School health care and multiprofessional collaboration in compulsory school – teaching staff’s perceptions

Abstract The school environment offers a unique platform for health promotion work with children and young people. Increasingly multifaceted health problems among children and young people and their families require investments in multiprofessional collaboration in schools. The aim of this study was to investigate teaching staff’s perceptions of the school nurse’s role in compulsory school and explore multiprofessional collaboration between school health care and teaching staff. Semi-structured interviews were conducted with teaching staff from Finland-Swedish compulsory schools in Finland and qualitative content analysis was used as method. Three main categories and eleven subcategories were found, describing the teaching staff’s views on the role of school health nurses in schools, factors that hinder and promote multiprofessional collaboration, and development proposals for collaboration. The complexity of multiprofessional collaboration in a school context is highlighted. Improved collaboration is important for increasing the chances of finding and helping students and their families early on.


Introduction
According to Articles 24 and 28 of the UN Convention on the Rights of the Child, all children, and young people under the age of 18 have the right to the best possible health, to health care and education (United Nations, 1989).This means that during their childhood all children and young people must receive education and support in achieving the best possible health.Schools can thus serve as a platform where children and young people can be comprehensively reached and offered the services needed for positive growth and development.Studies in the Nordic countries have shown that investments in the school environment are needed for children and youth to experience a good level of justice and well-being (Simonsen et al., 2016), and pupils in Finland believe more investment is needed in the promotion of, among other things, school well-being, physical and mental health, and social well-being (Summanen et al., 2018).
In the Nordic countries, efforts have been made to promote health and lower the threshold for children and young people and their families to seek help, by offering various support functions in schools called student health or student welfare, including school health care.School health care is offered in schools around the world, but varies greatly, from merely clinical care measures to more preventive and health promoting measures.School health care in Finland is a free, statutory part of primary health care, where the main focus is health promotion (Ministry of Social Affairs and Health, 2004;THL, 2021b;THL, 2021c).The task of the school health nurse in Finnish student health work is health promotion, primarily on an individual level.The basic idea of Finnish school health care is to find and identify students and families in need of help or special support as early as possible through annual health examinations and to be able to support them and, if necessary, to refer them further.School health care also works generally for the well-being of the entire school and is part of the school's cross-sectoral student health care (Finlex, 2010: Health Care Act 30.12.2010/1326 ch. 2, section 16; Finlex, 2011: Government Decree on maternity and child health clinic services, school and student health services and preventive oral health services for children and youth 6.4.2011/338;Finlex, 2013: Student Welfare Act 1287/2013;Ministry of Social Affairs and Health 2004;THL, 2021b).Research highlights the importance of school health care being arranged in school during the school day so that it is easily accessible to students and school staff (Granrud, Theander, et al., 2019;Reuterswärd & Hylander, 2017;Ministry of Social Affairs and Health;2004), and studies also emphasize collaboration across professional boundaries, where school health care, teaching staff and various collaboration groups must collaborate multiprofessionally for students' well-being in school in order to achieve successful results (Granrud, Theander, et al., 2019;McIntosh et al., 2021;Ministry of Social Affairs and Health;2004).Only limited studies exist (Barnes et al., 2004, Mäenpää, 2008;Maughan & Adams, 2011;McIntosh et al., 2021;Winland & Shannon, 2004) on how school health care is experienced in schools and on what collaboration with school health care looks like and how it works based on the perceptions of teaching staff in particular, which justifies this study.
Collaboration as a concept means that several people have a common task to perform with a common purpose (Kontio, 2013;Nationalencyklopedin, n.d.) and collaboration in school is described as a daily, evolving process of interaction between the school's various actors (Isoherranen, 2012;Kontio, 2013).Multiprofessional collaboration is a cross-cutting term that is often used in health care in Finland when describing cross-professional collaboration (Isoherranen, 2012).The concept refers to reaching a holistic understanding by combining different professional groups' working methods, information, and know-how (Kontio, 2013) and is concerned with that most professional groups work together towards a common goal within a certain context to find the best solutions (Green & Johnson, 2015).
Today, multifaceted health problems handled in health care are increasing causing different professions to become more dependent on each other to effectively succeed in bringing about changes in a person's health (D´amour et al., 2005;Isoherranen, 2012).According to the World Health Organization (WHO, 2010), multiprofessional collaboration can influence most of the global challenges in health care including collaboration and the use of knowledge from different professions to promote the health of families.Multiprofessional collaboration has also been recommended to promote health among young people with school difficulties (Granrud, Theander, et al., 2019) and it has great potential in health promotion in a school context, as the collaboration between different professional groups can provide a broader understanding of the health problems among students and strengthen the quality of care (McIntosh et al., 2021).Known routines and rules for multiprofessional collaboration and a culture that promotes this type of collaboration are important so that it can be applied in the best possible way (Granrud, Theander, et al., 2019).When several occupational groups are part of the collaboration, and all the professional groups involved work together towards a common goal, the versatile professional competence can promote collaboration (Granrud, Theander, et al., 2019).Multiprofessional collaboration does not work solely by creating groups for different areas of work but requires that members of the groups can trust each other before collaborative processes can begin.The interaction and dynamics between the people in the group are important for the collaboration to be seen as a humane process (D´amour et al., 2005).
In order to better understand multiprofessional collaboration, knowledge is needed of how teaching staff view the role of school health care.Studies highlight that an ambiguity exists between school health nurses' and teachers' views on the role of school health care (Maughan, 2003).Teachers reported that their school health nurses cared well for the health-related needs of students, such as chronic illnesses, acute care-intensive situations, and traditional health care tasks (Biag et al., 2015;Maughan & Adams, 2011).They also appreciated the medical training that school health nurses offered and highlight the positive contact between the school health nurse and the students' families (Biag et al., 2015).For some, however, it was unclear what the actual role of the school health nurse is at the school and to what extent individual health education is provided by the school health nurse at the individual clinic (Maughan & Adams, 2011;Reuterswärd & Hylander, 2017;Winland and Shannon (2004).Thus, the school health care provider's healthpromoting role is partly shrouded in obscurity.The school health nurses themselves saw their role as broad, with a focus on health promotion work both individually and collectively in the school environment (Reuterswärd & Hylander, 2017;Winland & Shannon, 2004).They felt that, in addition to other professions in the school system, their own task was to maintain the health and safety of the students and thus keep them in school and help them with any health obstacles and to achieve the goals in education (Reuterswärd & Hylander, 2017).Consequently, the research shows that teachers' views and school health nurses' own views on the duties of school health nurses vary greatly (Maughan & Adams, 2011).Studies show that the school health nurse offers an important support function, especially for vulnerable students; since school health care is available at the school, these students have a chance to receive early support in their health-related problems and can be able to reduce their absence statistics and cope better with school (Biag et al., 2015;Maughan, 2003).However, the most common form of support was provided on an individual level, for example, through health audits, despite also taking place on other levels (Reuterswärd & Hylander, 2017;THL, 2021b).
For school health nurses, it was important to create a sense of security for the students, a safe place where the students and their parents could discuss everyday matters.Accessibility was important in creating this safe place and also promoted school-specific collaboration-the more often different professional groups were present at the same time in the school, the more collaboration there was.Collaboration developed in a positive direction when the school health nurse was perceived as accessible and included them in the collaboration (Hjälmhult et al., 2002;Reuterswärd & Hylander, 2017).When the availability of student welfare services was perceived as sufficient, teachers found that collaboration with school health care achieved good quality (Ekornes, 2015), while poor access to the school health nurse's services was described as problematic by teachers.Many of the school health nurses have multiple schools on their shoulders resulting in limited resources per school (Winland & Shannon, 2004).As the school nurse was not always on site and hence not available for such engagements as expert group meetings or student welfare meetings, the collaboration suffered (Borg & Drange, 2019, Hjälmhult et al., 2002;Reuterswärd & Hylander, 2017).From the school health nurse's point of view, the collaboration with student welfare services was considered to be comprehensible, manageable and meaningful if both the role of the school health nurse and the group's meeting agenda were clear and other professional groups were also available at the school.Cross-sectoral collaboration was made more difficult if the partners did not have offices in the school building (Reuterswärd & Hylander, 2017) and came to a complete standstill if the school nurse was not available, which could happen if collaboration sessions or meetings were held on such days when the school nurse was not present at the school (Hjälmhult et al., 2002).The possibility of informal contact, for example over lunch or conversations in the corridor, was also considered relevant because it lays the foundation for good collaboration in formal contexts.Informal contacts require that the professional groups are regularly physically present in the same place (Granrud, Theander, et al., 2019).Research shows the importance of public health nurses making themselves and their competence visible, being proactive and not passively waiting for contact, in order to enable cross-professional collaboration (Paavilainen et al., 2000).School health nurses highlighted that beginning a functioning collaboration depends on all parties (Reuterswärd & Hylander, 2017).Visibility was also facilitated if the school health nurse was physically present at the school (Dahlen Granrud, Anderzén-Carlsson, et al., 2019;Maughan & Adams, 2011).Teachers have great respect and appreciation for the work that the school health nurse does, but satisfaction was directly linked to how much the school health nurse was on site.The teachers reported that they were able to focus more on learning and that the students' learning and learning environments were positively affected when school health care was active at the school on a daily basis (Biag et al., 2015).
In health promotion work, face-to-face meetings are needed for the collaboration to work (J.Corbin & Mittlemark, 2008).School staff felt that the school health nurses were less involved in the work with the students if they did not participate in the collaboration sessions that were arranged, but with improved resources, the school health nurse had increased opportunities to participate in the classroom or in student welfare meetings, which was requested by the school staff.The school health nurses themselves felt that there is a need for more school health nurses in schools because the problem areas among the students have increased in society (Maughan & Adams, 2011).For the school health nurse to be able to carry out successful health promotion work, the organization needs to understand what is required in health promotion work and of the school health nurse's role in the organization.If the role of the school health nurse is unclear to the rest of the organization, the health promotion work deteriorates (Reuterswärd & Lagerström, 2009;Winland & Shannon, 2004).To ensure and promote good multiprofessional collaboration it is important that the different professional groups know the rights and obligations of each other (Granrud, Theander, et al., 2019).
The school nurse needs to be professional and understand the school's culture and teaching culture to be seen as a valuable member of the team.The school health nurse has a unique role and is preferably in contact with the same students for a long period of time.In this way, the school health nurse, the school staff and the students and their families can build a long-term relationship (Maughan & Adams, 2011).Thus, continuity also becomes an important factor, as large or frequent changes in health care personnel make collaboration more difficult (Granrud, Anderzén-Carlsson, et al., 2019) because the school health care may not have time to become acquainted with the school environment, the teachers' college, or the students' families.The teachers felt that they did not have enough support regarding health-related concerns and wished that the school health nurse was available more often at school (Biag et al., 2015).The lack of substitutes in school health care was also highlighted as a negative factor, as sick leave without substitute help could have a negative impact on the availability of school health care and thus on collaboration (Hjälmhult et al., 2002).Lack of time emerges as an obstacle to collaboration in most studies.Lack of time was one of the main reasons why the school health nurse does not arrange health-promoting group activities in school (Reuterswärd & Lagerström, 2009) and may be owing to, for example, too large a workload, limited resources, and a lack of staff in the teaching profession and other professional groups (Ekornes, 2015).Continuous communication between professional groups is needed in health promotion collaboration (J.Corbin & Mittlemark, 2008) in order to be able to offer the necessary support students needed to complete their schooling.Lack of communication occurred more easily if the school nurse was not present daily.The teachers pointed out that there is a need for improved communication between the school health service and the teachers' college (Biag et al., 2015).
Previous research indicates that information sharing between professional groups is an important part of cross-professional collaboration, but because it is partly governed by laws and regulations, for instance regarding confidentiality, it can also make such collaboration more difficult (Borg & Drange, 2019;Granrud, Anderzén-Carlsson, et al., 2019;Ekornes, 2015).School health nurses are subject to a different level of confidentiality than others within the school community, which affects their ability to talk freely about cases without the consent of the students and their guardians (Barnes et al., 2004).The obligations and rules of different professions thus affect multiprofessional collaboration.The teachers often felt that they gave the other party in the collaboration information about students, but rarely received any information back.This meant that the teachers felt that they had reduced opportunities to follow up on the students' well-being (Ekornes, 2015).An opportunity is opened for the professional groups to be able to work together without the confidentiality hindering the treatment of cases when parents and students give their consent for the cases to be handled multiprofessionally in school (Reuterswärd & Hylander, 2017;THL, 2021d), and it appears that the parents rarely objected to the student's case being handled multiprofessionally (Granrud, Anderzén-Carlsson, et al., 2019).
Public health nurses in the school context need collaboration with other professions in the school system (Granrud, Anderzén-Carlsson, et al., 2019) in order to be able to offer health care services in schools in an efficient way (Winland & Shannon, 2004).Several positive factors of collaboration with other professions were described, including expanded understanding of the student's needs and early identification of students with support needs.The collaboration with the student welfare group was also seen as something positive thanks to the opportunity to obtain different perspectives on the student's difficulties and thus be able to find different solutions.However, the school health nurse had difficulty integrating into the college and becoming part of the school's staff (Borg & Drange, 2019).The public health nurses considered teachers to be their most important partner, but teachers have the power to choose whether or not to cooperate with the public health nurse, who has only a marginal opportunity to influence collaboration with other professions and depends on teachers and principals for good collaboration (Granrud, Anderzén-Carlsson et al., 2019;Reuterswärd & Hylander, 2017).This may be one reason why the public health nurse is not always included in the multiprofessional collaboration.The school health nurses saw the importance of the teacher's role in the collaboration, as the teacher meets the child more continuously in school, which allows for a greater chance of identifying and following up on any problems.Since the teachers possess this knowledge of the students, it is of the utmost importance that the collaboration between the school health care and the teachers' college is well-functioning (Paavilainen et al., 2000).
The literature also highlights leadership within school, primarily the principal's role, in relation to multiprofessional collaboration.The principal has an important part to play in supporting the school's staff to succeed with multiprofessional collaboration (Ekornes, 2015).It is relevant that the school's management and principal view health promotion positively and consider the work of the student welfare team to be important (Reuterswärd & Hylander, 2017;Reuterswärd & Lagerström, 2009).For example, principals have the opportunity to influence which actors are part of the multiprofessional team in the school (Granrud, Anderzén-Carlsson, et al., 2019), in Finland called a student health group (Finlex, 2013: Student Welfare Act 1287/ 201 Chapter 3, Section 2, Section 14).The school principal also has the power to involve the school health nurse in general school problems, which gives meaning to the school health nurse's work.By having a good relationship with the principal, the school health nurse will be consulted to a greater extent on various issues (Maughan & Adams, 2011).School leaders need to ensure that there are clear guidelines for collaboration and regular meetings between teachers and professionals in areas such as mental health (Reuterswärd & Hylander, 2017) including school health care.It is also critical to ensure that existing resources are used in an informed way, as a lack of resources in schools and health care is a fact (Ekornes, 2015).Committed and clear leadership is a prerequisite for successful multiprofessional collaboration (Borg & Drange, 2019).
The present study uses Healthy Alliances (HALL) (Koelen et al., 2012) and Antonovsky's theory of salutogenesis and sense of coherence (SOC) (Antonovsky, 1996(Antonovsky, , 2005) ) as the theoretical framework against which the findings will be reflected in the discussion.The theory about SOC, containing the concepts comprehensibility, manageability, and meaningfulness (Antonovsky, 1996(Antonovsky, , 2005) ) is used in forming a broader understanding of the underlying aspects of the collaboration and health promoting work in schools.Healthy Alliances Framework in turn describes essential factors to the multiprofessional collaboration in healthcare and divide these factors into categories, all important in understanding how alliances work (Koelen et al., 2012), which was relevant when exploring the factors for multiprofessional collaboration between teaching staff and school nurses.

Current study
The aim of this study is to investigate the teaching staff's perceptions of the role of the school nurse in compulsory schools and to explore the multiprofessional collaboration between school health care and teaching staff.Two key objectives steered our work, expressed here in the form of research questions: (1) What are the teaching staff's views on the role of school health nurses and school health services in compulsory schools?
(2) How do teaching staff experience multiprofessional collaboration between school health care and teachers and other staff within the compulsory school context, and how could this collaboration be developed for the benefit of the students' well-being?

Setting, sampling and recruitment
The participants were selected from Finland-Swedish compulsory schools in Finland.They were contacted through the principals of the selected schools and also personally through e-mail.The participants received oral and written information about the study in advance.The selection was determined by a combination of strategic selection and self-selection.The participants included in the study belonged to the school's teaching staff and include teachers, principals, special needs teachers and resource educators who work closely with the pupils in compulsory schools in Finland.These occupational groups were included because their experiences of collaboration with school health care were considered relevant for the purpose of the study.A total of 10 participants (two men and eight women) participated and their professional time in the school world ranged from one year up to more than 25 years.Information about the participants can be seen in Table 1.The schools where the participants worked had school health nurses on site from at least three weekdays per week to every weekday per week.

Data collection and data analysis
The interviews were semi-structured and followed an elaborate interview guide but also allowed room for follow-up questions and free discussions, depending on the informant's initiative.The interviews were conducted online due to the COVID-19 pandemic and lasted between 26 minutes up to 55 minutes; average 38,75 min per interview.All data was transcribed by the first author.The data collected through the interviews was analyzed through qualitative content analysis according to Lundman andGraneheim (2017, 2004).The material was condensed, and the meaning units were coded and categorized to find similarities.From the dataset, three main categories and eleven subcategories was obtained through the analysis.For an example of the conducted data analysis see Table 2.

Ethical considerations
The study was conducted in accordance with the instructions by the Finnish National Advisory Board on Research Ethics TENK (2023) concerning ethical scientific practice.Written and oral information regarding the study were given to the participants who gave their informed consent.Ethical approval was also granted from an ethical committee at the university where the researchers were situated.

Findings
The main categories obtained through the qualitative content analysis were a total of three in number: Individual-related factors, Interpersonal factors, and Organizational factors.Eleven subcategories were also found.The results are presented below according to the main categories and subcategories.Finally, suggested development needs are presented and related to the main categories (See Table 3).
The first main category displayed that some of the factors for collaboration, and the school health nurse's role in school, were related to the person as an individual.The individual-related factors were described through the subcategories of 1 Holistically caring for school students on an individual and general level, 2 Being a visible and easily accessible low-threshold contact in the school environment, and 3 Profession tied to the person.

Holistically caring for school students on an individual and general level
Several of the participants described the school health nurse as a person who looks after the students' best interests in a holistic way and cares about the students' well-being and development.
Everything that makes the student feel good belongs to the school health care, so food, sleep, there are injuries, it is everything that is kind of the basis for the student to feel good, that is what I think of when I hear the word school health care.(P6-Holistic approach) The participants also had to give an account of their views on whether the school nurse has any specific role in school, and many of the participants then mentioned the physical part, injuries, emergency situations or first aid as the school health care's main field of work.As the discussion continued, however, it emerged that the school health nurse cares for the students in more ways than just taking care of physical ailments.The participants detailed everything from health reviews and class activities to the school health nurse participating together with teaching staff in student welfare and in student-specific, multiprofessional student welfare meetings.In these forums collaboration between school health care and teaching staff precisely takes place.
The school health nurse plays a pretty important role in catching up with these students precisely because she meets with all the students during these grade-wise reviews.She meets all the students and has time to talk to them and handle that discussion, so she has a pretty good overview of how our students are doing and what their everyday lives really look like.(P6-Role of the nurse)

Being a visible and easily accessible low-threshold contact in the school environment
The participants frequently highlighted the words visible and visibility when discussing promoting factors in the multiprofessional collaboration with school health care.Even when the participants described the qualities that were considered important in a school health nurse, they emphasized that they see it as positive that the school nurse is visible in the school because they noticed that such visibility facilitated collaboration.As one informant described it: I always invite them for coffee, every day they are here, they have to be in through the teachers' room.They can't just sit there, in the closet, but they have to come out of there at some point during the day, meet teachers, that they've seen and be seen in the hallways so that we know they're part of this.Otherwise, they disappear into some kind of anonymity. (P5-Visibility) Lack of visibility was considered to negatively affect collaboration as it was perceived as more difficult to connect, while according to the participants, visibility was clearly promoted by the school nurse being physically present at the school, and participating in various events, being together with students and teaching staff during the breaks and on hand in the teachers' room at regular intervals.The participants highlighted as a factor for a well-functioning collaboration, the importance of the easy accessibility of school health care in the school environment, both for students and for teaching staff.Ease of access is closely linked to the low threshold that the participants highlighted as an important factor in the multiprofessional collaboration, and which was also considered essential for the role of the school health nurse.Many of the participants experienced that the school health nurse should preferably be centrally located in a school and not completely separated from the school building, because that would raise the low threshold that they felt the school health care represents.Some of the participants indicated that the threshold for school health care is lower than for other student health actors.

Profession tied to the person
"The work of the school nurse is very firm on how good the school nurse is.There's a difference!"(P5-Tied to the person).Personal chemistry, trust, skills and interest in collaboration were considered to play a part in the proper functioning of collaboration between teaching staff and school health services.The participants related that the role of the school health nurse and the collaboration with the school health care was dependent on how the school nurse is as a person.The participants highlighted this as either negative or positive depending on the characteristics of the school health nurse.The interviews showed that personal collaboration skills or qualities and interest in collaboration could affect how the teaching staff perceived collaboration with school health care.
The participants related that the school health nurse and teaching staff need to have certain qualities and skills, commitment, and a personal interest in collaboration for a multiprofessional collaboration to work optimally in the school environment.Qualities that were considered important for both professional groups were having confidence in one another's professional skills and in each other as persons.Trust was described as necessary for fruitful collaboration, as the employees possess different skills and need to enlist each other's help in multifaceted student problems.
Although the participants described the importance of personal skills for collaboration, most of them thought that the school health nurses with whom they cooperated do have the collaborative qualities in question.

Interpersonal factors
The second main category showed that most of the factors that influenced the collaboration include components that are important in the contact between people and professions in the school environment.The subcategories that describe interpersonal factors are: 4 Meaningful partner and safe counselor to lean on in student welfare issues, 5 Investment in common values, Safe atmosphere and collegial community, 6 Unhindered and fast communication between professional groups and 7 Lack of continuity causes problems in relationship building.

Meaningful partner and safe counselor to lean on in student welfare issues
The participants described the school health nurse as a safe person at school, a person they considered professional and someone with whom they could consult on various student welfare issues; Turning to a public health nurse somehow feels safe.' (P1-Safety).The teaching staff perceived the school health nurse as a person they can ask for help and discuss their thoughts with regarding various student matters.The school health nurse was involved in various forms of student matters, both for emergency and preventive purposes and was considered a valuable asset in the collaboration around the students.The participants believed that the school health nurse is included as part of the student welfare group or student welfare team that supports, helps and, together with the teacher, thinks about what paths to take to move forward in the student case.
In several interviews, the school health nurse's network was highlighted as an important function in collaboration.Contact with other student health actors, school doctors, social workers, parents and other actors was mentioned as crucial.The school nurse was described as the spider in the network who can coordinate collaboration between different actors.This can be related to the fact that the school health nurse played a meaningful role when it came to the referral of various student matters that the teaching staff encountered in their school day.Since the school nurse has contact with the school doctor, and can also refer the students to different bodies, the teaching staff considered it important to cooperate with the school health care to get the student on to the help or care needed.

Investment in common values, safe atmosphere, and collegial community
The atmosphere and shared values were described by the teaching staff as two important pieces of the puzzle when it comes to creating well-functioning multiprofessional collaboration with the school health care.According to the participants, the school's culture affects the collaboration.By creating a safe atmosphere in the college, where the staff can be themselves, the participants felt that it is easier to cooperate with each other: "If you're allowed to be yourself, I think you let others be themselves too, you accept each other, and then it's easier to cooperate."(P7-Safe atmosphere) The creation and maintenance of a common set of values in schools was highlighted as a relevant factor in the collaboration.The child and the family need to be put at the center, everyone is pulling in the same direction and cares about the students.By having the opportunity to connect with each other, create participation and do other things together than just deal with student matters, a collegial community is created that many of the participants considered a cornerstone of successful multiprofessional activity.According to the participants natural interaction such as eating together and inviting the school health care to various events that the school organizes for the staff outside school hours were examples of how the community can be positively affected.
And then I think that, just such a thing, because you work in middle school, and everyone might not eat in the canteen, but we're a couple who eat in the teachers' room.Because the school nurse also eats with us, so I don't know, sometimes it feels like you have a little closer collaboration just because you sit and eat together as well, it's like more than just those student cases.(P6-Collegial community)

Unhindered and fast communication between professional groups
Communication between the professional groups also emerged as a decisive factor in multiprofessional collaboration.According to the participants, communication should be quick and unhindered so that the work for the students can begin immediately.According to the participants, the communication takes place on different levels and in both directions: "There is still that give and take or, or to get information but also to provide information, mutual collaboration."(P9-Mutual communication) However, it was highlighted that the school nurse less often made spontaneous contact with the teaching staff-it was more often the participants who turned to the school nurse in matters that concerned students.The participants felt that it was important for the school health service to inform about various things related to their work, for example, before health audits, if the nurse is away from school or in other health-related situations that affect students and teachers.Several participants highlighted as the beneficial route for communication and information sharing direct communication with the school health nurse, meeting and talking faceto-face.Most participants felt that it was easy to get in touch with school health care.

Lack of continuity causes problems in relationship building
Difficulties in becoming acquainted with the school nurse and creating a relationship with them were described by the participants as hindering factors for collaboration.The participants highlighted the lack of continuity in school health care as contributing factors for them not getting to know the school nurse and thus experiencing impaired collaboration.Continuity was considered a main factor in creating a relationship with school health care, and in developing collaboration and student welfare work in a school.When the different professionals know each other, it is easier to find a common form of collaboration.The participants related that it takes time to become acquainted with another person and know how they think and what they mean, which proves the importance of continuity in collaboration.
And we notice that then the work has developed, as this person has been here for five years now. . .During that time, there was actually some clear development of school health care and development of school collaboration in a completely different way than it used to be.That this continuity is so important.If the school is also active in student welfare and school health issues, then it generates something.(P5-Continuity) Since community and a safe atmosphere were considered important interpersonal factors for effective collaboration, the creation of a work community or its improvement also emerged as a development proposal.The participants also believed that it is important that the community has inspired employees in order for the student welfare work to run smoother.
You get to the last quality work with school health care, that content that's like mortar between those bricks, I usually say, so then this is what's in the air and that's where you can, that's where you build it up and build together.Everyone has their bricks, everybody, all the schools and all the school health nurses, but it's how you put them together that does what it becomes, that whole.(P5-Creating a community)

Organizational factors
The third main category consists of the subcategories 8 Collective investment in collaboration and students' well-being through clear management and structure, 9 Lack of sufficient resources and common time for collaboration, 10 Confidentiality and 11 Unclear process, work picture and division of responsibilities in the collaboration.Most organizational factors were negative for collaboration, which the participants highlighted as hindering factors in collaboration with school health care.Within this main category, however, there were also the most development proposals.

Collective investment in collaboration and students' well-being through clear management and structure
The participants saw the principal's position in the promotion and maintenance of student health and collaboration as significant for the collaboration.The principal's approach to and the management's views on health and well-being as well as multiprofessional collaboration were crucial for the school to invest in these and to actively work together for students' well-being in the school day.I'm absolutely convinced that we probably have a principal and a management that is very concerned about student health and well-being, and I do think we have in our school quite a bit of, like a low threshold.Partly to deal with problems, but also like. . . the students' wellbeing is a high priority, and you notice that this permeates everything (P4-Collective investment in student well-being) The management's view was considered to affect the possibility of investing in collaboration.Obtaining permission from one's own management to set aside time for collaboration, and including collaboration in the job description, was critical to beginning a functioning collaboration.The participants also believed that a clear structure around student welfare work played a part when it came to collaboration and student health.According to the participants, student welfare work needs to be developed regularly.The schools included in the study had a multiprofessional student welfare group and their meetings were scheduled and held regularly, ranging from once a month to every week or every two weeks, depending on the size and processes of the school.

Lack of sufficient resources and common time for collaboration
Lack of joint time was described by several of the participants as a contributing factor to impaired collaboration with school health care.One of the participants underscored that it is difficult to keep up with everything that needs to be included in the tasks, both for teaching staff and school health care.Another informant highlighted the large number of students per class director or school health nurse as a contributing factor to not having time to deal with the students' problems to a sufficient extent.Time constraints thus apply to both the school health nurse and the teachers themselves in their work role.The lack of joint time contributed to that there is not enough space for the natural coexistence, which was presented above as an important factor for collaboration.
Well maybe it was that before there was somehow more time, I remember that then the public health nurse could also come and drink coffee on our coffee break. . .Time is probably in short supply for just this kind of thing, you know, face-to-face discussions and stuff like that. . .(P1-Lack of time) Insufficient human resources and a lack of substitutes in school health care were also described as hindering factors in the collaboration.For example, several of the participants explained that during the COVID-19 pandemic they periodically had to do without school health nurses at school as they were involved in other tasks outside the school's activities.
Well, we were completely without school health nurses here last month, for example when they were called for vaccination, corona vaccination, that's not good, we can probably say, so it was a big minus.But it wasn't the school health nurse's fault, there were other factors.(P4-Lack of resources) The participants highlighted that they want more time and resources for collaboration with school health care as the biggest development proposal.They wanted the school health care to be physically present all weekdays and that they would thus have had time to work more preventively together, which would be beneficial for the students.
Yes, I believe it would be so nice if there were more health workers, then the resources would be even greater.Surely, it would be wonderful if she were here Monday through Friday with us, you know, then that would be a completely different thing.She would be able to move around in school in a different way and she could, or he, be here in the teachers' room so that, more resources.(P1-Need for increased resources)

Confidentiality
The duty of confidentiality arose in the majority of interviews as a negative factor when it comes to collaboration.Both teaching staff and school health care are subject to professional secrecy in student welfare matters.The occupational groups are located under different organizational ceilings and are partly subject to different laws that, according to the participants, negatively affected the collaboration.The participants related that they can discuss cases freely with their professional colleagues, while the students' or parents' consent is needed if they want to consult the school health service on any matter.
We have a duty of confidentiality, and that's the way it is.We don't automatically get to tell each other what we know, even though you might sometimes need to know a little.The school health nurse can know certain things that might be good for us to know when working with the student.But there is also that to ask, "Can I talk to the teacher or the teachers?"and in some cases it may have been no and then we have not been told more than necessary for the collaboration, so it can affect it.(P9-Confidentiality) By obtaining the consent of the student or parents to handle the student's case together with the school health care, teaching staff were able to cooperate with the school health care despite the duty of confidentiality.Nameless, anonymous consultations were used by teaching staff in contact with the school health nurse in case consent was lacking.Such anonymous consultations were used to brainstorm or exchange ideas without breaking the duty of confidentiality.These were, however, perceived as less valuable than non-anonymous consultations.

Unclear process, work picture and division of responsibilities in the collaboration
Many of the participants felt that the school nurse's work picture was unclear.They did not know what the school health nurse's duties include and when and in what cases to turn to the school health service: "Oh huh difficult question really, it's clear that they [by implication the school health care] fulfill a function, they probably do for sure but I honestly have a pretty poor grasp of what they really do." (P10-Unclear work picture) The participants note that this had a negative impact on collaboration.Several of the participants also experienced that the division of responsibilities or roles between the different actors in the collaboration sometimes was unclear.The participants were asked if they feel that there is a need for practice around collaboration in the form of guidelines or directives that support them in their professional role when it comes to collaboration with school health care.Some of the participants knew that there is some form of guidelines, while others were unsure if guidelines for multiprofessional collaboration exist in their organization.However, the majority of participants felt that guidelines for collaboration with school health care would be important, especially when new colleagues arrive at the workplace.
A major organizational development proposal that was requested was a conscious change to clarify practices around collaboration and the division of roles, as well as to create guidelines or directives for collaboration.Requests that were expressed were that the teaching staff would be able to sit down together with the school health care and talk, have time to discuss the class situations so that everyone is aware of what is going on and the school health care would be more active in class activities and at various staff meetings.The proposals require more resources both for teaching staff and for school health care, but the participants felt that the proposals would be valuable for collaboration.
It would be great, we've probably talked a little bit about it too with her, if she would have time to come also to staff meetings and teacher meetings and tell us perhaps the latest news, about let's say . . .cardiopulmonary resuscitation or epilepsy or diabetes, you know, things that increase too.(P1-Development of health promotion activities) Written directives for collaboration with school health care and other student health services were considered by the participants to play an important role in the development of collaboration, especially for new colleagues and people who are not as familiar with the work of student welfare.The participants also wanted more information about the school nurse's work picture.By clarifying the work picture and the work role at the beginning of the autumn term, the staff receives information about the student matters they can turn to the school health care, and written directives help the staff to cooperate during the school year.
It would be nice if there would also be something in writing, but that the writing would somehow still also appear orally at the beginning of each academic year.That would probably be useful.It is clear that sometimes you do not have any problems at all in a class, so it is clear that for some it is completely unnecessary that information.It might be optional to come and find out just like that info about them, but I still think it could be offered.It is like a security for yourself that you know how to handle it and know your own role and what is expected of you, that you also do not do too much or too little (P10-Clarification of roles)

Discussion
The teaching staff sees the role of the school nurse as multifaceted and meaningful in the collaboration.The participants emphasized that collaboration with the school health service is essential and needed for the promotion of student well-being.Especially when students have concerns or problems, the collaboration needs to work without obstacles.However, there are factors that facilitate or hinder collaboration.The collaboration also needs to be constantly developed and several concrete ideas emerged in the results of this study.

Characteristics linked to collaboration
Important characteristics described by the participants as important in the role of the school health nurse are strongly linked to the factors that they believe influence multiprofessional collaboration in a positive direction.At best, the school health nurse is a meaningful, visible and easily accessible lowthreshold contact, who is in place at school and acts as a safe partner-a person who cares about the students' health in a holistic way and is on hand when the school's staff needs a sounding board for student welfare issues.The availability of professional staff in schools increases communication and collaboration (Biag et al., 2015;Reuterswärd & Hylander, 2017).The participants stressed that they prefer to physically meet the school health nurse in student welfare matters because this improves collaboration.The teaching staff's understanding of the school health care provider's health-promoting role at the school, together with personal characteristics, influences how well the collaboration works between the professional groups, which is supported by the previous research conducted in the field (Maughan, 2003;Maughan & Adams, 2011;Reuterswärd & Hylander, 2017;Winland and Shannon (2004).Lack of trust was the personal quality the participants highlighted as affecting collaboration most negatively.Trust emerges, according to Koelen et al. (2012), as an interpersonal factor that affects collaboration either positively or negatively.The interpersonal relationship in collaboration needs to be based on trust (J.H. Corbin et al., 2018) and respect.If the partners do not trust each other, the desire to cooperate decreases.Together with the lack of resources and time, the obligation of confidentiality as an obstacle to collaboration was highlighted the largest number of times.

Resources and regulations impact the collaboration
Time constraints and shortage of resources are persistent phenomena in the health care and education sectors, where recurring savings requirements have a direct impact on preventive work.This has been particularly evident during the COVID-19 pandemic (Kestilä et al., 2021).The lack of resources (Ekornes, 2015;Maughan & Adams, 2011;Reuterswärd & Lagerström, 2009) and problems related to professional secrecy (Barnes et al., 2004;Borg & Drange, 2019;Granrud, Anderzén-Carlsson, et al., 2019;Granrud, Theander, et al., 2019;Ekornes, 2015;Reuterswärd & Hylander, 2017) also appear in previous research in the field.However, the participants pointed out that the obstacle posed by the duty of confidentiality could be addressed by asking for the consent of parents or students to handle the student case.This shows the importance of staff having a routine for requesting consent for case management in school.However, procedures for this were not expressed by the participants as a direct development need.The parties must be willing to invest in the collaboration in order to succeed (Koelen et al., 2012) and the participants stated that lack of interest and commitment negatively affected collaboration.Since student welfare work in Finland is governed by Finnish law, schools are obliged to carry out student welfare work as part of their activities (Student Welfare Act 1287/2013), which includes collaboration with actors such as school health care.Despite this, unless student welfare work and collaboration are seen as meaningful, and if resources are lacking for collaboration, a sense of coherence will not appear.This, in turn, means that people do not see the importance of investing energy and commitment in these tasks (Antonovsky, 2005).
The constant lack of resources and non-functioning collaboration in prevention predisposes to a risk of what Antonovsky (2005) calls overload, which is a direct threat to manageability and thus also to the sense of coherence.Other obstacles to collaboration were an unclear process and division of roles in the collaboration and difficulties in becoming acquainted with the school nurse when continuity is lacking.The reality that the professional groups know each other's rights and obligations (Granrud, Theander, et al., 2019) is supported by the findings of this study.The less experienced participants wanted a clearer division of roles in collaboration, while the participants with over 10 years of professional experience thought that the division of roles was quite clear.Through a clear division of roles, that is, clarification of what is expected of which professional group in the collaboration the collaboration can be made more understandable to all parties, which is consistent with Antonovsky's theory of SOC (Antonovsky, 2005).The division of roles is thus an important factor for the staff''s sense of coherence and for promoting well-functioning collaboration.Antonovsky (2005) and Koelen et al. (2012) also highlight social relationships as essential for a sense of coherence, manageability and multiprofessional collaboration.Other promoting factors for collaboration are investing in the community and atmosphere of the staff and the school, as well as designing a common set of values.

Meaningful collaboration and health promotion needs leadership, shared values and goals
The participants saw development needs in promoting the community in the school as influencing the collaboration more positively.Work based on a common set of values and towards a common goal is emphasized within the HALL framework (Koelen et al., 2012) as an important factor that determines whether one is willing to invest time and energy in the alliance.It is directly crucial to making the work feel meaningful (Antonovsky, 2005).The participants argued that without continuity and time, it was difficult to form relationships with school health care and collaboration was negatively affected (Helleve et al., 2020), which can be interpreted as reducing the sense of manageability.This makes it challenging to find a sense of coherence, and consequently reduces the willingness to engage in collaboration (Antonovsky, 2005).Koelen et al. (2012) argue that collaboration or alliances need a shared attitude that it is possible to achieve more collectively than as individuals, which is also supported by the present study's findings.As the school's management and principal view health promotion positively and consider the work of the student welfare team to be important, collaboration between teaching staff and school health care is also promoted (Reuterswärd & Hylander, 2017;Reuterswärd & Lagerström, 2009).The participants believed that clear leadership sets the foundation for successful multiprofessional student welfare work.A good leader can communicate, understands all sides of the collaboration, and supports and encourages collaboration (Koelen et al., 2012).These qualities were also underscored by the participants as important qualities for the school principal.
Especially in crisis situations (Martinsson et al., 2021) and the time after the COVID-19 pandemic, the participants considered multiprofessional collaboration to be extra important.Preventive resources are often redeployed or neglected in the context of more acute crises (WHO, 2010).This has also happened with preventive work and school health care, especially in Finland during the COVID-19 pandemic (Kestilä et al., 2021), despite the fact that the pandemic has demonstrably negatively affected the well-being of children and young people in particular (Gotlib et al., 2022;Samij et al., 2022).Although a few participants believed that multiprofessional collaboration does not need to be developed, the authors believe that previous research and the study results highlight the need to support factors that enable multiprofessional collaboration with a focus on student health promotion.This gives the school nurse a natural key role in the collaboration.The actors engaged in the collaboration need to feel that student welfare work, and thus multiprofessional collaboration, is meaningful and creates a sense of coherence for them to be willing to become involved.The school's management, workplaces and society therefore need to ensure that preventive work and multiprofessional collaboration are valued and that these are allocated sufficient resources.

Strengths and limitations
This study confirmed several of the collaboration factors that emerged from previous research, supporting the validity of the present study, and the study findings could answer the research questions.Credibility is strengthened through illustrating the different categories with representative and appropriate quotations.The interviewer used an interview guide to remain close to the aim of the study, but also allowed the participants to discuss the theme more broadly to get hold of potential areas that could be important to include in the study, showing dependability to the study design.Only 10 informants participated; recruitment was difficult partly because of the ongoing COVID-19 pandemic.However, data saturation was achieved at 10 participants, so the researchers felt that there was no need to include more participants.Nevertheless, participants with different professional titles and work experience were included, representing various perspectives (Graneheim & Lundman, 2004) and the teaching staff as a whole, which can be mentioned as a strength in credibility, and as such the study yields rich data.However, since there were only 10 participants there is not enough data to claim potential disparities between the different professional groups included but this could be further explored in future studies.

Conclusion and suggestions
The present study highlights the importance and complexity of multiprofessional collaboration between school health care and teaching staff in promoting students' health and well-being in schools.The focus needs to be on minimizing factors hindering collaboration and investing in resources that promote collaboration facilitating factors.Continuous development of the collaboration is also needed and requested.Improved collaboration increases the chances of finding and helping children and young people and their families at an early stage and highlights the relevance of effective collaboration between the school health service and the school's staff to be able to support the students and their families.Multiprofessional collaboration and a joint investment in well-being in the school environment, led by the principal, provides opportunities to promote the holistic health of students and thus positively affecting their schooling.For suggestions regarding multiprofessional collaboration between school health nurses and teaching staff in school health promotion see Table 4.To increase the understanding of the role of school health care in multiprofessional collaboration, future studies should focus on school health nurses' own views and thoughts on collaboration with the school staff.

Suggestions for multiprofessional collaboration between school health nurses and teaching staff in school health promotion
The collaborative health-promotive work at schools starts with a joint investment in creating solidarity, a shared base of values and a shared aim Clarify the structure, praxis, roles, and expectations of the professional groups involved in the multiprofessional collaboration Invest time and resources in the development and maintaining of collaborative relationships between the different professionals in schools The leadership builds the foundation for a successful multiprofessional student care Collaboration with the school health nurse is necessary to promote the student's wellbeing holistically