School health promotion: a professional practice in an institutional context Open Access

This study explores school health promotion (HP) as an institutionally embedded professional practice. Institutions are “durable systems of established and embedded social rules that structure social interactions” (Hodgson, 2006, p. 13). Organizations are institutions that have sovereignty, membership rules and chains of command (Hodgson, 2006). In this sense, schools are organizations within the educational institution where value systems operate, often via some form of governance (Adolfsson and Alvunger, 2020; Greenwood et al., 2011). HP, “the process of enabling people to increase control over, and to improve their health” (Nutbeam and Muscat, 2021, p. 1580), is an instrumental school practice linked to students’ wellbeing and learning, as well as to school development (Iudici, 2015; Sandström, 2021).

The success and sustainability of school HP have been linked to its institutional setup which produces structures that can support or challenge the practice (Koh et al., 2023; Murphy et al., 2021). Three institutional elements can shape school HP: regulative, normative and cultural-cognitive. The regulative element relates to rule and policy compliance thus emphasizing legal legitimacy. The normative element is grounded in social obligation and prescribes the agreed upon means of pursuing ends. The cultural-cognitive element refers to actors’ cognitive processes (e.g. reasonings) which influence how they enact practice regulations (Scott, 2014).

Policies regulating school HP are often enacted in various ways across settings and actors (Simovska et al., 2016). This variety can arise from inter-actor differences in policy interpretation or from differences in school cultures, governance approaches or leadership styles which affect HP organization and professional performances (Adams et al., 2023; Bennett et al., 2016; Gherardi, 2019; Schatzki, 2015). Professionals working with school HP are active agents whose professions impose “normative and cognitive structures” that prompt certain actions (Palmer and Biggart, 2017, p. 263). However, in the course of practice, they also need to adjust to organizational cultures, collaborate with other professionals and accommodate student needs (Bennett et al., 2016). Thus, they often draw on relevant expertise and values to make contextualized sense (rational accounts of social contexts that support effective actions) of policies and perform discretionary actions (Blake, 2023; Lipsky, 2010; Maitlis, 2005). This sense-making can be influenced by the logics prevalent in a given institution (Schatzki, 2023).

Institutional logics (ILs) are the socio-historic practices, values, beliefs and assumptions by which individuals interpret and (re)produce social reality (Thornton and Ocasio, 1999). ILs provide frames of reference that co(shape) actors’ sense-making of societal constructs including policy directives and professional demands (Scott, 2014; Thornton et al., 2012). The co-existence of multiple potentially conflicting ILs (e.g. professional, market) in schools can give rise to institutional complexity (Ackesjö, 2022; Greenwood et al., 2011).

The relations between institutional complexity and organizational responses have been repeatedly explored in literature (Wu et al., 2023). However, less attention has been awarded to how professional practices are accomplished within this complexity (Schatzki, 2023). The multiplicity of ILs in schools can support some practices such as teaching (Gullberg and Svensson, 2020). However, it may be a challenge for the multidisciplinary school HP where diverse bodies of knowledge and value systems (e.g. medical, social) coexist (Elsayed et al., 2023).

In school HP, professionals can rigidly draw upon diverse ILs precipitating tensions or flexibly apply these logics to circumvent complexities (Blake, 2023; Ekornes, 2015). Drawing on various logics, professionals make practice-relevant choices. For example, they can choose to build up a collective awareness of daily tasks that promotes interprofessional collaboration (Sandström, 2021) or to simplify problem representations thus facilitating decision-making (Gherardi, 2019). These choices need to be analyzed as they may lead to unintended outcomes or become de facto policies (Lipsky, 2010). This type of analysis is particularly important in institutionally complex school systems, e.g. with multiple tiers of governance (Bradshaw and Toubiana, 2013). The Swedish school is one such system.

In Sweden, where there are 290 municipalities and over 4,000 schools, school HP is regulated via a national guide as well as municipal and school health plans thus creating a plethora of policy documents (SCB, n.d.; Skolverket, 2020b; Socialstyrelsen and Skolverket, 2017). The school system is rather decentralized. Schools are governed at a macro level (national curricula and laws), a micro level (principal governance) and an in-between mesolevel represented by local school owners who enjoy some autonomy but abide by national regulations. These owners are the municipalities in case of municipal schools and independent actors in case of independent (state-funded) and private (fee-based) schools (Skott, 2022). However, there has been a recent trend of recentralization where the State exerts more control over schools (Adolfsson and Alvunger, 2020). School HP is institutionally incorporated in the student health service organization which operates via a school unit and oftentimes another municipal unit (Hjörne, 2018).

The above-described institutional setup can have several implications for HP. First, the multitude of policies can challenge professional attention precipitating stress or confusion (Gherardi, 2019). Furthermore, ambiguities in the formulations of some of these documents have been detected raising concerns about potential inconsistencies in practice across settings and actors (Bergnehr and Johansson, 2023; Elsayed et al., 2023). Second, the high level of decentralization precipitates local differences in HP organization (Sandström, 2021) and creates substructures where some organizations (e.g. student health) are nested within others (school and municipality). These differences and substructures can influence professional performance and collaboration (Bradshaw and Toubiana, 2013). Finally, the (partial) recentralization risks that HP becomes contested across heterogenous school organizations which have developed different practice cultures (cf. Hjörne and Säljö, 2021). HP constructs may become floating terms rather than domains of collective action due to asymmetrical understandings and values across settings (Sandström, 2021). In this context, it is informative to explore how school professionals navigate this institutional setup. This navigation can affect their actions which are in turn linked to HP efficiency and student wellbeing (Kostenius and Bergmark, 2016; Murphy et al., 2024).

Scholars from different countries have argued for the interconnectedness between efficient HP practice and upscaling institutional variables such as policy directives and organizational structures (Bennett, 2024; Bringaker and Dahl, 2024; Gugglberger and Dür, 2011; Takens et al., 2024). This suggests that school HP would benefit from institutional development. To ensure situational appropriateness and professional engagement, this development must take in consideration how school professionals understand and relate to the institutional context of the practice (Powell and Graham, 2017).

An expanding body of literature has explored institutional variables related to school HP (e.g. Adams et al., 2023; Chavula et al., 2023; Simovska et al., 2016). However, little seems to be known about how professionals understand and navigate the institutional landscapes of HP, perhaps due to a tendency to dismiss the cognitive aspects of practice in empirical inquiry (Nersessian, 2004). An Australian study explored professional understandings at what they referred to as the policy–practice nexus (Powell and Graham, 2017). The study, though edifying, provided information about one aspect of the institutional landscape (policies) and reflected the perspectives of only teachers and principals. Institutional variables that affect school practices are not limited to policy discourses but include also governance, leadership and institutional values (Scott, 2014). Moreover, several professional groups (e.g. nurse, counselor) collaborate within the multidisciplinary school HP (Elsayed et al., 2023). Thus, mapping out realistic approaches to institutional development calls for more extensive and multi-perspective inquiries.

This study aims to construct a multi-perspective conceptualization of professionals’ understandings of the institutional context of HP. Unlike several prior studies which focused on one institutional variable such as policy discourses (Powell and Graham, 2017) or leadership styles (Adams et al., 2023), this study explores the institutional landscape at large including policies, organizational structures and values. The study explores school HP as a routine school practice rather than examining a particular HP intervention, as has been repeatedly done in previous literature (Askell-Williams et al., 2013; Durbeej et al., 2021). The research questions are:

• (1)

  How do school professionals make sense of HP as an institutionally embedded practice?

• (2)

  Which ILs foreground professionals’ sense-making of HP in schools and how do these logics interact?

This study is informed by practice theory and an ILs perspective. Practice theory is a constellation of theoretical lenses conceptualizing practice as the central unit of social phenomena (Nicolini, 2012). The ILs perspective is a meta-theoretical framework recently recommended for enhancing analytical rigor in institutionally situated practice studies (Schatzki, 2023; Thornton et al., 2012).

In practice theory, practices are “routinized social regimes of materially mediated doings, sayings, knowing, and ways of relating, organized around a negotiated end” (Nicolini and Mengis, 2024, p. 216). This conceptualization acknowledges cognition (knowing and relating) as a meaningful practice dimension. Cognitive processes are invisible yet meaningful aspects of practices. Performances are often underpinned by practitioners’ assumptions and value systems (Trede, 2009). Practice contexts may influence practitioners’ cognition, for instance by driving them to (re)conceptualize practice strategies or (re)distribute professional attention (Jarzabkowski et al., 2016; Nicolini and Mengis, 2024). Professional reflections can reveal how practitioners conceptualize practices (Schmidt, 2016).

Practices are organized via rules, understandings and teleoaffective (goal orientation) structures. They are performed in bundles within and across which actions are linked via different relations such as co-dependence and governance (Schatzki, 2019). Governance, the “intentional shaping, directing or influencing”, permeates practices but does not always generate intended outcomes (Schatzki, 2015, p. 19). The same set of rules may be associated with various professional understandings and actions in different contexts (Schatzki, 2019). Practice analyses should account for the contexts (e.g. institutional) which (co)shape practitioners’ understandings and actions (Jarzabkowski et al., 2016).

Institutions impose normative infrastructures on practices. For example, practitioners’ enactment of rules can be influenced by differences in their organizational roles, i.e. asymmetrical positioning. Institutional practices are normalized via joint regulation where rules imposed from without are (re)contextualized from within an organization. Rules can be resources for practice or domains for professional negotiation (Gherardi, 2019).

ILs (co)shape practitioners’ understandings potentially influencing how they enact rules (Schatzki, 2023). Practitioners can mobilize shared understandings of ILs to either (re)produce or challenge rules (Thornton et al., 2012). In negotiating rules, practitioners may reconcile, generate or disrupt multiple ILs (Jarzabkowski et al., 2009; Schatzki, 2023). Thornton et al. (2012) described several generic ILs that could have various instantiations in different contexts. Of conceptual significance to this study are two logics: the profession logic which emphasizes the value of professional expertise and reputation, and the corporation logic which valorizes bureaucratic roles and organizational arrangements.

In Sweden, school HP entails improving students’ psychosocial health determinants. It is thus a joint responsibility among many school professionals and included in various school activities such as health education (in various subjects), counselling, and appropriation of learning environments to physical and psychological student needs. School nurses have scheduled HP dialogues with students. Nurses also provide need-based dialogues as per students’ requests or teachers’ referrals. Each school has a multi-professional student health team ^[1] for addressing students’ health related difficulties (Hjörne and Säljö, 2021). Schools may recruit private providers for some HP services. To construct a more comprehensive understanding of this rather diffuse practice, a diverse study population was needed. Thus, a varied set of participants was recruited via a combination of maximum variation and snow-ball sampling (Tracy, 2012).

Participants were originally invited via existing researcher networks in schools or via invitation emails to schools in different municipalities. Invitations were purposefully directed towards a broad spectrum of professional groups (e.g. teachers, nurses, leaders). To provide a more comprehensive understanding of the institutional context, participants were invited from different types of school organizations (municipal, independent, private) as well as from private organizations that collaborated in school HP. Contacted professionals were asked to suggest other actors from their professional network(s) who could provide further/different insights into the research topic. These actors were also contacted and invited to participate. Preliminary exploratory coding was initiated in parallel with interviewing. Recruitment was ceased when pragmatic saturation was achieved (Low, 2019).

Nineteen professionals were interviewed. The interviewees differed in professions, experience (duration, student cohort) and organizational affiliation (see Table 1). Semi structured in-depth interviewing was used (Miller and Glassner, 2016). The interviewer inquired about relevant policies for school HP work and how they were understood as well as about how institutional variables affected practice. The interviews, conducted between spring 2021 and autumn 2022, lasted on average 45 min. They were audio recorded then transcribed verbatim.

Data analysis started by exploratory reading of the transcripts. Key policies (e.g. Socialstyrelsen and Skolverket, 2017) and materials (e.g. annual wheel, Figure 1) highlighted by participants were identified as auxiliary research material, i.e. not analyzed but used to contextualize participants’ accounts. Data were coded in four rounds 2–24 weeks apart (to reduce researcher bias at the beginning of each round). The first coding round overlapped with latter interviews allowing for alternative rounds of data production and analysis and supporting the refinement of emerging ideas (Rapley, 2016). Code books were kept for each round and used for an audit trail and peer debriefing, both of which informed revision of categories (Creswell and Miller, 2000).

Iterative rounds of inductive and deductive reasoning were used for coding. Inductive reasoning generated codes that depicted participants’ lived experiences. These codes were then contrasted against key practice theory concepts, e.g. understandings and governance, an approach inspired by directed content analysis (Hsieh and Shannon, 2005). Key ILs used by participants were identified using a combination of pattern induction (from data) and pattern matching (with ideal types) (Reay and Jones, 2016; Thornton et al., 2012). Codes were iteratively refined then arranged into themes and supported by representative quotes (Lingard, 2019).

The study was approved by the Swedish Ethical Review Board. Participants signed informed consent forms. Data were stored on a secure university server and processed in accordance with the GDPR (Datainspektionen, 2018). Data were anonymized. An ethically responsive stance to research was continuously maintained (Markham, 2018).

Data analysis generated two professional understandings of school HP as an institutional practice. Four ILs (bureaucratic, competence, pragmatic and entrepreneurial) mediated the construction of these understandings. These logics represent different instantiations of Thornton et al.’s (2012) generic logics. The bureaucratic logic is an instantiation of corporate logic while the competence, pragmatic and entrepreneurial logics represent three instantiations of the profession logic emphasizing different professional values (see Table 2).

Participants indicated that HP practices were regulated by multilevel (national, municipal, school) and heterogeneous (education, health care) policies. While national policies outlined the spectrum of HP, practice routines were predicated on how these policies were translated into school health plans. In municipal schools, this translation must also take into account municipal directives.

National policies represent then an infrastructure that supports different institutional directives in various settings. For example, a visit to the school physician is mandatory only in some municipalities. Monika (nurse) explained: “It’s the student health guide that is the foundation, but different municipalities can organize the basic program [municipal plan]in slightly different ways”. Thus, national policies are used as resources for further discursive action at the local level representing a case of joint regulation of the practice from without (state/municipality) and within (school). This led to a multiplicity of policies that participants found occasionally problematic.

Participants struggled with keeping track of the multiple policies regulating HP. They navigated this multiplicity using various strategies. For example, Rita (special needs educator) reflected:

Here professional attention is challenged by the myriad of rules informing HP and in response Rita’s understanding is shifted to a more collective policy conceptualization.

Another navigation strategy was foregrounding some policies and backgrounding others. For example, some participants focused on municipal plans and downplayed the need for adherence to the national guide. A nurse in a municipal school reflected:

A nurse in an independent school used the guide to formulate a school plan reflecting:

Although both nurses obviously consider the national guide referential, they approach it within an understanding of their asymmetrical institutional positioning (municipally employed or not). Monika readily embraces the municipal plan backgrounding the national guide. Gunilla who must formulate an institutionally sanctioned school health plan, with no other directives than the guide, is apparently more deferential towards it.

Participants found some policy formulations professionally unsupportive due to ambiguity or unrealism. For example, some participants thought HP was vaguely defined in policy documents making it difficult to have a consensus about appropriate practices.

Here, the perceived ambiguity of policy rhetoric is addressed by trying to mobilize a shared understanding of HP across communities of practice.

The occasional mismatch between policy demands and available resources was also highlighted:

Here policies invoke a tension between the competence and bureaucratic (meeting State demands within allocated resources) logics. Anna apparently cannot find a professionally gratifying way to reconcile the two logics and thus chooses to disrupt the existent bureaucratic logic by suggesting another form of governance which can ensure if not the desired availability of resources, then at least their equitable (re)distribution.

Participants indicated that HP was governed by municipalities and schools. This dual governance was occasionally problematic.

Participants problematized two issues with municipal governance: its potential impact on practice negotiation and its occasional nonconformity with school needs.

Municipal governance of HP was either centralized (professional works across municipal schools) or decentralized (professional stationed at a school). In decentralized governance, control over a professional’s work situation (e.g. salary negotiations) was delegated to the school principal. The decentralized model could provide better access to schools. However, it could also precipitate tensions with principals.

Hans has apparently constructed a multidimensional understanding of practice by drawing on multiple ILs: bureaucratic (acknowledging principal authority), competence (contributing to organizational development), pragmatic (realistic anticipation of consequences) and entrepreneurial (using diplomacy to sell organizational development ideas).

In contrast, professionals not placed under the principal’s jurisdiction (e.g. consultants) did not feel obliged to sugarcoat their professional opinions.

Here, the compromise between the bureaucratic (principal authority) and competence (performance quality) logics is mediated via an entrepreneurial logic (resourcefulness) supported by Tara’s affiliation with a private provider which presumably mitigates the principal-professional power gradient.

The contrast between the two reasonings (Hans, Tara) exemplifies a case of asymmetrical positioning where sensemaking of the practice and response to governance are interlinked with organizational affiliations.

Municipal governance sometimes did not accommodate school requirements. For example, the working time (full or part) of some professionals was determined according to a municipally calculated index which did not always correspond to school needs. A nurse working in a school where counselor time was reduced by 50% explained:

A special needs educator also found this index problematic but reflected:

Here the governance style invokes a conflict between institutional regulation and professional competence. Monika succumbs to a bureaucratic logic thereby accepting the resultant practice depreciation (less group HP). Nina invokes a pragmatic instantiation of the professional logic to compromise between bureaucracy and competence. This contrast may be grounded in professional and organizational differences between the two participants. Monika who has 3 years’ experience and answers to school and municipal authorities may be more likely to capitulate to institutional pressure. Nina, a private provider, is possibly less subject to institutional pressure. She has also worked in various school organizations over the past 14 years probably becoming versed in institutional compromises.

HP practicalities such as routines and monitoring were school governed. One way of governance was using material artefacts, e.g. the annual wheel used to represent a time frame for executing HP activities (Figure 1). The wheel was perceived as valuable for HP practice on the individual (structuring tasks) and group (collective reflection) levels.

Olivia (counsellor) pointed out that HP practice varied across student cohorts in response to evolving needs posing a risk that some activities become overlooked or unequally implemented. Using the annual wheel mitigated this risk, “it’s also a way to get things done … That it doesn’t peter out, and now we didn’t have time for this or that” (Olivia). The wheel is then seen as a resource for practice that aligns with two logics: pragmatic (concise directives) and bureaucratic (standardizing practice).

A significant element of school governance was leadership, perceived by participants as the force that dynamically linked policies to practices. However, differences in leaders’ understandings of HP (e.g. scope, professional roles) could affect practice strategies

Supportive leadership was often linked to leader engagement, operationalization of professional competences, fostering professional autonomy and the ability to negotiate with other organizations (e.g. municipality).

A special needs educator (Rita) was satisfied with HP organization indicating the principal was passionate about HP and granted professionals considerable autonomy thus fostering engagement. Moreover, the principal did not avoid practice relevant confrontations with municipal superiors. According to Rita “maybe not everyone dares to do it”.

On the other hand, Olivia (counsellor) indicated that the principal “thought that a counselor is like a nice aunt who sits and talks to children … didn’t really understand what I was working with at all”. Olivia thought this undermined her professional role which should be accomplished on multiple levels (individual, group, organization). Here, there are apparently mismatched understandings of professional responsibilities coupled with asymmetrical power positions in the school organization.

Participants working in student health (e.g. psychologist, nurse) in municipal schools answered to two organizations (school, municipality). They had two superiors: the principal (oversees work organization) and the head of municipal student health (oversees professional development).

This duality was occasionally a source of tension. For example, Olivia (counselor) experienced scheduling conflicts where she was simultaneously booked for HP tasks (school) and professional development opportunities (municipality). Paula (special needs educator) also problematized the dual governance, which sometimes created confusions about actions and responsibilities, remarking that student health sometimes felt like “two different organizations”.

This study explored school HP as an institutionally embedded professional practice. The findings indicate that school professionals construct practical understandings of HP at the intersection between institutional directives and professional values. Professionals recognized official policies and local governance systems as practice rules. They drew on different ILs to make sense of these rules suggesting that ILs (co)mediate the relation between two components of HP organization: rules and understandings (Schatzki, 2019). This supports Thornton et al.’s (2012) argument that ILs are intertwined with practice dynamics.

Professionals drew on a bureaucratic logic to rationalize decisions and legitimize actions. They also drew on different instantiations of a professional logic suggesting a strong commitment to professional values. The three professional logic instantiations bespeak of professional resilience where different sets of values are invoked in various contexts in the manner perceived to maximize efficiency (Meroni et al., 2021). However, these different instantiations also suggest that professionals perceive some degree of institutional complexity (Greenwood et al., 2011).

Professionals occasionally leveraged the bureaucratic logic for professional gains particularly when local governance provided prescriptions perceived as more contextually relevant and/or easier to implement than national ones. In such cases, the bureaucratic logic was employed to justify backgrounding national directives. The implied argument was that although the national policy was backgrounded, a local one was observed keeping the practice institutionally compliant (cf. Gullberg and Svensson, 2020). In this context, the bureaucratic logic is employed to achieve what is probably perceived as an optimal allocation of attention.

Attention is a scarce resource in professional practices and the way it is allocated can have serious implications for practice and for student wellbeing (Connolly et al., 2023; Gherardi, 2019). Professionals faced with information overloads often focus on information perceived as more relevant, a process known as selective attention (Bater and Jordan, 2020). This selectivity presumably reduces cognitive challenge and facilitates decision-making (Bhui et al., 2021). The manner in which this selectivity is exercised is grounded in professional reasoning which is in turn (co)shaped by institutional variables such as organizational roles and policy landscapes (Bater and Jordan, 2020; Nicolini and Mengis, 2024).

Within school HP, the need to attend to shifting student needs and make potentially critical decisions often strains professionals (Botelho et al., 2016). Facing numerous and hybrid institutional rules can compound this strain and drive professionals to exercise selective attention (Gherardi, 2019; Regehr et al., 2022). While selective attention can improve professionals’ working experience by reducing stress (Blake, 2023; Regehr et al., 2022), it is not necessarily associated with decision accuracy and may lead to suboptimal actions (Schwartzstein, 2014; Zizlsperger et al., 2012). Moreover, a widespread exercise of selective attention may precipitate disagreement among professionals who react differently to rules due to selectively focusing on different subsets of these rules (Zizlsperger et al., 2012), something which can undermine an essentially collaborative practice such as school HP.

School professionals were also challenged by policy ambiguities. One way of negotiating ambiguity was reconciling the bureaucratic and competence (or pragmatic) logics by way of bracketing professional competence and contextual responsivity within institutional compliance. Although this negotiation may be situationally beneficial (Gherardi, 2019), it should be observed that some policy ambiguities can hinder the attainment of HP objectives (Ronto et al., 2020). Professionals in this study experienced ambiguity about the definition of HP which can create a lack of consensus about practice strategies precipitating discordant actions. Prior research suggests that policy ambiguities can instigate professional confusion and undermine school HP (Powell and Graham, 2017).

Professionals also problematized some institutionally imposed demands perceived as situationally inappropriate. In response, professionals employed ILs in various ways including compromises between the bureaucratic logic and various instantiations of professional logic. When this was unrealizable, the governance system could actively be contested. An example was Anna (teacher) who suggested that a centralized system would ensure more efficient allocation of resources. While this was remarkable, it cannot be seen as a collective advocacy for recentralization. Other professionals (often those experiencing supportive leadership) thought decentralization supported professional autonomy and situational awareness.

Professionals saw school leadership as the linchpin that linked decontextualized policy discourses to contextualized professional practices. The role of leadership in sustaining school HP, recognized across geographical and organizational settings (Adams et al., 2023), may be particularly meaningful in Swedish schools where principals have considerable autonomy and can make pivotal organizational choices that influence the interprofessional and interorganizational collaborations essential for HP (Kostenius and Lundqvist, 2022; Skott, 2022).

Some participants highlighted professional-leadership tensions linked to asymmetrical understandings of professional roles. One explanation for this asymmetry is that professionals often prioritize different values based on their institutional roles (Scott, 2014). For example, counselors may focus on care, whereas principals focus on accountability and performativity (Guvå and Hylander, 2012; Jarl et al., 2021). These tensions may also be related to vague and inconsistent descriptions of professional roles in HP policies which provide room for asymmetrical understandings (Bergnehr and Johansson, 2023). These mismatched understandings may be particularly hard to resolve in Swedish schools where there is a high rate of principal turnover (Skolverket, 2020a). This makes it more difficult for professionals and leaders to develop long-term professional relationships during which they can harmonize professional understandings.

Notwithstanding struggles with policy formulations and local governance, professionals generally deferred to the institutional setup of school HP. They constructed professionally mindful and situationally responsive practice understandings but strived to remain within the scope of institutional directives. A salient example is Hans (psychologist) who sought to maximize professional performance by addressing organizational shortcomings that undermine HP. To fulfill this ambition, Hans developed a multidimensional understanding of his professional role whereby the competence dimension of professionalism was supplemented by pragmatic and entrepreneurial dimensions constructing a more viable and institutionally compatible understanding of the professional self. This resonates with prior empirical findings highlighting psychologists’ negotiations of their practices within existing organizational structures to get better access to schools and reinforce professional roles (Meroni et al., 2021). Professionals apparently resort to compromises between professional and institutional values because the exercise of a pure form of professional logic is often unattainable in schools (Blake, 2023).

The findings can be used to map out domains for institutional development to support school HP. One important domain is the revision and disambiguation of policy formulations to establish shared understandings and facilitate professional collaboration. It would also be useful to reduce the number of directives informing school HP to foster a more efficient allocation of professional attention thereby enhancing performance (Gherardi, 2019).

The findings highlight the need for improving institutional communication, for example through dynamic cross-level (municipality, school) dialogues that cultivate compatible understandings of professional roles and expectations. These dialogues can serve as forums for interlinking professional values with organizational action. Professional insights can inform the shaping of situationally appropriate policy possibilities that support collaborative practices not only within the school organization but also with other relevant organizations that professionals come in contact with such as social services (Bradshaw and Toubiana, 2013). This would be an obvious gain on the school level as well as on the public policy level. The findings also suggest that organizational variables (e.g. high principal turnover), previously considered in relation to pedagogical activities and outcomes need also be explored from a HP perspective (see Skolverket, 2020a).

Alleviating institutional and professional tensions can enhance the effectiveness of HP actions in schools (Gugglberger and Dür, 2011). This in turn translates into improved student wellbeing. Recent research indicates that institutional variables can affect how students perceive and utilize school health services and can enable or constrain student involvement and sense of belonging (Canosa et al., 2024). Improved student health is not only a welfare and moral gain but can also be linked to broader societal gains. Student ill health has been linked to poor academic achievement and higher rates of school dropout (Andersen et al., 2021; Nasuuna et al., 2016). School dropouts are linked to social, psychological and economic difficulties (Ramsdal et al., 2018). Moreover, institutional developments supporting school HP have (per se) been linked to better social functioning within families and communities (Katewongsa et al., 2023; Schmidt et al., 2020). Careful and efficiently designed institutional developments can give rise to palpable societal benefits thus consolidating the social, economic and welfare roles of education.

In this study, a rather novel analytic approach (combining practice theory and ILs) was used. ILs are inherently complex and subject to different conceptualizations (Thornton et al., 2012). Thus, iterative rounds of pattern induction and matching (as well as peer debriefing) were undertaken to define relevant ILs and to ensure that their meaningfulness for practice was neither over nor underestimated. The analytic combination can be seen as a strength in that it allowed for a more situationally conscious exploration of school HP. Moreover, the findings provided an empirical demonstration of how ILs link institutional rules to professional understandings. Hence, the study can be seen as a theoretical contribution that extends the conceptualization of professional practices and drives the development of what Schatzki (2023, p. 18) calls a “new form of structuralism”.

The diversified study population can be seen as a strength as it allowed for constructing a multi-perspective view of school HP in different organizational settings (Peräkylä, 2016). Moreover, the study simultaneously explored several institutional variables thus providing a more assimilated understanding of the institutional landscape than that garnered from investigating each of these variables on its own. Furthermore, the examination of typical practices rather than focusing on a particular HP initiative allowed for constructing knowledge about HP as part of everyday school life rather than as a set of atypical actions. This contributes to better conceptualization of HP as an integral part of school life. This kind of conceptualization is important for the sustainability and development of school HP (Gugglberger and Dür, 2011).

Another strength is the empirical orientation towards professional understanding which allowed for exploring cognition, an invisible and often overlooked aspect of practice (Nersessian, 2004; Solberg, 2021; Trede, 2009). Knowledge about professional understandings can inform professionally acceptable bottom up institutional changes and provide insights into school climates (affected by these understandings) that influence student health (Aldridge and McChesney, 2018; Bradshaw and Toubiana, 2013). The study, though situated in the Swedish context, does not yield findings that are unique to Sweden (cf. Powell and Graham, 2017). It can thus be conceptually and theoretically informative to a broad range of school and societal actors.

A limitation of this study is that the professional understandings described here are not contextualized within the social relations in each school. These relations may influence rule negotiation and professional actions (Lave and Wenger, 1991). However, it should be observed that the study aim was to provide a panoramic view of school HP in Sweden rather than dissect a particular local practice. Moreover, participants were individually interviewed even when they belonged to the same organization to cultivate a safer interview atmosphere. Mapping social relations in this context violates individual and organizational privacy (Markham, 2018). Future research can build on the current findings to design more elaborate or multi-site case studies that would contribute to the construction of a more exhaustive view of school HP.

School professionals approached HP practices as professional accomplishments but strived to conform with institutional directives by observing practice rules (policies and governance systems). Rules were used as resources for structuring practice but were occasionally perceived as professional challenges due to multiplicity, ambiguity or lack of situational appropriateness. Professional understandings of rules were mediated by a bureaucratic logic as well as by three instantiations of a professional logic (competence, pragmatic and entrepreneurial). The different instantiations allowed for some form of an uneasy and contingent co-existence of professional values and institutional regulations.

The findings highlight school leadership as a key link between institutional directives and professional practices. The study highlights the need for institutional development that involves policy and organizational structures. Institutional development can support the improvement of HP and reinforce the social role of the school. This development must be grounded in professional understandings to secure professional engagement. Professional engagement contributes to practice efficiency and sustainability as well as to improved student reception and utilization of school health services.

I would like to express my gratitude to all the study participants who have contributed a wealth of professional experiences and reflections to this study. I would like to thank Associate Professor Linda Bradley, Professor Mona Lundin, and Senior lecturer Markus Nivala for providing peer debriefing during data analysis. Linda also generously conducted an audit trail of the analysis. I am grateful to Professor Venka Simovska for a very informative conceptual and theoretical discussion. Special thanks to Professor Roger Säljö who recommended informative readings and provided valuable insights that drove this work forward.