk to each other completely openly, when you have a co-worker who has goals and visions and gives feedback both on the unit activities and the manager, then I think it's nice. Some co-workers stand out and would like to have feedback themselves, and I think that's rewarding. It is fun when you have the recurring dialogues, when you can look at old goals and say "now you've done that, what can we find out for you in the future?", then I think it's fun (2).
The participants said that the benefit from a managerial perspective was partly gaining feedback from coworkers on their own management, so they could develop and adapt their leadership to the needs of their group. Secondly, a closer contact with the coworkers created security in the relationship between manager and co-worker. That led to a more relaxed dialogue about work experience and what the coworker needs to do in order to do a good job. Another aspect was that suggestions for improvement or problems that co-workers had not previously mentioned often came up during a CWD. The manager could then gather the suggestions and discuss them with the whole work group, such as improvements in routines or cooperation problems in the work group. According to some participants, the benefit of CWD at an overall organizational level left a lot to be desired. While they agreed that CWD was a fundamental part of co-operational work and that dialogue with co-workers contributed to the organization as a whole, the participants felt that they were left alone with the co-worker meetings and did not know what was expected by the hospital management. The dialogues should be carried out because they were required to have them. The participants wished that the organization had gone out with a joint approach where there was a clear link between the hospitalwide goals (in relation to monetary, patient, and coworker aspects), and the unit goals (of assignments to meet the overall goals), so the co-workers' individual goals could finally be clarified with regard to what actual work tasks and activities helped to fulfil the unit goals. This was not done. Some participants described that they tried to link unit assignments and co-worker activity plan to the CWD, but they felt this was difficult. Also, they wanted to know how the CWD could provide a better follow-up and a clearer link to other activities carried out by co-workers, such as co-worker surveys and health projects. The participants felt this was needed.
[. . .] I want to see this continuity, that there is an assignment from the overall organization to which the hospital belongs, and it goes down to the hospital and then to the clinic since if we are to deliver it must somewhere end up with each individual as well. And where are they in this big organization? It's not so easy, really, and our goals are often very fuzzy but there is hope. Hopefully, you'll have the ability to put them [the co-workers] into a context so they understand their part in this great machinery (13).

Content
The participants described different contents of their CWD because their conditions varied. There were participants who had a clear breakdown into three meetings per co-worker and year: 1) a monetarybased performance appraisal [PA], 2) CWD, and 3) a meeting with notice of the new salary. There were also participants who had one meeting with both PA and CWD during the same meeting, and a separate short one later with notice of the new salary. For those who had a PA and CWD at the same meeting, some participants emphasized the importance of being clear with the borderline between PA and CWD to show different dialogue focus. Focus on evaluating performance in relation to salary at the PA, and focus on personal development and resources to do and feel good at work in the CWD. There were also participants who did an all-in-one and without a clear border between the meetings. There was no clear relationship between the number of co-workers and the number of meetings. The participants knew that there was a hospital recommendation of three meetings per co-worker and year, but some participants found this impossible due to the number of co-workers and thus the time aspect to carry out all three meetings in a qualitative and meaningful manner. Others did not see any problem with managing three meetings per co-worker.
[. . .] I have had two different meetings, so I personally think they should be different. In both dialogues, it's actually the co-worker who is going to take action, but in the performance appraisal, I still have more assessment and feedback in which to tell the co-worker as well as discuss it. I think the idea of the CWD is to enable more discussion. There is more to hear what the co-worker thinks about different things (9).
It's the same. First of all, I have a performance appraisal part for the past year, and we look at the performance appraisal criteria and discuss them. And then we're also getting a hint of what's going to happen next and that's how we talk about how to work things out (14).
Essentially, the part relating to PA had a joint content and focused on the following three parts in relation to co-worker performance: 1) profession, 2) unit/clinic activity, and 3) social interaction. The manager assessed the co-worker's performance, and the coworker assessed his/her own performance, after which the assessments were discussed jointly. The participants said that making the assessment was difficult for some co-workers who overestimated themselves and some who underestimated themselves. Likewise, as a manager, you had to be aware of the extra effort that some co-workers made in silence and not just see what was presented to you. Then, the overall performance appraisal formed the basis for the salary received by the co-worker, which was announced at a meeting with notice of the new salary.
The content of the CWD concerning the co-workers' personal development was not about performance but how the co-worker experienced the work situation, and it focused on development and new goals for the co-worker. The participants described that the content also involved checking up each coworker to see ongoing activities, and the content of the dialogue became deeper than everyday talks. When participants described the CWD templates they used as the starting point, it turned out that there were almost as many templates as participants. Common to most of the templates described were that they addressed the following content: follow-up of previous year's action plan, cooperation with colleagues, suggestions for improvements at the clinic/ unit, and suggestions for improvements for the coworker's individual development. Specifically, both short-term and long-term goals were often set. Short-term goals could be to take breaks or improve patient communication. Long-term goals could be a specialist education or a new area of responsibility. The participants said that the hospital management needed to have a joint approach to the purpose and content of both the PA and the CWD, because the participants themselves had to emphasize the content of their PA and CWD and implement them to the best of their ability. However, they wished that there had been separate templates for PA and CWD with some basic questions, but with the freedom to partially adjust the content to suit their respective clinics/units. The content of the CWD was summarized in an action plan to work on for the year and sometimes also for coming years. Finally, questions about how the co-worker felt (physically, mentally and socially), and was able to handle the balance between work and private life, were not commonly taken up directly by the participants, but they said that this often came up during the CWD. Most often, negative aspects such as stress, injury or illness, came up. Some participants did not want to ask about the co-worker´s private life, because they felt they were invading the privacy of their co-workers, while others considered it important to know more about their co-workers because it affected their work performance. The participants said that coworker health, both in relation to work and private life, was important for the overall work experience and performance, and therefore it was also emphasized that a dialogue about health should be part of the CWD. The CWD templates that the participants worked from rarely contained questions about health, so the participants said that there was a potential for improvement in this regard. I do not have it [health] as a part, but we are often talking about the balance between free time and work and training and so on, I like to have a holistic approach so I think we should talk about it, do it enough, but I cannot say I do that with all co-workers (15).

Implementation
The time of year when participants completed their CWD varied, but it was most commonly in the spring. Participants described many details about how the actual implementation of CWD was done and what happened before, during and after the dialogue. In order to implement a CWD, participants needed a considerable amount of time for the dialogues, as they ranged from 45 to more than 120 minutes. Then, the participants booked a time with each co-worker and they did it differently. Some gave the co-workers the opportunity to book themselves, while others went directly to each co-worker and booked a time. Some participants reported that they sometimes had co-workers who did not want a CWD, and some then failed to have it, while others felt it was the coworker's obligation to come and to contribute to the clinic/unit. Participants always sent out a CWD template and expected the co-workers to come prepared for the dialogue. But they said that this varied a lot, as some co-workers came well prepared and others came with a blank paper.
Yes, here it has always been the same with regard to who does it and who does not do it. Some do not prepare themselves; it is just a few, not many, but no, I do not know what it's really like, maybe they do not think that it's so valuable either, I do not know (8).
The participants felt that they were always prepared for each individual dialogue, but very differently depending on which co-worker they would meet. The preparation could be based on e.g. being able to offer development opportunities for motivated coworkers; to consider ways to increase co-worker commitment; meet to discuss a problem; or not having to prepare so much because the manager felt comfortable and relaxed in the relationship with the coworker.
Yes, some dialogues I think through more before, what I want to say and what I want to achieve from it and so on, so I'm ready myself (7).
During the CWD implementation, participants believed that both practical and emotional aspects were involved. Practical, such as where the dialogue took place (usually at the managers' office), but in many cases the managers chose to book other rooms in the hospital to have a neutral location. The participants were also aware that their place in the room could have a bearing on the dialogue, so they chose to sit close to their co-workers or next to them. Privacy was important so the participants always switched off their phone and put a "Do not disturb" sign on the door. Some participants described how they tried to create a pleasant atmosphere with coffee, some candy or cookies. The dialogues often started with some small talk about the weather to create an open atmosphere and then get into the CWD. They were aware that co-workers came to CWD with different mindsets, such as joy, nervousness, anxiety, drive, or indifference, and the participants said it was important to try to know or ask so there could be a good dialogue based on the co-worker's starting point. The participants described that favourable conditions for a good dialogue were largely about the co-worker and the manager being prepared and having thought about things before the CWD. The role the managers took during the dialogue varied depending on the coworker they had in front of them. They said that they usually assumed a coaching role, but sometimes they needed to be more authoritarian or more caring. Sometimes, they needed to address problems that were related to the co-worker, e.g. patient or cooperation problems, and it could be inconvenient to cause conflicts. But they considered it one of their duties as a manager. Some participants followed their CWD template strictly, others said that they had a more open dialogue and only used the template for support. The participants said that a successful CWD had taken the co-worker a clear step forward. Initially, the parties did not have to agree, but when the dialogue was over, consensus should have been reached between the manager and the co-worker, and a plan outlined on what the co-worker should work on and develop until the next CWD.
[. . .] I like trying to coach, I like to work to get coworkers to think things over, and find, and getting started on ideas that make them develop both personally and professionally [. . .] (17).
Afterwards, the participants documented the essence of the dialogue, and both manager and co-worker signed the action plan with activities and goals for the co-worker in the future. Sometimes, the participants followed up co-worker activities more closely, depending on their nature, and whether it could wait until next year.
In the participants' descriptions of implementing CWD, they expressed a wish for training in CWD techniques. Common to the participants was that no one had received training in implementing CWD, but it was assumed that they would conduct annual meetings as managers. The participants felt it should be part of the executive education, and that they should be offered continuous support from the HR department. Issues that participants would like to discuss with other managers were how co-workers' involvement and commitment could be increased during the CWD, e.g. by clarifying expectations, emphasizing the importance of preparation before the dialogue, and how they could deal with uncomfortable issues.
In addition, there were also requests for improved documentation. The participants primarily documented on paper, and they said that there was no transfer between managers when a staff member changed his/ her workplace within the hospital or a manager left. There was no routine for handing over co-worker documentation from CWDs, and the participants felt the profit aspect was lost. They just had to start all over again. The participants said it would benefit everyone if all co-workers had an individual file, similar to what the patients had, where everything that was work-related was collected digitally in a system and followed the co-worker, and that the managers should have access to these files.
[. . .] I would like to have a report system for each coworker to get answers on questions like: how was it now, has he/she been on sick leave and for how long?, or what did we agree on, that he/she should not take that education or what?, or what did he/she need to learn in order to take blood samples better? Or just about anything about a co-worker. As it is now, we have a system that does not work and it's only a sick leave system, a completely useless system really, as we do not have any more documentation systems for co-workers (1).

Discussion
How Swedish healthcare managers experience and implement co-worker dialogues [CWD] to foster coworker health and personal development, and how this could contribute to an empowering development culture in the workplace will be discussed based on the three themes in the findings: (1) Utility; (2) Content; and (3) Implementation. These three themes showed prerequisites and detailed resources that could strengthen empowerment both individually and collectively at the workplace. A focus on health and personal development in the CWD gives potential for a salutogenic approach, which means that the prerequisites to enhance co-workers health development are highlighted (Jenny, Bauer, Vinje, Vogt, & Torp, 2017).
The first theme, Utility, emphasizes that CWD is useful at different levels: individual, managerial, work group, and organizational levels, in different ways. The participants emphasized that CWD gave individualized time with the co-worker and also feedback on their leadership, as significant benefits. Both of these actions can strengthen the relationship between manager and co-worker. They can lead to a more open approach, increased loyalty and willingness to make an effort at work (Bouskila-Yam & Kluger, 2011), and positive effects of feeling more involved and actively participating (Roberts, 2003). The participants wanted a joint approach to CWD, with clear goals (organizational, unit, and individual co-worker goals) and a model for how to link CWD to other ongoing organizational processes, co-worker surveys and systematic work environment management, aiming to improve the work environment for the co-workers both physically, mentally, and socially. It is worth noting here that the managers demand a top-down approach, which is not in line with the participatory WHPapproach (ENWHP, 2007), but on the other hand it points to a whole-system approach (Eriksson et al., 2017). However, a practical implication is that the usefulness of CWD has to be discussed and clarified at all the different levels, so the value of implementing and participating in CWD increases and is prioritized. An active awareness of the top-down and bottom-up of the CWD is preferred, and Sirola-Karvinen et al.
(2010) point out that the commitment of both parties involved is important for a well-functioning organization and for enhanced individual empowerment. Active participation is one of the criteria for WHP (ENWHP, 1999), as well as the management responsibility for a comprehensive and joint approach in the workplace to encourage commitment and thereby foster collective empowerment (Jenny et al., 2017;Vaandrager & Kennedy, 2017).
The second theme, Content, highlights that the content of the CWD could vary depending on the manager who conducts it. Some focused more on PA, which was related to evaluation of performance in relation to salary, some focused more on CWD for personal development, while others made a mix of the two. Some of the managers did not seem to fully understand the difference between PA and CWD. They thought they meant the same things, and therefore they assembled PA and CWD into one meeting. Others understood the difference and made a clear distinction, because they realized the importance of both parts. The problem is that the organization does not have a common approach and clear descriptions of the purpose and content of PA and CWD, respectively. A consensus and a joint template could facilitate and clarify things for the managers. It is worrying that the organization does not have a coherence with the CWD content and process, but according to Gordon and Stewart (2009) it is common for organizations to change templates often, and in a large organization, everyone may not be updated, which means that many different templates flourish. Another prominent point was the lack of dialogue about co-worker health. Health was rarely discussed, except if it came up naturally during the CWD. An important aspect to take into account about health is the ethical issue (Tengland, 2016). Issues to discuss are whether private questions are OK at a CWD, and what health issues are relevant for discussion in relation to their importance for the work performance and employment in general. Otherwise, personal development, problems, and various positive resources for managing work tasks were more in focus for the discussion, and that is a prerequisite for the strengthening of individual empowerment (Jenny et al., 2017). Thus, a practical implication is to have a joint dialogue template for the CWD. This creates a joint approach for the entire organization and gives managers and co-workers confidence to work on the same criteria in the CWD. This is in line with Eriksson et al. (2017), who highlight that having clear goals at all levels will strengthen the coworkers, the work environment, and the organization as a whole. There is good reason to follow up strengths and development areas (Sirola-Karvinen et al., 2010). It is therefore important to see a joint dialogue template for CWD as a top-down action that may become too static. Instead, a compromise may be a joint template with the ability to have add-ons that are local/specific for each work group. It is also important to discuss health-related questions and an acceptable levels for them. All these questions, as well as the CWD purpose and its meaningfulness, should be discussed in the current work group that will use them to make them relevant, as well as for preparation (DeNisi & Murphy, 2017).
The third theme, Implementation, shows details and descriptions of how the participants implement CWD in various ways (before, during, and after). One reflection was that some managers felt that they had too many co-workers to be able to manage all the three meetings: (1) PA; (2) CWD; and (3) a meeting with notice of the new salary, which the organization recommended. Managers with few co-workers did not experience that problem. It is a good intention of the organization that each co-worker should be given time for all three meetings, but the managers were not given the prerequisites needed for their implementation considering their number of co-workers. Then, the meetings will be implemented as described in the findings, namely that the managers find their own solutions for handling the time pressure. The risk with individual solutions is that the actual purposes of the meeting may be lost. The organization's desired efficiency may unconsciously lead to a more performance-focused PA, rather than valuing PA and CWD as equally important, but from different angles. Within the organization, it is important that there is room for discussions of CWD expectations, purposes and goals, to increase the managers' awareness that PA and CWD have different purposes (Bouskila-Yam & Kluger, 2011;Sandlund et al., 2011;Spence & Wood, 2007). The managers expressed the ability to get continuous support from each other, i.e. collegial support, to discuss the implementation of CWD. Another request was to receive training in communication techniques and implementation strategies for CWD as basic support from the management, because none of the participants had been given CWD training during their years as managers. Other studies have also commented on poorly trained appraisers for a long time (Gordon & Stewart, 2009;Green & Knippen, 1999), and Spence and Wood (2007) emphasize the value of communication training. Therefore, a practical implication is to encourage and create conditions for collegial discussions about CWD implementation between the managers so they can support each other in the work before and after CWDs. A salutogenic WHP strategy (Jenny et al., 2017) emphasizes the importance of analyzing and continually improving WHP processes in terms of comprehensibility, manageability, and meaningfulness, and this is what also needs to be done with CWD processes. In a system-oriented PM, factors such as culture and values are included (Bae, 2006), and it is important to discuss these in order to gain knowledge on how colleagues think and act at the CWD and thereby get tips on how to raise difficult questions and how to keep the distance in demanding situations. Kluger and Nir (2009) also show that feedback on managers' performance is important in order to increase the effectiveness of coworker dialogues. Another supportive feature the managers wanted was a digital documentation system, as the participants said they still document on paper. The managers want a system where all the documentation on a co-worker is available for both managers and coworkers, such as results from CWDs, PAs, co-worker surveys, sick leave statistics, and other important information that would create the best conditions for each individual co-worker to be able to work and focus on their current best abilities. Conversation training, collegial discussions, and a documentation system are all related to the criteria for WHP, a collective empowerment and a whole-system approach, which highlights the importance of encouraging personal development and that the management should provide supportive resources (Eriksson et al., 2017;ENWHP, 1999;Jenny et al., 2017;Vaandrager & Kennedy, 2017).
A CWD can connect co-workers' personal development and health experience in the same activity, and this is different from a traditional PA. It provides new insight to connecting and learning from various organizational processes (WHP and PM) and creates something that fits each unique organization. It is in line with the wholesystem approach to WHP (Eriksson et al., 2017), and it stresses that all parts affect each other in an organization and thus, there is need to collaborate (Sirola-Karvinen et al., 2010). Although CWD has a greater focus on the dialogue between managers and co-workers, and on the co-worker's personal development, the findings indicate that CWD sometimes lacks in clarity of what achievements are expected with regard to the golas of the entire organization. Clear expectations are highlighted by Spence and Wood (2007) as an important feature in PAs. A recent longitudinal study showed that PAs without monetary incentives do not have a positive impact on job satisfaction (Kampkötter, 2017), while an earlier study (Kuvaas, 2006) showed that co-workers with high intrinsic work motivation increased their work motivation even more through PA, in contrast to those with low intrinsic work motivation. One challenge for the managers is to get everyone, not just few co-workers who are already motivated, to perceive the CWD as an opportunity to create motivation and conditions for the co-workers' own success in achieving the desired goals and a chance to improve the workplace (Kuvaas, 2006), instead of a time-consuming task and "a must" once a year (Kromrei, 2015). In these cases, a stronger focus on PA with monetary insights as an external motivator could be a starting point, followed by gradually inserting more of the personal development and work motivation in CWD, according to Kuvaas (2006) and Kampkötter (2017). Therefore, a question for further research could be whether CWD really contributes effectively to coworker health and personal development compared to a traditional PA, and if it differs in various settings, e.g. a health care organization versus a profit-making company. In order to create a more sustainable organizational whole, (Eriksson et al., 2017;Jenny et al., 2017;Kira & Forslin, 2008), increased quality in co-worker performance (Bae, 2006), and improved co-worker health (Sirola-Karvinen et al., 2010), together with practical tools and models, should be implemented and combined in various work-related processes to create and evaluate continuity. For example, a model combining CWD, PA, Systematic work environment management, and co-worker surveys could be tested. Thus, if all levels of the organization could work better together towards co-worker health and development, there would be possibilities for an empowering development culture in the organization. Broad aspects of health among individuals, work groups, and the organization would then be taken into account, and could thus positively affect the entire organization regarding co-worker health, personal development, empowerment, and sustainability.

Methodological discussion
Ethical considerations were met as the interviews were characterized by commitment, and all managers participated voluntarily, after signing an informed consent form. The credibility of the study was indicated by the participants' honest answers to the interview questions, as they provided a detailed image of CWD. The fact that the participants knew the interviewer on beforehand contributed positively to the credibility. To allow transparency, the analysis was described step by step, and the findings were illustrated with quotes from the interviews. As all managers who participated represented different hospital areas, differed in age and sex, as well as how many co-workers they managed, transferability to other settings is strengthened. There is always a risk that the analysis was guided by the researchers' preunderstanding, so to minimize this risk and strengthen the confirmability, two researchers collaborated in the analysis work. It allowed for questions between the researchers and discussions during the analysis. The study's confirmability is also about the researchers finding something unpredicted. Prior to the interviews, we anticipated that we would find various approaches to CWD, but it was surprising that CWD was so undefined and unstructured by the organization, and that basically it was entirely up to the managers to implement it themselves. Furthermore, it was astonishing that health issues were of secondary significance in CWD, although all participants thought it was an important part of the discussion with their co-workers.

Disclosure statement
No potential conflict of interest was reported by the authors.