Relationships between healthcare employees and managers as a resource for well-being at work

ABSTRACT Relationships at work are important to the psychosocial work environment and may be resources for the employees’ well-being. There is a need for a better understanding of what generate positive relationships at work. The aim of the study was to gain a better understanding of the relationship between employees and managers in municipal healthcare. A qualitative study with twenty-seven individual interviews was conducted with healthcare employees and managers in municipal healthcare. The relationship between manager and employees and its possible contribution to well-being was a key focus. A comparison and tentative analysis, inspired by hermeneutics, was used in order to analyse similarities and differences in employee and manager experiences. The findings revealed similarities as well as considerable differences between employees and managers in their experiences. Two themes emerged from the interpretation of the text: (i) Health-promoting relationships are characterized by asymmetry and by a manager that stands outside the group; and (ii) Health-promoting relationships are characterized by mutuality and symmetry and by a manager that is part of the group. The relationship between the employees and the managers are both a resource for doing a good job and a means for achieving belongingness at work. To highlight well-working aspects of relationships at work, may contribute to a better psychosocial work environment and, ultimately, the well-being among healthcare recipients.


Introduction
In many Western countries, the workload within the healthcare sector is extensive and the psychosocial work environment contributes to poor health among healthcare employees. Moreover, work absenteeism due to psychosocial factors is increasing (Kuoppala, Lamminpää, Liira, & Vainio, 2008;Social Security Report, 2014). However, positive relationships at work may be a resource that can help individuals and organisations to develop and flourish (Ragins, 2006;Social Security Report, 2014) as well as affect how we make sense of and feel meaning in our daily lives and our work situations (Nilsson, Andersson, Ejlertsson, & Troein, 2012). Organizational activities, such as information sharing, motivation, and decision-making, occur all in the context of workplace relationships as generative processes and with positive outcomes, as a vital health resource among healthcare employees (Seligman & Csikszentmihalyi, 2000;Sias, 2013;Tourangeau, Cranley, Laschinger, & Pachis, 2010). The relationship between managers and employees is a major part of the psychosocial work environment (Clausen, Tufte, & Borg, 2014;Landstad & Vinberg, 2013;Ljungblad, Granström, Dellve, & Åkerlind, 2014), and this study focuses on experiences of how relationships between employees and managers contribute to well-being at work (Ragins, 2007). Thus, efforts to improve relationships could increase the general quality of the workplace climate. Identifying experiences from the perspectives of both employees and managers is one contributory factor for workplace health promotion.
Workplace health promotion is described as the health development process of enabling people to control and improve their health at work (Lundqvist, 2013). Health promotion can be explored from either a salutogenic perspective, with a focus on promoting factors of health, or a pathogenic perspective, with a focus on risk factors of health (The World Health Organization (WHO), 1986). From a salutogenic perspective, there are several theories for understanding occupational health, and one of them are Sense of Coherence (SOC). The theory was originally developed by Aaron Antonovsky (1987b) and it is a commonly used theory within the field of health promotion from a salutogenic perspective (Bauer, Davies, & Pelikan, 2006). The SOC theory describes how an individual, via biological, physical and psychosocial resources such as social support and knowledge, provides strength to cope with stressors and achieve a strong SOC. The core components of the SOC theory are comprehensibility, manageability and meaningfulness. In the workplace context, comprehensibility refers to the ways in which individuals perceive their work situation as structured and understandable. Manageability is about a feeling that one has enough resources to cope with upcoming situations or work tasks, while meaningfulness is connected to work motivation (Jenny, Bauer, Vinje, Vogt, & Torp, 2017).
Most research on workplace relationships has focused on negative interpersonal relationships and conflicts (Antonovsky, 1987b;Saarnio, Sarvimäki, Laukkala, & Isola, 2012;Sarafis et al., 2016). Even though relationships as a resource at the workplace so far have not received much attention in the field of workplace health promotion (WHP), a salutogenic perspective on relationships and workplace health promotion has been highlighted (Arnold & Boggs, 2016;Clausen et al., 2014). Previous studies in the healthcare sector have revealed that feeling cared for by other employees can lead to better healthcare for others and establish positive relationships with the healthcare recipients (Dickson-Swift, Fox, Marshall, Welch, & Willis, 2014;Thylefors, 2013;Westerberg & Tafvelin, 2014). Although we know that relationships can be vital to employee well-being and, more generally, what is needed for relationships to improve, there are few qualitative studies that have used a salutogenic perspective to deepen knowledge about employees working with health care of older persons (Ljungblad et al., 2014). To compare experiences by both employees and managers may contribute to knowledge about how to reach a health-promoting workplace and improved healthcare.

Aim
The aim of this study was to gain better understanding of positive relationships between employees and managers in municipal healthcare. The specific research questions were: 1) What are the prerequisites for positive workplace relationships between the employees and managers in municipal healthcare? and 2) How do the views on positive workplace relationships differ between the employees and the managers?

Method
In this study, a qualitative and comparative hermeneutic approach was used to gain a better understanding of the experiences of municipal healthcare employees and managers. According to its ontology and epistemology, hermeneutic philosophy claims that, instead of talking about the truth, we should realize that everything is interpreted and that the reality can always be seen from different perspectives. To be open to another person's horizon of knowing, a new understanding is needed (Gadamer, Marshall, & Weinsheimer, 2004).
Thus, how we interpret and understand one phenomena depend on context and preunderstanding (Gadamer et al., 2004). Our preunderstanding was that positive relationships between employees and managers could be promotive for health. Also we believed the intermediary manager role as problematic, a difficult double role that calls for loyalty in all directions in the organization. Yet what was problematic was not clear to us. Finally, we also had a pre-understanding that the involvement of both parts in the relationship i.e. the employees and the managers, should be the starting point for understanding positive relationships and their prerequisites.
The chosen approach aims at allowing the reader to follow the analysis and interpretations. Therefore, the findings first give a description of how the employees' experienced the positive relationship with the managers, followed by a similar description of the managers' experiences. These descriptions are followed by a comparison between the experiences of the employees and the experiences of the managers, ensued by a tentative interpretation. Finally, a comprehensive interpretation is provided.

Setting
The study was conducted in a rural area with approximately 2700 inhabitants in southern Sweden. The choice was based on a desire from the municipality to participate in the study and to use the findings in their own efforts to improve their working environment. The study involved five healthcare units comprising of two residential healthcare units for older persons, two units for persons with certain physical disabilities and one home healthcare service unit. In the units, all residents had their own apartment and used common areas for meals and socializing. The residential healthcare units were similar to what is known internationally as nursing homes. A home healthcare service unit consists of a manager and a group of assistant nurses, who support older persons in their own homes.

Participants
The participants were 18 assistant nurses, 2 registered nurses, 2 occupational therapists, 1 physiotherapist and 4 managers (n = 27). The assistant nurses were on duty around the clock while the registered nurses were available during daytime on weekdays. In the evenings, at night and at weekends, they served healthcare units on a consultative basis. The managers, occupational therapists and physiotherapists worked during the daytime on weekdays. The healthcare employees in all units in the district were informed about the study by the first author at staff meetings. A poster with information about the study and a sign-up form were placed in the staff rooms. A self-selection strategy among eligible employees was used and all employees who signed up were included in the study. All four managers (females) in the area took part in the study. The size of the units that the managers were responsible for varied between approximately 20 and 55 employees. Three managers worked in the same building as the staff while one manager had the office in another place. To achieve variation in the sample, all five units were included, with the employees being 21 women and 2 men who had worked between 5 and 36 years.

Data collection
To access experiences of positive relationships among the employees and managers, individual interviews were conducted between November 2012 and February 2013 and between March and June 2014. To identify the salutogenic aspects the interviews started with an overall explanation of the purpose of the study: "We want to gain a better understanding of when you experience your workplace relationships as health-promoting i.e. what makes you feel satisfied when you get home from a day at work." To understand the meaning of these experiences, we wanted the interviewees to tell stories from their everyday work. The initial request was, "Please describe agood day or a positive situation at work in relation to healthcare recipients, colleagues and managers." In order to expand the interviews, probing questions were asked, such as "What were you thinking at that time?" and "What did you do then?" During the interviews, it became apparent that the participants spoke differently about the relationships. They described their relationships with healthcare recipients and colleagues more dynamically than they talked about their relationship with the managers. Therefore, employee relationships with healthcare recipients and colleagues are presented in a separate paper while this article focuses only on relationships between employees and managers. The interviews were conducted in a private room at the workplace and lasted between 25 and 135 minutes, with an average length of around 70 minutes. All interviews were audio recorded and transcribed verbatim.

Data analysis
We used a comparative and tentative interpretation of the texts inspired by the hermeneutic approach (Gadamer et al., 2004;Nyström, Dahlberg, & Carlsson, 2003). The analysis of the data was conducted in four steps. In step 1, all five researchers read the interview transcripts several times to get a sense of the whole picture. In step 2, the interview transcripts were re-read. This reading showed that the participants spoke about relationships that encouraged doing a good job and relationships that led to good fellowship at work. These two ways of expressing positive, health-promoting relationships became our analytical structure for the analyses (Nyström et al., 2003). Therefore, all text was sorted according to whether the text was about relationships that encouraged doing a good job or relationships that led to good fellowship at work. In step 3, statements from employees and managers were described and compared and a tentative interpretation was performed. In step 4, we performed a comprehensive interpretation of the data by comparing the tentative themes. The comprehensive interpretation was an attempt to move from understanding a part of the text to understanding the entire text. In order to improve the credibility of the interpretations, we presented and discussed the interpretations with the employees and the managers at staff meetings.

Ethical considerations
In order to create trustworthiness for the study and trust between the interviewer and participants, oral and written information about the study was given in advance. From the information, all the participants had a free choice to decide if they wanted to participate or not. When accepting, an informed consent to participate in the study was obtained from all participants. During the interview, participants were given the opportunity to partly steer the content of the interview themselves based on an overall question where they should describe a good day or a positive situation at work i.e. what made them feel satisfied when they got home from a day at work, in relation to healthcare recipients, colleagues and managers. Several of the participants expressed that they had never reflected about the importance of relationships for a health-promoting workplace, but all were positive about talking about their experiences of relationships at work. To have the opportunity to talk about their positive experiences and that someone actually asked them about their view was perceived as healthpromotive in it self, among the participants. Since the participants were instructed to talk about positive, salutogenic aspects of their relationship they did not touch any sensitive or vulnerable areas during the interviews and therefore no ethical dilemma arose.
The study followed the Swedish law of ethics, SFS 2003:460, and was performed in accordance with the ethical guidelines of the Helsinki Declaration. The study was part of a comprehensive PhD thesis work, ethically approved by the Regional Ethical Review Board at Lund University, an Ethical Committee that is a government-appointed board of directors, independent from the University.

Findings
When the perspective of the employees and the managers were described and compared in order to gain a deeper understanding of the health-promoting relationship, two tentative themes emerged. Under each theme, the findings are presented in the following structure: the employees perspective and managers perspective, followed by a comparison and a tentative interpretation. Representative quotes from employees and managers are presented in each theme.
Theme 1: Health-promoting relationships are characterized by asymmetry and by a manager that stands outside the group.
Under this theme, the employees' and the managers' views about relationships that encouraged doing a good job are presented.

The employees' perspective
The employees described a positive relationship with the manager as a resource for reaching the goal of doing a good job. The relationship was positive when the manager took responsibility but at the same time respected the individual employees in their professional roles and had the courage to ask them for their opinion on work-related issues.
The manager is not the 'manager'. The manager never tries to stand out [by saying], 'I'm the manager'. She doesn't have that attitude (AN10).
The employees emphasized that to strengthen them, the manager needed to be open to their ideas, thoughts and suggestions. Such openness enhanced the employees' feelings of being important and believing that their work made a difference. According to the employees, it was also important not to feel obliged to always think through what to say to the manager. When the employee knew where the manager stood, the employee was able to focus on the tasks.
[…] when you have a question for the manager. As soon as something comes up, you don't have to think about it before you call. Like you don't have to feel, ugh, now I have to call the manager to ask this. Instead, you get a good response. That feels good. I know where I have the person; you can trust each other (AN03).
The employees also emphasized the importance of the manager's approach to create a sense of belonging within the workgroup. Belonging occurred when the manager was happy, proactive and affirmative.
A friendly manager, who greeted everyone, noticed the members of the workgroup and asked them how they felt, contributed to a positive feeling in the workgroup. Clarity was also described as having a positive impact on the team spirit. Furthermore, collegial belonging was described as occurring when the manager provided opportunities for team building and encouraged the employees to talk about their experiences at work during staff meetings.
The manager carries out group exercises at the meetings. We talk about how we feel. People talk to each other. People think about things for a bit, maybe; there's a sense of togetherness (AN03).
Furthermore, pointing to the qualities and performance in the workgroup, as well as giving responsibility, enhanced and encouraged the group to take more initiatives at work. The employees appreciated a manager who was around and who confirmed them in their daily work. They said that the manager's presence helped create a peaceful environment for the workgroup and at the workplace. In addition, it led to increased confidence within the group.
The manager introduces new little things. The manager is involved with the employees. She brings out the energy of each one. It's fantastic. She always says 'Good morning, how are you?' She always says people's names when she talks with them. That's really important. Little things that become so big (AN09).
The employees described situations when the manager was clear about both decisions and work procedures, and how this required courage by the manager. When difficult problems arose and the manager grabbed a problem and took the responsibility, it became easier for the group to focus on the mission and to do a good job. This could be a situation as when a care recipient became aggressive and the employees felt unsure of what they were entitled to do or when disagreements between relatives and healthcare staff arose. When the employees knew what the manager had decided, they also found it easier to handle the work situation.

The managers' perspective
The managers emphasized their support for the individual employees, as a way of enabling the employees to do a good job. They said that they encouraged the employees to use their own initiative. When the managers spoke about positive relationships with the employees, they emphasized that the employees worked for the healthcare recipients, which required that the manager create a permissive culture. In addition, the managers spoke about the value of creating an environment in which feelings were accepted and everyone was able to act based on professional experience.
They know that they can come to me with everything; in other words, I've been quite clear about it, that there are no stupid suggestions, so just dare to do it. No, but it gives happiness, so you just feel that … and they come up with such good suggestions […] I'm not the only one who comes up with it (suggestions), they dare (M01).
The managers said that delegating tasks was one way of enhancing self-confidence among employees. They felt that supporting the employees by confirming their good work, listening to them and being available at the workplace was vital for the managers themselves in order to experience satisfaction in their work. To be a supportive manager meant to create an open climate where everyone's suggestions were welcome, which permitted the employees to focus on the mission and to do a good job. To have the courage, as a manager, to make decisions and take responsibility for difficult work-related issues was considered essential to enhanced confidence in the relationship. At the same time, the managers highlighted the need for everyone to take responsibility and initiatives on their own in order to achieve work goals. When the members of the workgroup were striving towards the same goal, were focused on their duties and carried out their work without complaints, the managers felt that their efforts to empower the employees in their work had paid off, and this was satisfying to them.
[…] yes, now we've decided to […]. And they hatched it themselves, on the basis of … yes … well, a problem, what should we do? The way we have it today isn't working well, for various reasons.
[…] And I thought it turned out great and that is exactly how we should work.
[…] No, so I was really happy about it. That they had … well, starting from the care recipients and the best interests of the care recipients.
[…] Yes, it made me really happy, because they had dealt with the problem … they formulated the problem and solved the problem, and they came up with a great solution (M03).
Colleague belonging was described as a way to get the workgroup together to do a good job. The managers used team-building exercises and education to create belonging in the workgroup. When the managers reflected on positive relationships at work, they mentioned being able to show that they cared about the individual employees as well as the workgroup by way of oral feedback for the employees daily work, when a individual employee had challenged new tasks, or give praise to the group once they have solved a difficult work situation. The managers also mentioned that an enhanced relationship contributed to reduce misunderstandings.
But then it actually feels really good, because then I think that I actually care about my employees and do something worthwhile (M04).
A comparison of the employees' and the managers' perspectives showed that both the employees and the managers highlighted the importance of having a manager who stands outside the group as important in order to support the employees in doing a good job. This could be done by encouraging the individual employee as well at by encouraging the working group. While the employees expressed the view that this required that the managers had the courage to show openness and be permissive, the managers emphasized that it required the ability to give the employees' responsibility and let them take initiatives to achieve goals. Thus, both groups emphasized a relationship in which the manager enhanced the individual employees in their profession and enhanced collegial belonging in order to focus on the mission of doing a good job. A tentative interpretation is that a health-promoting relationship as a resource for doing a good job is asymmetrical because the manager confirms, delegates and decides. However, both groups have hidden expectations on each other. The managers consider it as their task to get the employees to take their own initiative while the employees, on the other hand, wait for the manager's approval before they take the initiative.
Theme 2: Health-promoting relationships are characterized by mutuality and symmetry and by a manager that is part of the group.
Under this theme, the employees' and the managers' views about relationships that led to good fellowship are presented.

The employees' perspective
The employees mainly emphasized that healthpromoting relationships were characterized by appreciation. The employees highlighted moments when the manager was felt like one of the group, which allowed them as employees to be themselves. Such an approach also allowed them to reveal emotions without feeling stupid, and it contributed to a sense of ease.
You can ask her what she thinks about something without feeling stupid (laughter). You can tell her if something is wrong. Just that a manager is like that.
That it feels like she's one of us in the group. Simple. Mmm (AN04).
The employees said that it was important that the manager had the courage to ask for advice. They realized that it took some courage for the managers to honestly express their uncertainty and to acknowledge that the employees knew more about something than they did.
She often comes personally and asks different people, 'What do you think we should do?'like that. 'You know so much better; how should we deal with it?' People discuss the situation to find a solution together (AN10).

The managers' perspective
The managers mainly emphasized the importance of their own approach to be accepted as part of a workgroup, which was described as a way of getting closer to the employees. The managers appreciated that the employees cared, and feeling that they were part of the team was crucial to a positive relationship. When the managers spoke about a good day at work, they highlighted the possibility of talking and laughing together with the employees. Taking time for small talk was highly valued. Experiencing happiness together with the workgroup created a feeling of being part of the team and of being appreciated at a personal level.
It's one of those mornings when everyone is cheerful and alert, and then the rest of the gang comes in, and then we have our report […] and so we laughed a little, and then everyone goes out and works […] one of those mornings when like everyone is sweet and happy and comes to work with the balloon filled with energy. And yes, there are those days you feel that, yes … you really feel this is the most fun job to have (M01).
One of the gang, one of the team. I can be one of the gang. Job satisfaction, I think it's fun. You should have fun at work, you'll laugh a lot (M01).
However, the managers also highlighted the significance of the employees' approach for creating extended belonging. The managers said that confirmation, in terms of small, positive comments from the employees, helped them to feel good at work and get a sense of belonging to the group. The managers mentioned situations when the employees had expressed that the manager had made a good job, when they employees shared things that had happened in the group, or gave small comments that showed that the managers were appreciated in the group. These comments made them feel appreciated, as a part of the group and acknowledged in their work as managers.
Well […] I don't know; it's small comments here and there, and it's enough of a confirmation for me. For my own part, and then I hear, of course, that they are satisfied (M03).
A comparison of the employees´and the managersṕ erspectives showed that both employees and managers highlighted the importance of a relationship in which the manager sometimes felt like and was perceived as 'one of the team'. The employees said that this required that the managers expressed their uncertainty honestly when needed and that they had the courage to ask for advice. Meanwhile, the managers emphasized the opportunities for small talk and receiving positive comments from the group members. A tentative interpretation is that a healthpromoting relationship as a resource for extended belonging is of a more symmetrical and mutual nature, where both parties want the manager to be an equal member, like a colleague among others in the workgroup. However, employees are unaware of how much expressing their appreciation of the manager matters to the creation of a positive relationship where the manager is part of the group.

Comprehensive interpretation and discussion
An asymmetrical but relationally focused leadership emerges when the manager supports the employee to participate actively by sharing opinions, advising and motivating the individual employee to do a good job. However, confirming the employees and involving them in decisions not only promotes employee health but also gives the managers satisfaction and thus promotes the managers' own work situation. This can be linked to salutogenic principles as Antonovsky states that participation is a prerequisite for feeling that the work is meaningful (Antovonsky, 1987a;Dahlberg, Nyström, & Dahlberg, 2007). Another interpretation is that a relationship, in which the manager stands outside the workgroup and actively works with clarity and caring, has an enhancing impact on the team spirit and promotes collegial belonging. This is comparable to previous studies showing that an asymmetrical relationship is sometimes required for a manager to do a good job (Westerberg & Tafvelin, 2014).
A symmetrical relationship, in which the manager and the employee are equals at a personal level, is another important part of a health-promoting workplace relationship. It is a prerequisite for a sense of extended belonging where the manager is part of the group. This demands mutual appreciation, with each participant confirming the other. A symmetrical relationship creates control and coping for the individual, which is comparable to the SOC component of manageability (Antonovsky, 1987b). It has also been shown that caring for each other is needed in order to create healthy work environments (Antonovsky, 1996).
Our comprehensive interpretation is that relationships between employees and managers can be a resource for doing a good job and a means for achieving collegial belonging within the workgroup. In order to reach relationships that enhance wellbeing, the managers have a dual role. In some situations, an asymmetrical relationship in which the manager takes the role of a person who stands outside the group and is responsible for enhancing individual employees and collegial belonging, whereas other situations a symmetrical relationship is needed, in which the manager and the employees are equal at a personal level and a sense of extended belonging is reached. Nonetheless, the findings showed that employees must respect the manager's dual role by letting the manager step away from the group to conduct formal decision-making and team-building tasks, while allowing the manager to return to a position of extended belonging in the group again. Therefore, a balance between symmetrical and asymmetrical relationships is necessary for the relationship between employees and managers in order to be health promoting.
To achieve health-promoting relationships, our comprehensive interpretation indicates that clear expectations of each other are also required. The SOC component of comprehensibility describes how clear expectations remove uncertainty so that individuals perceive work situations as understandable (Antonovsky, 1987a). It has been found that all team members need clear roles to have a chance to be effective (Cummings et al., 2010). However, meeting another person's expectations requires the ability to see the other person's different ways of understanding. Gadamer et al. (2004) described the mutual understanding of each other's beliefs as a fusion of horizons. In a similar way, Schuster (2013) claims that when an individual opens up to another person's understanding and allows that understanding to merge with his or her own, a new understanding is created. Our study contributes the insight that an awareness of both the manager's dual role and the clarification of both employees' and manager's expectations of each other may contribute to a health-promoting workplace.

Strengths and limitations
Methodological considerations have been made on the basis of the criteria of credibility, confirmability and transferability, in order to establish credible and trustworthy qualitative research (Schuster, 2013). The credibility of the present study refers to striving to establish logical categories and show the depth of the interviews by presenting quotes from the interview transcripts (Guba, 1981). The informants talked about the positive aspects of their relationships, which seemed to be easy to talk around and neither was a sensitive subject which ensured the honesty of the informants. The credibility also refers to the total sample of the managers and all employees who expressed interest in the study were allowed to participate and were included in the study.
The researchers preunderstandings are always a risk that the findings may reflect the researchers' views rather than the interviewees' reality which may reduce a study's confirmability (Guba, 1981). Initially, we believed the intermediary manager role as problematic, a difficult double role that calls for loyalty in all directions in the organization. But if and how relationships affect the manager's role was not clear to us. However, the preunderstanding partly changed through the course of the study. Our understanding changed when we realized the problem of a manager who was friend with the working group, but also that it was problematic with managers who were very authoritarian. What kind of relationship that promoted health was something we hardly had reflected on.
Transferability of findings may be questioned, in cases were the way of organising health care work and the organisation of different responsibilities of managers in Sweden may differ from other countries. To enable the reader to assess whether the findings can be transferred to other environments, we sought to provide a clear description of the local context (Shenton, 2004). However, a weakness is that the study does not focus the structure or organizational aspects of the interface in the relationship between managers and employees. In this study we have merely concentrated the analysis about the personal relationship and limited the analysis to prerequisites for health promotion at the workplace in the health care sector. Although the contexts and working conditions varied among the participants, it did not seem to have had any significance, since the data did not show any differences between managers working in healthcare units or in home healthcare service. Probably the data material is too small to show such differences. Differences and the questions in the interview study were not specifically targeted to show such differences. Thus, we believe that the level of abstractness of the main findings may allow transferability to other contexts (Nyström et al., 2003). Hence, the findings are most likely applicable to workplaces in general and are not unique to Sweden, nor to healthcare organizations. Since relationships influence all occupations to some extent, it is likely that the findings in this study will apply to other cultures and groups.

Implications for practice
To make the relationship between employees and managers in healthcare a resource, the balance of power structures and expectations of each other need to be highlighted. It is hard to define the balance of power structures and it is unique for each workplace, as some individuals want a fluid relationship with the manager and others want a clear hierarchy. The findings in this study indicate that raised awareness and role expectations through dialogues may be a way to develop workplace health promotion. A suggestion is to use series of dialogues at workplace meetings. Based on our findings, concrete dialogue questions that can be linked to the manager not being part of the group (asymmetric relationships) are: In what way do you want to see that I as a manager, can support you for doing a good job? Give examples of when you experience this as promotive and positive for you. What can I do to bring more of this? Examples of dialogue questions to rise about the manager being part of the group (symmetric relationships) are: When do you feel that we together have a positive atmosphere in the working group? What expectations do you have on me as being both your manager and part of the group? How can we together create such situations more often? Hopefully such dialogues lead to concrete examples of asymmetric and symmetric relationships and how to develop them further in the work group and as a manager.
A further vital aspect needed in order to develop workplace health promotion refers to relationships that enhance belonging and generate a positive work climate. Efforts to improve relationships may have a positive influence on well-being at work and, ultimately, well-being among healthcare recipients. As a next step in research, it is suggested that future studies investigate the distribution of the findings of this study using quantitative methods. Another suggestion is to conduct an intervention study in order to allow participants to discuss relationships at work and how the participants' suggestions could be inplemented.