Successful health-promoting leadership – A question of synchronisation

Abstract

Purpose

The aim of this paper is to identify the role of the principal in establishing a whole school approach for health and wellbeing. Two questions are asked: (1) What do successful Swedish principals do when they take on a whole school approach? (2) How do these results relate to previous research on successful school leadership?

Design/methodology/approach

This paper focuses on the complexity of organisational processes and considers the role of successful leadership in managing a whole school approach to health promotion. It presents findings from two different but interlinked projects, and draws on document studies and interviews with principals, student health team members and teachers in Sweden.

Findings

This paper argues that successful school leaders are crucial in establishing a whole school approach, because of the work they do to synchronise the health-promoting activities in schools. The study identifies four aspects of coordination that need to be enacted simultaneously when leading health-promoting processes. The fifth aspect identified is that a whole school approach is not limited to the school, but the whole local school context, i.e. a synchronisation between different system levels.

Originality/value

Although limited in scale, this paper reports key findings that could have practical implications for school leaders. The study suggests that successful school leadership research needs to use a health-promoting lens in order to make leadership practices health-promoting practices. It also proposes extended comparative research from different fields and contexts.

Citation

Skott, P. (2022), "Successful health-promoting leadership – A question of synchronisation", Health Education, Vol. 122 No. 3, pp. 286-303. https://doi.org/10.1108/HE-09-2020-0079

1. Topic and aim

This paper takes as its starting point two global trends related to schools. The first is the predominant focus on school performance, where countries and individuals are measured and ranked. Consequently, school leaders have been identified as important for school development and considered successful if they improve students' learning and performance (Robinson et al., 2009; Leithwood and Seashore, 2011). Research has identified four domains of practice in which successful school leaders engage: setting direction, building relationships and developing people, developing the organisation to support desired practices, and improving instructional practice (Leithwood et al., 2019). These domains have played important roles in the preparation and training of principals (Lumby et al., 2008; Young et al., 2017). The main focus of school leadership research and principal preparation has been leading teachers' learning and improving their teaching through instructional leadership. Other professionals who can work in schools to establish health and wellbeing have been excluded from the research, or not considered as the principal's main focus.

The second trend concerns the central importance of wellbeing and student health issues (Hughes et al., 2019), which are predominantly studied within another research field focusing on health promotion. For more than 20 years, health promotion research has been carried out in the Nordic countries (Kokko et al., 2018) and schools have been included in this research. School health promotion (SHP), in contrast to leadership research, is built on a whole school approach and considers health promotion as a part of everyday school life (Parsons et al., 1997; Green and Tones, 2010; Carlsson, 2016), covering both teaching activities and time between classes (e.g. breaks and meals). One key aspect of this research considers the complexity of organisational processes in which different professionals are supposed to work together. Even though health research identifies the school leader as important, it has not yet had the school leader as the primary focus.

This paper explores what can be learned if these research fields are merged and challenges previous school leadership research and its narrow focus on instructional leadership. From a more holistic perspective on schools, the starting point of this paper is rather that school leaders are responsible for, and possible key actors in, leadership for health-promoting activities as part of their wider responsibility for education. Consequently, research on successful health-promoting leadership becomes essential. The aim of this paper is to identify the role of the principal in establishing a whole school approach for health and wellbeing.

This paper focuses on Sweden, where there is a law regulating health promotion work in schools and the principal's role in making this happen. There have also been attempts by national authorities to help school leaders develop a more holistic perspective. The results in this paper build on research about these efforts.

2. From research on successful school leadership or holistic health promotion work to research on successful leadership from a whole school approach

The following section is divided into three parts. In the first part, the focus is on school leadership research, to identify what successful school leaders do. The second part considers health research and the importance of a “whole school approach”. The third part identifies the research gap and the research question of the paper.

2.1 Successful school leadership

As indicated in the introduction, the primary focus of school leadership research has often not been on wellbeing and health, but on instructional practices and what successful school leaders do to improve students' learning in the classroom. Consequently, successful school leadership is predominantly measured through performance on tests and, according to aggregated results from this research field (Leithwood et al., 2008, 2019), successful school leaders focus on four essential practices:

1. Setting the direction;

2. Building relationships and developing people;

3. Developing the organisation to support desired practices; and

4. Improving instructional practice.

This means that school leaders are identified as important for improving students' results, but they do this by working through teachers. Setting the direction is about building shared visions and identifying specific goals and communicating them. When developing people, this can be done by stimulating growth in the professional capacities of staff, but also providing support for staff. Trusting relationships includes several actors, i.e. staff, students and parents. School leadership can be considered as an individual's work. Today, however, distributed leadership is one of the main fields within school leadership research and building a collaborative culture using distributed leadership is a main task for school leaders. This last practice has become one of the most important leadership practices for principals, and is achieved by working closely with teachers and monitoring student learning and school improvement progress (Leithwood et al., 2019).

For over a decade, these practices have been central to school leaders' work. In many countries, they have even been established as standards within preparation programmes (Ingvarsson et al., 2006; Ylimäki, 2013; Young et al., 2017) and linked to various leadership models such as distributed leadership, instructional leadership, transformational leadership and teacher leadership (Gumus et al., 2018; Leithwood et al., 2019). It is stressed that teachers' work is the most important factor in students' results, but, when wellbeing is added, it improves the chances of student success (Leithwood et al., 2019).

However, a holistic approach including multi-professional coordination and a multipurpose approach including different aims for schools is excluded from most school leadership research. This might be because of differences between countries regarding the presence of health professionals in schools, which makes it difficult to compare. There is, however, a growing interest in complexity (Day et al., 2016; Hallinger, 2018; Hawkins and James, 2018; Leithwood et al., 2019; Rönnström and Skott, 2019). This paper explores complexity further and uses knowledge about the Swedish school system to explore successful health-promoting school leadership.

2.2 The holistic health approach

The instructional focus of school leadership research on the teaching core excludes what health research has called a “whole school approach” (Carlsson, 2016). This approach includes learning about health through teaching as well as establishing health and wellbeing in schools. St. Leger and Young (2009) assert that a whole school approach for health-promoting work enhances learning, increases emotional wellbeing and reduces risk behaviours. A challenge of this, however, is that efforts for change must be comprehensive, including work on relations between teachers and students, and the development of teacher-, parent- and local context involvement as well as cross-educational levels (Weare and Nind, 2011).

Jourdan et al. (2016) examine the difficulty of establishing a health-promoting approach and identify the importance of working in the awareness of teachers' professional identities, i.e. teachers need to feel the relevance of it to their profession. Hence, health-promotion research to some extent identifies the same kind of success factors identified by leadership research (the importance of teachers' work) but overlooks the importance of leadership practices and multi-professional coordination. No single profession can carry the change, so it is not enough just to point to the importance of management and the ability to handle complex organisational challenges (Boot and de Vries, 2010); there needs to be research on what works and why.

2.3 Bridging the gap

When considering the two research fields separately, it seems as if their improvement is being hindered because of their traditional focus. In this study, a first step to merging the fields is combining research on successful school leadership with the holistic approach of the health research. By bridging the gap between them, the fields can improve together. Since the focus of this paper is the school leader, the previous research on school leadership will be the starting point. The whole school approach on health is used to ask new questions and make new aspects of leadership visible.

An important step in this merging of perspectives is to consider the meaning of the term “success”. Here, it should be remembered that research on school leadership is closely related to research on school effectiveness (SE) and school improvement (SI), which are combined in what Reynolds et al. (2014) call “educational effectiveness research” (EER). EER developed out of the early belief that schools and school leaders could not compensate for differences in society (Coleman et al., 1966; Reynolds et al., 2014; Pashiardis and Johansson, 2016). Several decades later, the field has helped address questions such as what makes a school a good school and how this is achieved, including leadership (p. 197). From the start, the question of learning outcomes was key to effectiveness and success.

Even though learning outcomes can include academic and social development, student achievement has been the predominant effectiveness criterion (Reynolds et al., 2014, p. 205). The two main dimensions of school effectiveness at the heart of the research are quality and equity. Quality is about the scoring between schools, while equity is the difference made within a school (Reynolds, 2014; Pashiardis and Johansson, 2016). When student wellbeing is considered within this tradition, the focus is predominantly on wellbeing as a measurable output. As Pashiardis and Johansson (2016) suggest, there are reasons to problematise what we mean by success, and consider not only products but also processes and context. Context considers the fact that, while all schools are similar on one level of understanding, the everyday life of a school includes unique students, parents, teachers and principals. For one thing, students have different socioeconomic backgrounds (Hallinger, 2018) Focusing on processes means paying attention to the everyday activities and relations between school actors, which in turn means focusing on the doings of schools. One problem with this is that, even though we define success as something wider than academic results and processes, important processes exist on many levels within multiple contexts (Skott, 2009; Clark and Wildy, 2016). These include reform work, leadership at different levels, and development work at the school level. This means that to establish health promotion work in schools it is necessary to pay attention to the complexity of processes.

This paper focuses on the complexity of organisational processes at the school level and considers the role of successful leadership in managing a whole school approach for health promotion. It considers schools as responsible for both health and learning and examines the Swedish school context.

The research questions are:

RQ1.

What do successful school leaders do when they take on a whole school approach?

RQ2.

How do these results relate to previous research on successful school leadership?

To answer these questions, this paper draws on empirical data from two projects in Sweden. The term “principal” is used when identifying school leaders at the school level.

3. Health-promoting school leadership: the Swedish context

For ten years, the Educational Act of Sweden (SFS, 2010:800) has stipulated that principals are responsible for leading “Student Health Services”, which are defined as health-promoting and illness-preventing activities. Each school must have a student health team (elevhälsoteam/EHT) comprising different professional competences such as counsellors, psychologists, doctors, school nurses and special educators). Together with the teachers, they are supposed to develop student wellbeing through health-promoting work, which is seen as highly related to students' learning and performance. One can consider this law itself as a whole school approach. One of the reasons the intention behind the law has proved difficult to establish in practice is that it challenges the perception of schools as places consisting mainly of classrooms where teachers work with students, and not as places for collaboration between different professionals, working together (Törnsén, 2018; Hylander, 2016).

Törnsén (2018) finds that professionals in the EHT team generally consider the principal's leadership to be important for the team and the whole school. The principals considered health work as something outside the core business and did not understand how it was interlinked with the rest of the school work or how the organisation could work in a more holistic way. They did not coordinate competence development for different professional groups and there were weak learning environments. Consequently, the support was given to students only when problems appeared, instead of identifying what they needed to remain healthy and what support they needed to be able to participate in the teaching. The principals thus did not enact a health-promoting leadership from a whole school approach, despite the fact that all principals in Sweden participate in a mandatory training programme built on school leadership research (Brauckmann et al., 2020).

This was also a reason why The National Agency for Special Needs Education and Schools (SPSM) started to collect inspiring examples from their development work and put together an internet-based course called To develop the school's health care work, which the principals and their EHT teams could attend. Close to 1,000 schools have so far participated, including 4,600 participants. Over time SPSM identified that most schools developed their work, but only some schools became really successful. Therefore, four researchers were invited to shadow the principals and their teams to identify the difficulties in establishing a whole school approach. This paper emanates from a follow up study of the schools that were identified as most successful in establishing a whole school approach. It identifies what it was the principals in these schools did to make a difference.

One problem of comparing countries is that school systems differ widely. To understand the Swedish context, it is important to understand that the governing system of schools is built on a three-level structure. On the macro level, the state regulates all schools through common laws, regulations and curricula that are enacted at the micro level of schools where principals are responsible for what is called the “inner work”. To assist the principals in this work, there are two national authorities that provide materials and assistance – SPSM is one of those.

In between the macro and micro levels, there is also a meso level. This is the local owner level, which consists of the 290 municipalities (public) and thousands of independent school owners (private). All local owners follow the same national school law and curricula, and are publicly funded and inspected. It is their responsibility to make sure the national regulations are followed. In this study, the focus is strictly on municipality contexts. Important to note here is that, within these municipality contexts, all schools are run by a politically appointed school board with the mandatory administrative function of a superintendent. This position is a link between the board and the principals. To describe the importance of interlinked processes, the term “governing chains” has been used (Moos et al., 2015), and this study will pay attention to these interlinked processes.

4. Method

4.1 Background

This paper combines the results from two different projects. The first project started out as an evaluation of a government-funded online course. Over the course of a year, the participating principals and their student health teams worked through digital modules and sent their reflections to a team of researchers from different research fields and perspectives, including leadership and organisational perspectives. The researchers analysed the material individually and collectively to investigate high-quality work with “student health” (Löfberg, 2018). The findings were the starting point for a second project – a follow-up study of schools that had successfully developed their health-promoting work during the course. In this second project, two of the researchers continued to explore what it was that these schools and principals had done to become successful.

4.2 Selection and data

The successful schools were identified through the quality of their formal plans and other documentation, including professionals' writing about the schools' processes and personal contacts the SPSM had with the principals and their teams over a year. Their documents, texts and stories indicated a qualitative difference in their work. One important aspect of this was how well the schools coordinated the professionals within the student health team and also the team and the teachers. In the first study, two models that identified different stages of development were developed. These models were tested with other principals in the period between the studies to make sure that the different stages made sense to the principals. Some found the models so useful that they used them in their local quality work. The models were then used to identify schools that had moved from having multi-professional teams to having interprofessional teams and combining them with new kinds of cooperation with the teachers, i.e. not only taking care of problems but working interactively with the principals to establish health-promoting practices.

The selection of schools was done in two steps. In the first round, 18 well-developed health-promoting schools were selected from the same cohort, which was studied in the first study. This selection was done to identify practices that could be analysed for more in-depth studies, including professionals' perspectives on the health promoting work. The design included four schools, but added interviews with principals from other successful schools to broaden the dataset. One difficulty was that, to be identified as a case school, it was necessary for the principal and team members to still be working at the school and be able to participate in the follow-up study. Without them, it would be impossible to collect data about the development processes. Only three schools could be selected from the original cohort, and one was added through recognition in a previous course group. Several of the principals did, however, agree to be interviewed even though they had changed schools.

Out of the four case schools, two schools were primary schools and two were upper secondary schools. At each school, the principal, deputy principals, student health team and a representative selection of teachers (chosen by the principal) were interviewed. Since most schools work with teacher team leaders, this was in most cases the participating teachers. Students were not included in the study since the focus was on organisational aspects in which the students were not involved. Some superintendents of the four schools were also included since the meso level seemed to matter for success. This was a result of the study and was added after the first school visit.

Altogether, the study included 57 informants, including 17 principals, 18 participants from student health teams, 21 teachers and 3 superintendents. Two principals were interviewed also as superintendents. For an overview see Table 1.

This paper builds on a larger research report (Hylander and Skott, 2020) and includes all the collected data. However, in what follows, the focus is mainly on the interviews with the principals. Hence, this paper highlights the work principals do to establish a whole school approach and predominantly uses the interviews with them to identify successful health-promoting leadership. The other interviews are used to put the principals' stories into perspective, i.e. to make sure the principals' stories were in line with those of the student health teams and staff; this proved to be the case, no matter if the school was successful or not.

The study also included analyses of 19 health plans, which will not be referred to in this paper. They were, however, important because all the successful schools had plans that were living, not dead, documents. The focus here, however, is not on the texts as texts, but on the lived practices and what the principals did to improve these practices.

4.3 Setting and data collection

First, all schools were contacted by two civil servants at SPSM whom the principals knew from the course. This personal contact with the principals was to make them comfortable with asking questions, help them understand the purpose of the study and respond honestly whether it was possible for the two researchers to come and perform the interviews. The principals could also read the researchers' conclusions from the first project. When the principals had agreed to participate, the researchers sent an email with a request to have a first contact to plan for the study.

All the case study interviews were done on-site and the rest were done by phone. All interviews were performed by the two researchers and were semi-structured (see Appendix 1 for the interview guide). The focus of the interviews with principals was on current and previous student health work in order to capture the organisational processes and leadership aspects.

The interviews with the principals were mostly individual or with the deputy principal. There was one focus group, which included principals from schools 2–6 that all had the same superintendent (who was silently present with a development leader). The interview was considered a learning event by the participants and the presence of the superintendent was discussed with them before the interview. All considered it important that she was present. On average, the interviews lasted for around 75 min and were performed with informed consent. All interviewees were informed they could withdraw from the study at any time.

The on-site interviews were complemented by walks through the school environment to help capture the different contexts. These were guided by the principals before the interviews and were important both as an introduction and for building trust, and were often used as a reference point by the principals in the interviews when describing the schools' work.

4.4 Data analysis

The interviews were recorded, transcribed and analysed qualitatively, using thematic analysis to identify themes and patterns.

The transcribed material was analysed by the two researchers. The author of this paper – an academic within the field of educational leadership – performed and analysed the interviews with the principals. The other researcher – an expert in EHT teams – performed and analysed the interviews with the EHT-teams and teachers. Since the interviews were made by the researchers and relatively small in numbers, the coding was done manually by the researchers. And since the purpose was to identify unknown success factors, inductive coding was used to identify themes.

Before the coding, each researcher read through all the transcribed interviews to get an overview of the material. However, the deeper analysis was done only by the researcher who performed each particular interview. The two researchers then discussed the identified themes together and one notable finding that came from this interaction concerned the importance of the principal's “inner turn around”. The leadership researcher considered the principal's turn around to be interesting, but the researcher on student health teams disagreed. The turn around in question had been done by the team members a decade ago, and it did not appear noteworthy until the data was analysed on a deeper level. It was then that it became one of the major findings, i.e. that principals must have a deep understanding of what it is they are supposed to change, otherwise their leadership cannot contribute to achieving it.

One important aspect of the analysis work was that the two researchers spent much time together before and after the interviews working on how to capture the multiple processes at the schools. Before visiting a school, the researchers analysed the health plans and other documents the school had provided. These documents were discussed, so that each of the researchers knew the important questions to ask regarding processes. All the interviews at each of the four schools were completed on the same day, and the researchers went there together. At the end of each day, the researchers met to describe in a systematic way their first impressions of the interviews, and also what can be easy to forget, such as the feeling when entering the school and performing the interviews. Everything was written down and taken into consideration when analysing the material.

5. Results

The study included 17 successful school principals. All of their schools showed remarkable progress in their processes during the course. From their stories about the change work, it was possible to identify what it is that successful principals do when they take on a whole school approach: They synchronise the health-promoting activities at the schools. This is a complex task that includes five aspects of everyday work:

1. They build their actions on a holistic approach regarding curriculum assignments.

2. They coordinate the student health team's work and establish prerequisites for a health-promoting, distributed leadership.

3. They work with cross-professional coordination.

4. They take health promotion as a starting point for local quality work and link the quality work to health-promoting capacity building.

5. They widen the holistic approach, coordinating leadership between different system levels.

In the first results section, these aspects will be described in more depth. To explain what made the successful leadership possible, the second section highlights what all principals described as the most important factor for a whole school approach to be realised: a turnaround within themselves.

5.1 Synchronisation of the five aspects

Successful health-promoting processes take time to establish. One principal described a journey over five years, starting from zero. Several others described “fragility” and sustainability challenges due to the change work being built on human actors' understandings and coordinated actions. Since a holistic approach includes many actors, the processes were repeatedly interrupted when there was a staff change in important positions. Positive change is not something that can be established overnight – it takes time and constant effort. Those that managed it focused on the following aspects.

5.1.1 A holistic approach regarding curriculum assignments

For us, it was an important signal to show that student health is a part of the whole school, and safety and wellbeing is as important and crucial for the students as gaining knowledge. Therefore, we have worked to make student health an important and obvious part of everything that we do. (Ps 2, P)

To understand the difference the successful principals made, it is necessary to look beyond leadership practices and doings. The holistic approach starts with a genuine understanding of the overall purpose of schools and a deep knowledge about the whole curriculum. This includes norms and values, and each student's right to support in achieving their academic goals. All the principals described how the different parts of the curriculum were bound together to assist learning and development. Values work was considered an important part of the core business. Key to success was transforming the complexity in the guiding documents into lived and synchronised actions. It is, as one principal described it, a focus on “student health all the time”.

To be able to work with all aspects of the curriculum, one school had divided the student health team into two parts: one health team and one comfort team (trygghetsteam). The latter managed the preventive and promotional elements (linked to values). Among other things, they worked on the basis of incident reports and described the plan against discrimination and defamatory treatment as the backbone of health promotion work. The counsellor was responsible for creating a respectful school environment. The team also included a school nurse, two safety hosts, a special needs teacher and a host for comfort. They all coordinated their activities to achieve equal coverage between classes. Thus, it was not a single teacher working with values, but a team working for the whole school, which the principals talked about and made visible to students and parents. The principals said the aim was equivalence between the classes and a single spirit throughout the school.

Another frequent expression of this holistic work is the whole school day approach, where the teaching and all sub-activities during the school day are considered important. In Sweden, schools provide aftercare (fritidshem) for children under the age of thirteen, until the parents' work day is over. At the successful schools in this study, this part of the day was integrated with the rest of the school day. Added to this, they identified that a lot was going on during the school day that was likely to permeate classrooms and obstruct good teaching. They found it was calmer and safer if the breaks were structured. One important change was having the same adults always present at the soccer field, where many fights started and needed adults to break them up before the students could enter the classrooms. Investment in rest activities was a common feature in the primary schools that had come a long way in their health promotion work.

An important task for the principal was to monitor the health-promoting aspects of everyday activities and make sure that there was an experienced difference. One principal said the transition work started by changing a teacher team beset by negative storytelling into a group that thrived and laughed together. Another principal stressed that one of the biggest success factors was that the organisational system of the school was made known to everyone, including students and parents. The most crucial part was that these structures were recognised in everyday practice.

Leading health work is thus a much more complicated task than leading the work of student health teams or teaching alone. It's about enacting the whole curriculum and creating a healthy environment. At the successful schools, the difference was clear upon entering them – there was a welcoming atmosphere and a sense of joy and pride.

5.1.2 Coordinating the student health team's work and establishing prerequisites for a healthpromoting, distributed leadership

I could never go back to the way I worked before…to think that I did not have the special teacher by my side and did not have the counsellor and school nurse close, to interact with…it would be difficult…. It's a change…or perhaps it's a change in me, I do not know. (Ps 1, P)

Health promotion work is not only about learning health for the future. It's also about living health promotion during school days, including in regular teaching activities. One important part of leading health-promoting activities is that the principals are knowledgeable about inclusive teaching so that they can lead the change in school practice. This can be about seeing, questioning and instructing on different health-promoting practices. However, this is not only the work of a single leader, but something that can be done together with the student health team.

The principals described the importance of actively coordinating professionals within the student health team, i.e. building a synchronised team and working together to develop concrete structures and tools. A first and important step was spending time with the team and getting to know their different professional perspectives. As the participants in the team got to know each other's skills, it became easier to work together and spread the whole school approach. The coordination work included leading the team through different development phases. With a more developed teamwork, it also became easier to handle changes of staff.

When the team was established together with the principals, the leadership was perceived as more shared. Several spoke of working together to arrange their everyday practice, with plans, meetings, routines and responsibilities. One principal said that everything was now based on student health thinking, including overall organisation, scheduling, group assemblies, and more. More knowledgeable and synchronised team members made it easier to get better traction in daily work: “keeping the inclusive vision alive”. The principal cannot be everywhere at once but, through others, change leadership can cover the entire organisation.

The principal and the health team had in many cases developed interdependency. The principal gained improved student health skills and enacted a health-promoting school leadership and the team became more integrated and assisted in the leadership of student health work. To assist the development work, the successful principals held many meetings, but were not always the ones leading them. Rather, it was a question of setting the direction, being firm about basic values, and distributing responsibility for coordination. This, however, could not be done without working with other professionals at the school.

5.1.3 Working through cross-professional coordination

This means that we easily end up with a focus on the individual, “how do we help this individual?” And this is where we all the time need to remind everyone but how do we change the whole learning environment…so that as many students as possible, that the base in the teaching is accessible so that we do not have to do individual adjustments. But it is easy to end up with the individual case, since we have many students in need of support. (Us, 2, P)

An important change factor in the successful schools was that the teachers wanted to be involved in the change work. This included a basic change in attitude, from formerly “dumping” problems with individual students on the health team, to considering the health team as co-players in the change work. The change was about preventing problems by using the team, as well as promoting health through reflective actions. One principal said there should be “easy roads into the student health team for the teachers, that there should be no obstacles”. This can be achieved by a shift in thought that student health is part of a school's basic competence that requires constant cooperation. The tricky thing is establishing these formulations in practice.

Achieving cross-professional cooperation required that the principals showed all professionals respect while staying firm in their health-promoting and inclusive perspective. While some teachers considered “difficult” students the responsibility of the special teachers, the principals described how they constantly followed up with a focus on the inclusion of individuals and groups. This was done while maintaining an understanding of the complexity of the teachers' work, who were not only supposed to handle large heterogeneous groups, but also mentor the students. The teachers needed to feel supported in this work, to be able to change their ways of acting and not be judged by other professionals.

The principals also pointed to the heterogeneity of the teacher group, where some, just as in the student groups, needed more support than others. Several principals highlighted the importance of mutual trust and that employees needed to show trust in the principal. As principal, it's about getting everyone onboard by gradually eliminating what one principal called “trip wires” through more knowledge and changed attitudes. A crucial aspect was therefore interprofessional respect. When this was established, the teachers at the successful schools saw that the change work was not extra work, but a possibility to develop their own teaching practice. One principal described how it created a different kind of organisation, with different names, moving away from old thought structures. This gradually changed the teachers' way of thinking and acting. Another described the change work as “branching out on the pedagogy platform”.

The schools that had come a long way in synchronising professionals' work had principals who had exercised strong management and leadership practices to establish the change. In these schools, all staff had stories about their development work. The teachers at these schools expressed great respect and admiration for their principal and student health team.

5.1.4 Taking health promotion as a starting point for local quality work and linking the quality work to health-promoting capacity building

All types of competence development…to be able to meet in these conversations, so that in a way…all kinds of competence development…the common and the more specific for different groups, are part of some kind of web, which we are weaving…with threads, to be able to meet in this thinking. (Ps 5, P1)

According to Swedish law, all schools must enact local, systematic quality work, which includes collecting data and identifying necessary changes. Research shows that it is difficult to establish quality work that makes a difference in practice (Kostenius and Lundqvist, 2019). The principals at the successful schools described how they brought the health-promoting perspective into the quality work, which became a tool “to organise the unique fabric where everything is woven together”. One crucial aspect that several interviewees mentioned was linking data regarding quality aspects to capacity-building activities. The cornerstone of the work was that analysis came before actions and were linked to the health-promoting vision.

One challenge was getting teachers to spend time on knowledge-building related to health promotion, rather than deepening their academic skills. To succeed in this change of perspective, the teachers were divided into smaller groups based on their expertise and areas of interest. The principals gave them a framework for what they wanted them to do and a time to meet each week. The teachers were free to decide the subject of their pedagogical assignment, but the principals identified guiding themes that were relevant to the entire organisation. Small groups of teachers were given the responsibility to plan learning activities for the other teachers, which changed the teachers' perspective on change work from being passive recipients of the principal's orders to driving it forward themselves. This work also made a stronger impact than previous development work – something happened when the principals were no longer the only ones leading it.

The principals did not shy away from the fact that there were always individuals who showed less willingness for change. One way of addressing this was for several principals to work in shorter development cycles to show how small changes can make big differences. One important aspect of this was bringing quality work into every conversation, including individual staff development meetings. The teachers began to take the health-promoting perspective into their individual meetings with students and mentor meetings with their classes. In this way, the quality aspects were advanced, no matter what the activity.

The principals described how they worked systematically at all levels of the school organisation with promotion and preventive student health work based on the school's quality work. One challenge of this was that, to succeed, each individual's action counted, every day.

5.1.5 Widening the holistic approach and coordinating leadership between system levels

The four aspects above mainly focus on the work at the school level, going into fine detail while keeping the holistic perspective in mind. Important, however, is that while Swedish principals are responsible for schools' inner work, they are also part of a larger local context, which means they need to link their actions to superintendents and other school leaders in a synchronised, multilevel leadership that includes vertical synchronisation.

All the schools in the study were public municipal schools. This means that they were not only following national laws and regulations, but working under a local school board and superintendents. In general, this means that local school work should be synchronised between system levels, with the school board deciding the focus of each school's development work. When it comes to student health issues in particular, each municipality has at least one responsible manager at the meso level. Some professionals in student health teams can also be based centrally and divide their working time between different schools. Consequently, there are inbuilt challenges of coordination regarding student health work.

One major finding of this study is that the vertical aspect of synchronised leadership is crucial. In several of the most developed schools, success was the result of superintendents' active work for holistic change. In these contexts, the quality work of the municipality was constructed from a health-promoting perspective and made development work between schools possible. It was not a coincidence that all the upper secondary schools in one municipality were on the list of successful schools. This was the result of intensive work led by the superintendent, who synchronised the development work over several years. This resulted in quality processes on a higher level, showing trust in the local health work:

I do not require a student health plan anymore, which I did at the beginning…just for them to do it. I do not care…now that we are through that phase. Now I see their work through the systematic quality work that we do. How they do it is their business. But this is my way to follow up that it is done. (US 2, superintendent)

Other municipalities showed similar synchronisation. But it was evident that it was a fragile construction where changes of superintendent could destroy the synchronised work at the school. Of course, this is never intentional, but one case clearly showed that if a superintendent does not understand the health-promoting perspective and starts to reorganise from other perspectives, this negatively affects the local school work. In this particular municipality, the superintendent merged two schools and installed a new principal to lead the student health work. The new principal had, however, no experience of this:

I received the mission as a kind of bonus, before I was to start my job. To begin with, I was to lead the vocational programmes, but then I had the question of whether I could take the responsibility for the student heath team. “Well – yes I can”. Unfortunately, this has meant that we lost it, the work they did…I simply have not had that possibility. So they have to start leading themselves somehow, and we have not really figured out how. (Us 1, P)

When the holistic perspective is lost, a lot of small integrated actions that have built up structures and cultures over time are also lost. Thus, the holistic perspective must include the whole local context, not only the school.

5.2 A turn around within the principal

It is evident that the principals were important for establishing a whole school approach. In the previous section, the focus was on what they did as successful leaders. Here, the focus is on why they did it, because one of the main findings was that all the principals shared the same change story – a kind of inner turn around. When they understood the essence of a health-promoting perspective, it changed their actions so that they mastered and enacted a more synchronising leadership.

I developed another knowledge base to stand on. Now, I think all the time: prevention, promotion. Before the course, I was in an emergency situation all the time, and it's so easy to be in a school and not focus on this kind of work that will show results in a year's time. So I'm so glad I prioritised the journey, precisely because I've got a new knowledge base, which makes me think differently. (Us 5, P)

The change meant taking a more holistic approach to school work, including health promotion. Making a difference required more than an excellent student health team where health issues were handled separately from teaching activities; the difference came when they started to see student health work as part of the core pedagogical business.

The essence of the above quotation was common among all the successful principals (see Appendix 2). They described how they started to widen their leadership practice from focusing strictly on instructional leadership with teachers in focus, to acting from a more holistic perspective, where the main task was coordinating multi-professional actions between parts of the organisation. One principal said that each action now was considered an opportunity to think from a preventive and health-promoting point of view. They started to synchronise all the other work from this starting point. The following figure illustrates this synchronising work (for further development, see Hylander and Skott, 2020) (see Figure 1).

The triangle illustrates that the principal's knowledge base and leadership are the foundation for positive change. The arrows in the middle represent the first four aspects of coordination described earlier. The left side of the triangle symbolises the student health team's development, where the principals change the ethos of the work from individual professionals to a synchronised team. The right side symbolises the teacher teams and other professionals working together at the school, who also need guidance to become more synchronised in health-promoting actions.

When the principals consciously led from a health-promoting perspective, the development work did not stop with the development of a student health team – the teaching teams also developed their health-promoting work (which included inclusive education and working with stress-reduction related to assessments) as an aspect of teaching. Even though the student health team in some cases had been strong before the change, the major difference came when principals kept their focus on health promotion and started to synchronise activities for sustainable and health-promoting school development.

When principals manage to develop and integrate both sides, this is recognised as health-promoting schools where all professionals work merge into a whole organisation – the triangle is closed, without gaps. What were previously separate professions in the school came together over time. The arrows within the triangle illustrate that there is not one single action that makes the difference, but many interlinked activities over time. The square around the triangle symbolises that a whole school approach is not limited to the school, but includes the local context and interlinked system levels (Factor 5, above). This is what in the beginning of the paper was called the complexity of organisational process.

6. Discussion

The aim of this paper was to identify the role of the principal when establishing a whole school approach for health and wellbeing. Two questions were asked. The first considered what successful school leaders do when they take on a whole school approach. The first finding was that principals' leadership is crucial for establishing a whole school approach. Without the synchronising work of principals, it is difficult to establish a health-promoting school. Their leadership is necessary for handling the complexity of organisational process. The paper summarises five coordinated aspects of school leadership. When principals actively engage in leading health promotion and stop considering health issues as separate from teaching practices, this make all the difference. It requires a turnaround within themselves. A holistic approach improves not only the possibility for student health teams to develop as teams, but it helps them to work interprofessional with synchronised teacher teams at the schools. Together, they develop health-promoting environments. While previous research identifies the importance of principals (Hylander, 2016; Törnsén, 2018), this study shows what can be accomplished through principals' leadership and how.

Since much is known about successful school leadership in general, the second question was whether successful health-promoting leadership differs from these general leadership practices. When compared, these original successful practices can at first appear similar to a health-promoting leadership. To begin with, health-promoting leaders need to set directions, but the important thing is that they cannot set just any direction – they need to build on deep knowledge about the whole curriculum and make health promotion part of the overall aim, known by everyone. Further, health-promoting work cannot be established without intensive work on building relationships and developing people. It is, however, important that the development of important health promotion issues is synchronised between different professionals. Essentially, this means developing the organisation to support desired practices, but accomplishing that is much more complex than what the single practices in the list reveal. Finally, a successful health-promoting school leader needs to work through instructional leadership and consider what the instruction should be about – it must be redefined to include health promotion. A principal who narrows the leadership to only be instructional can hardly be working from a whole school approach. Hence, health-promoting leadership is not an added leadership practice, but more like a “pentathlon” of practices with the aim of establishing student wellbeing and academic achievement through multiple synchronised actions. Taken together, successful school leadership practices need to be viewed through a health-promoting lens.

This study has several implications for practice. Compared to previous research, the most important finding here is that a successful leader must be able to develop a synchronising leadership. If the school leaders are not provided with a full understanding of what a health-promoting leadership requires, they run the risk of being too narrow in their leadership by following research-based standards that do not consider the complexity of organisational processes. The case studies suggest that a knowledgeable and multitasking principal is a crucial factor for success. Understanding the complexity is necessary, but not sufficient. Previous research shows that effective teaching is not about doing a small number of “big” things right, but doing a large number of little things well (Reynolds et al., 2014, p. 212). The same can be said about successful health-promoting school leaders, i.e. no change is possible if the school leader does not understand what health promotion is about.

This study also has implications for future research. It was built on a previous study where successful principals had been identified through their participation in a digital course and where the schools sent in their reflections over a year. Four schools were selected as case schools, where interviews were done with the principals, student health team members and teachers. Added interviews with other successful principals were done to broaden the dataset. The interviews were recorded, transcribed and analysed qualitatively using thematic analysis to identify themes and patterns. Even though these schools and principals were selected out of hundreds that participated in the course, the results in this paper are built on analysis of a small number of municipality schools. The data collection and analysis may also be biased since there were only two researchers involved in the qualitative project.

This means that there are reasons to explore these and other successful schools further. This study suggests that strong leadership is important. But how is that leadership enacted when performing the coordinating activities? What exactly is it that principals do when staff accept that the changes are necessary and require strong leadership? And how do the students experience successful student health work processes? Added to this, it is important to question the concept of a “whole school approach”, that is: what is a school? The results indicate that superintendents can sometimes be what Stringfield (1998) calls “change killers”, where new actors do not see the value in continuing a change work initiated by others. A holistic approach to health-promoting school leadership in countries like Sweden also needs to consider the local owner context. In future comparisons between countries, it is important to explore system differences within schools as well as in different local system contexts.

Even though the study is limited to a small selection of successful schools and principals in Sweden, the paper takes a first step to bridge the gap between leadership research and research on health promotion. International research on successful school leaders rarely addresses professions other than teaching and strongly focuses on instructional leadership for teaching and learning, while research on health promotion rarely considers contextual differences between countries. The main result of this study is that principals' leadership seems to be crucial when establishing a whole school approach. This is also why the paper encourages more research on successful health-promoting leadership.

Figures

Figure 1

A synchronised health-promoting leadership, built on a strong knowledge base

Table 1

Plans and informants

School	Plan	Principals	Student health teama	Teachers	Superintendents
Primary school 1	x	P, Pb	K, Ssk, Sp, R	3	Student health
Primary school 2	x	P, Dp1, Dp2	K, Ssk, R, D1c	6
Upper secondary 1	x	Pd, Pe	K, Sp, Syv, R	5	Upper secondary
Upper secondary 2	x	P	K, Ssk, Sp, Syv, R	7	Upper secondary
Primary school 3	x	P
Primary school 4	x	P
Primary school 5	x	P, Dp
Primary school 6	x	P, Pf
Upper secondary 3	x	Pg			Upper secondary
Upper secondary 4	x
Upper secondary 5	x	Ph
Upper secondary 6	x	Pi
Primary school 7	x
Primary school 8	x
Primary school 9	x
Upper secondary 7	x
Upper secondary 8	x
Upper secondary 9	x
Upper secondary 10	x

Note(s): ^aK = counsellor, Ssk = school nurse, Sp = special educator, Syv = guidance counsellors, Sp = school psychologist, R = principal

^bPreviously a principal (now a superintendent with a special responsibility for student health)

^cDp1 = deputy principal with responsibility for student health

^dProgramme principal with special responsibility for student health

^cPreviously a superintendent responsible for student health, now a parallel programme principal

^dPresent and previous principal. Separate interviews

^f,gGroup interviews

Appendix 1 Interview guide for meetings with principals

You have been selected for this interview since you are/were the principal(s) of a school which participated in the SPSM – course To develop the schools health care work. During the course you and your team were identified as schools which developed substantially. Now that one year has passed since you finished the course, we are interested in your own reflections about your work and the results.

1. Describe your own background/leadership experience and the role you have had in the development work at the school.

2. Describe the background of the schools and why it was decided to engage in this specific development work.

3. Describe the development processes for the team and for the school as a whole.

4. What were the main challenges during the development work?

5. What do you consider the most important results? And what do you consider as important for achieving those?

6. Have the results remained? If not, explain why.

7. If you reflect from a leader perspective, did you develop any new knowledge related to your role, and if so has this affected your leadership? What do you consider necessary for a principal to know and do to develop student health work?

Appendix 2 The principals' turnaround and synchronising work – sample quotations

We made a student health plan and started to give a lot of concrete expression regarding the promotion and prevention…what value base we stood on…the spirit we wanted to work with around our students and talked a lot about different perspectives on health and…we turned around the student health work. Earlier, we ran around and extinguished fires, just remediation. Now we focus on, “we'll have a good bottom”. Student health begins in the classroom. It is the teachers who meet the students every day. That's where we're going to focus. (PS 3, P)

I see that it is extremely important to embrace the idea that student health work begins in the classroom. That the class teacher can respond to students and adapt. That's the most important thing…first it's that you look at your own adaptations and treatment. Then you get the teacher team to help you. If that does not work, then you can go on to special education and discuss it. Wouldn't that work, it's EHT. You need to make that clear. A lot of people skip all those ranks…But while we were taking the course, we had to plant this mindset. (PS 6, P)

We strive to be a student health without an office as we say, that we should be where the student is, where the staff is, we'll be out in the school practice. I as an assistant principal with responsibility for student health should be visible, accessible, the counsellor is very out and works in classes, the school nurse is out a lot. And we want to get away from sitting in our offices. (PS2, DP 1)

The student health is here for the education, and from my point of view, student health is not as it says in the law, that it is the team members or the special professions. I keep saying we are all student health. And that student health is a verb, something you do, it's in every choice. (US 2, P)

• PS = Primary school

• US = Upper secondary school

• P = Principal

• DP = Deputy principal