Interprofessional collaboration in school: Effects on teaching and learning

Abstract

The main objective of this study is to identify and understand interprofessional collaboration practices in schools using a mixed-methods design. First, we conducted a literature review on interprofessional collaboration in schools to give insights into the ways teachers and other professions collaborate with each other, and what kind of interprofessional interventions show positive effects on teaching and learning. Second, we collected data from five Norwegian elementary schools to gain knowledge of factors that facilitate and hinder interprofessional collaboration. The results show that interprofessional collaboration was defined differently in the literature, and that research is lacking on interprofessional collaboration that involves multiple professions in school. Interventions in which social workers and school nurses were involved gave positive, though small-to-moderate, effects on a range of outcome measures. However, interventions that targeted the whole school were found to be the most promising for making changes that persist over time.

Keywords

Collaboration interprofessional learning school teaching

Introduction

Educational achievement and school completion are basic components of the healthy development of young children and youth, and schools are facing increasing pressure to improve the academic outcomes for young people. However, non-academic barriers to learning, such as emotional, behavioural and health problems, often create substantial difficulties in helping young people succeed in school (Anderson-Butcher et al., 2008; Maynard, Kjellstrand, & Thompson, 2013). In recent years, educational policy has highlighted the connection between mental health and learning by developing and evaluating initiatives/interventions for improving psychosocial environments, including mental health interventions, prevention work and early identification of students in need of special attention in school (Baweja et al., 2016; World Health Organization (WHO), 2004).

The school is an important arena for promoting the mental health of children and youth (Colman et al., 2009; Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011; Greenberg, 2010). Teachers are struggling to balance social and academic learning in their teaching, and while teachers show high levels of competence in the academic component of teaching, creating and upholding a positive psychosocial environment in the class and school is more demanding. The prevailing argument in educational policy is that schools need ability and expertise beyond the pedagogical to accommodate the diversity of students’ backgrounds and needs, an expertise that is currently lacking in teachers’ education (Ekornes, 2015; Porter, Epp, & Bryan, 2000; White Paper No. 19, 2009–2010).

Focusing on the psychosocial and academic aspects in school is thought to have positive effects on students’ well-being, learning environment and learning outcomes, to lower dropout rates and, in the long term, reduce mental health issues and decrease unemployment (Banks, Squires, & Anhalt, 2014; Holen & Waagene, 2014). Many researchers believe that collaboration across professions, that is, between teachers, nurses and social workers, is a necessary and viable tool in an educational world of increasing complexity (Mellin, 2009; Winitzky, Sheridan, Crow, Welch, & Kennedy, 1995). The expectation is that better utilization and coordination of existing resources, including providing schools with more and varied expertise through collaborative interprofessional teams, can help strengthen preventive work and the efforts related to early intervention and rapid assistance for students who need additional support from other services (Galvin & Erdal, 2013; Welch et al., 1992; Willumsen & Ødegård, 2016).

Although interprofessional collaboration has received increased attention in educational policy and mainstream discussion over the recent decades (Mellin, 2009), there is a lack of knowledge about whether and how collaboration between professions meets the needs of teachers and students. The aim of this article is therefore to identify and understand interprofessional collaboration practices in school. First, we conducted a literature review to discover what characterizes interprofessional collaboration with documented effects on teaching and learning. Second, we collected qualitative empirical material in five Norwegian elementary schools to provide insights into facilitating and hindering factors of interprofessional collaboration. Norway is interesting in this respect because there are no national guidelines for interprofessional collaborative practices. Education policy allows for local initiatives to improve collaboration between professions in accordance with local needs, but this may also maintain the status quo.

The intention of this article is to provide knowledge of interprofessional collaboration by bridging academic knowledge about effective interprofessional collaboration initiatives for teaching and learning, with experiential data on interprofessional collaboration derived from practice.

Interprofessional collaboration in school

Interprofessional collaboration refers to joint interprofessional efforts in teams to achieve mutually desired outcomes through shared decision-making (Canadian Interprofessional Health Collaborative, 2010; Gajda & Koliba, 2007). In the health domain, interprofessional collaboration is a response to fragmented healthcare practices (D’amour & Oandasan, 2005); however, interprofessional collaboration in schools between teachers and others is less articulated and discussed in research. Several factors suggest that collaboration among professions is an appropriate approach. First, schools are facing increasingly complex challenges in the student population, and different professions could attend to students’ different needs. Time constraints and a lack of resources make it difficult for teachers alone to attend to all students’ needs (Ekornes, 2015; Hornby & Atkinson, 2003). Second, students spend most of their day in school, making it an ideal place to promote mental health in children and youth. Integrating services that work with children and youth is thus effective and cost-efficient and, and as such, necessary (Mellin, 2009; Porter et al., 2000; Welch et al., 1992; Winitzky et al., 1995).

Various types of goals may require different types of collaboration. In some cases, efficiency is the prime goal, while in other cases, teams need to find innovative solutions to complex challenges (cf. Hammerness et al., 2005). In both cases, a partnership between professions is an appropriate model for a collaborative and coordinated approach. Regardless of the goal, having a supportive and organized context is necessary for high-quality collaboration (Cappella et al., 2015). Research shows that there is great potential to develop strategies to promote interprofessional partnerships that are beneficial for the teachers, students and collaborating services (Myrvold, 2006; Myrvold & Helgesen, 2009; OECD, 2013).

However, research shows that teamwork between professions can be challenging (Weist et al., 2012). Different professions have different educational and professional cultures and various approaches to dealing with challenges, which can lead to conflicts, territoriality and ineffective use of time and energy (Connolly & James, 2006; D’amour & Oandasan, 2005; Hall, 2005; Shoffner & Briggs, 2001; Weist et al., 2012). This is probably why there is extensive literature targeting the factors that predict successful collaboration between professions. Such factors are openness, mutual respect and trust (Ekornes, 2015; Hall, 2005; Mattessich & Monsey, 1992); effective sharing of important information and exchanging ideas (Hall, 2005; Norsen, Opladen, & Quinn, 1995); engagement in frequent, continuous and concrete discussions about practice and how the team works together (Gajda & Koliba, 2007; Little, 1987; Weist et al., 2012); sharing responsibility, and participating in group decision-making and planning (Hall, 2005; Norsen et al., 1995); and efficient organization of group tasks and assignments (Hall, 2005; Norsen et al., 1995). All of these factors may promote a partnership in collaboration, where different professions share expertise and experience to form a common goal (Bridges, Davidson, Odegard, Maki, & Tomkowaik, 2011).

The aim of this study is to identify and understand interprofessional collaboration practices in school. The research questions are (1) in what ways do teachers and other professionals collaborate with each other in schools, (2) what kind of interprofessional interventions show positive effects on teaching and learning and (3) what factors are experienced as facilitating and hindering to interprofessional collaboration?

Method

We used mixed methods in this article to identify and understand interprofessional collaboration practices in school. To study in what ways teachers and other professionals collaborate with each other in schools, and what kind of interprofessional interventions show effects on teaching and learning, we conducted a review of interprofessional collaboration in school. To study the facilitating and hindering factors for interprofessional collaboration in schools, we conducted observation and interviews in five schools during a school-development project aimed at promoting interprofessional collaboration in schools. The design made it possible to obtain different but complementary types of data on the same phenomenon (Creswell & Plano Clark, 2017).

Literature review

A literature review was conducted inspired by the Cochrane Handbook for Systematic Reviews of Interventions (Higgins & Green, 2011). Table 1 summarizes the inclusion and exclusion criteria in terms of population, intervention, comparison and outcome (PICO). The target population was students in primary and lower secondary education to consider the effects on students’ social and emotional development and academic attainment. The interventions of interest were models for interprofessional collaboration, but we also included research literature that describes the effects of including other professions in the classroom or in the school.

Table 1.

Inclusion and exclusion criteria.

	Inclusion criteria	Exclusion criteria
Population	Primary and lower secondary schools	Kindergarten, upper secondary schools, universities
Intervention	Multidisciplinary, interdisciplinary or interprofessional collaboration in schools	School-based intervention programmes
Comparison	Health professionals, social workers and teaching assistants	Other research that does not explicitly reference health professionals, social workers or teaching assistants
Outcome	Social qualification, emotional qualification and academic qualification	Obesity, overweight, dental health, alcohol, tobacco and drug use, sexual health, pregnancies, contraception
Study design	Systematic reviews RCT studies Quasi-experimental quantitative studies Qualitative studies

RCT: randomized controlled trial.

We conducted searches in the largest scientific databases in education science, social science and health science (ERIC, Academic Search Premier, Ovid PsycInfo, Google Scholar, and Web of Science) using the keywords presented in Table 2. The researchers used the subject terms in the keywords, titles and abstracts to identify the intervention, target group, study design and outcome. In addition, we searched the Cochrane library for systematic literature reviews on interprofessional collaboration in schools and social work in schools. The inclusion criteria covered research articles written in English or a Scandinavian language and published in scientific, peer-reviewed journals by March 6, 2014.

Table 2.

Subject terms used in the literature search.

Intervention	Target group	Design	Outcome
inter-professional collmulti-professional collschool managesocial workhealth visitorpublic health nurseschool nursesupport staffpaid adult support, teach assistant*adult support staffstaffprofessional development	comprehensive school elementary schoolmiddle schoolclassroomschool	RCTrandomized controlsystematic review literature reviewcase controlmodel*intervention experiment	LearningSocial and emotional learningPositive behaviorsocial behaviosocial skillsself-esteem competenceassetshealth promotion preventionstress reductionproblem solvingachievementbehavior

The final literature search resulted in 836 unique articles. Two researchers screened all abstracts for the inclusion/exclusion criteria. Of the 836 abstracts, only 80 were sufficiently relevant for a full-text reading. We ended up with 14 relevant studies, after reading the full-text documents.

We mainly included studies with a research design that allowed for the identification of causal effects. This research literature is limited in scope, and most of the studies with an experimental or a quasi-experimental design in this field were from the 2000s, as only two of the 14 included studies dated back to the latter half of the 1990s.

Case studies

The empirical study was carried out in five public Norwegian elementary schools as part of the R&D project, ‘A support network for teachers’ (SNT).¹ The objective was to gain insight into different kinds of interprofessional collaborative practices. We chose five Norwegian elementary schools that differed according to school size and geographical location to partake in this study.

The development work in SNT did not consist of introducing fully developed programmes or methods to promote interprofessional collaboration. Instead, the municipalities and schools received a combination of economic and implementation support to undertake development work to improve local practice. We used action research methods to support school management in this development work (Gustavsen, 1992; Pålshaugen, 2014). The project thus followed and documented the progress of school-development work closely, giving insights into how professional expertise was used in schools, the challenges they faced and how they worked to overcome these.

To develop the interprofessional collaboration practice in the schools a researcher (with expertise in action research), in collaboration with the schools’ leader group, arranged two dialogue conferences at each school where the staff (including social workers), the school nurse and representatives from the Educational and Psychological Counselling Service participated. In these meetings the participants were organized into groups to discuss obstacles for collaboration and make plans for improving collaboration between professions. A second researcher conducted observations in the group discussions to map the dynamics between professions in the groups, their discussions on obstacles to collaboration and their plans for promoting interprofessional collaboration. The plans were documented and followed up at the next dialogue conference meeting. Two members of the research team recorded written field notes during the dialogue conferences. To follow up on the development work in schools, two researchers had meetings, and spontaneous communication with the school leader and municipality contact. The researchers used a template to record the purpose of the interaction, the individuals present, the content of the interaction and reflections.

To further explore and understand in what ways teachers and other professions in school collaborate, successful collaboration models and the challenges they face, researchers conducted in total about² 10 semi-structured interviews per participating school/municipality. Individual interviews were conducted with the chief municipal education officer, the leader of the Educational and Psychological Counselling Service, the principal, the special education teacher, the school counsellors, the school nurse, and the Educational and Psychological Counselling Service counsellor. We also conducted group interviews with teachers, social workers and teacher assistants (TAs). The themes in the interviews were organization of interprofessional collaboration arenas, non-organized interprofessional collaboration, interprofessional collaboration directed towards individuals or groups of students, systemic interprofessional collaboration, examples of positive experiences with interprofessional collaboration and obstacles for interprofessional collaboration.

Results

In this section, we will present the literature review first, followed by the findings from the case studies.

Interventions targeting students

We found that interventions targeting students mainly involved non-pedagogical professions such as social workers (three studies) and school nurses (three studies). The studies in this section mainly involved non-pedagogical professions/staff working directly with individual students or groups of students (most prominent) and interventions targeting all students in classrooms (see Table 3 for all studies included in this section). The research aimed to report the effects of including a non-pedagogical profession in school to support students’ mental, behavioural and academic outcomes and had less of a focus on the collaboration between pedagogical staff and others. In these studies, interprofessional collaboration in school was mainly defined as a non-pedagogical professional or staff member working directly with students alongside teachers. There was little mention of collaboration between professions.

Table 3.

List of six studies targeting students identified by the search procedure.

Citation	Change target	Study design	Sample characteristics	Intervention	Results
Allen-Meares, Montgomery, and Kim (2013)	A variety of outcomes for youth with behavioural, emotional and learning problems	Systematic review	Literature review of school-based interventions that involved social workers (18 studies)	Effects of school-based interventions that involve social workers on a variety of outcomes	Positive effects of interventions aimed at treating outcomes such as sexual health, aggression, self-esteem, school attendance, identity and depression
Baisch, Lundeen, and Murphy (2011)	Promoting a healthy school environment and healthy, resilient learners	Quasi-experimental design with experimental and control groups	School staff in considered programme schools (n = 634), elementary school students in 11 programme schools with nurses (n = 9346), control school students (n = 7249)	Evaluating the effect of having a nurse at school serving the general population of students in school	School nurses positively influenced immunization rates and school staff experienced school nurse interventions as vital for eliminating barriers to learning
Early and Vonk (2001)	Mental health prevention, treatment efforts and school climate	Systematic review	Literature review of studies in school where one or more social workers were involved (21 studies)	Effects of social worker interventions on mental health prevention	A majority of the interventions were shown to be effective in helping children and adolescents acquire problem-solving skills, improving peer relations, and improving intrapersonal functioning
Franklin, Kim, and Tripodi (2009)	Reducing externalizing problems and internalizing problems. Increasing academic and school-related outcomes	Systematic review meta-analysis	Literature review of studies in school where one or more social workers were involved (21 studies)	Effects of social worker interventions on students’ mental health and education	Positive impact on students’ emotional, mental, behavioural and academic outcomes
Kvarme et al. (2010)	Increase self-efficacy in a group of socially withdrawn children	Non-randomized controlled trial with experimental and control groups	School children aged 12–13 years and identified as socially withdrawn (n = 156)	Implementing a solution-focused group intervention for 6 weeks led by the school nurse. Focused on building supportive relationships	General self-efficacy scores increased significantly for girls only. Three months after the intervention, no differences between groups were found
Maughan (2003)	Students’ academic achievement	Systematic review	Literature review of studies in school where school nurse was involved (15 studies)	Effects of nursing interventions on educational outcomes	Nursing interventions targeting specific populations, including parents, had significant effects on educational outcomes

Three systematic reviews on social work in school described interventions ranging from those resulting in no measurable effects, to those having positive effects on outcome measures, such as problem behaviour, absenteeism, motivation, self-efficacy and academic attainment.³ The documented effects of social work in schools were, however, small to moderate. Early and Vonk (2001) concluded that social workers in schools are an effective way to help students reach their academic goals and enhance their social skills. Franklin, Kim and Tripodi (2009) showed that the best results have been obtained by studies using education-related interventions and interventions targeting students’ mental health to change student behaviour. They also found that interventions aimed at increasing the level of knowledge about specific topics had a stronger effect than interventions that targeted behaviours such as attendance or absence. Allen-Meares, Montgomery and Kim (2013) showed that the most effective programmes were those directed at all students, that used professionals trained in providing treatment and that provided continuous interventions over several weeks. Studies directed at groups of students, with a few exceptions, were found to have small-to-moderate effects on the outcome measures (Allen-Meares et al., 2013).

A total of 12 years separated the studies of Early and Vonk (2001) and Allen-Meares et al. (2013); however, both pointed to the need for follow-up studies to investigate whether the positive results that appear immediately after an intervention indeed lead to permanent improvement. A limitation of these studies is that there was no emphasis on the implementation of the intervention or on how the social worker collaborated with the teachers inside or outside the classroom.

The literature search on health professionals identified one systematic review and two newer studies targeting students. Health professionals were mainly school nurses. Maughan’s (2003) literature review aimed to identify the educational benefits of school nurses, and she found that nurses in school have positive effects on the factors affecting students’ ability to learn and to finish school. The studies found significant correlations between nursing coverage in schools and students’ health, both of which related to disease and coping with illness in the school context. The author also referred to research showing that students who do not feel at home in school are more likely to seek out school health services. Moreover, the school health services’ contact with parents and the community around the school helped to increase the contact between school and home and reduced the likelihood of health-related absences from school and the classroom.

Recent research corroborates that school nurses are important for students’ health and academic attainment (Baisch, Lundeen, & Murphy, 2011; Kvarme et al., 2010) and that professional collaboration between teachers and school nurses can strengthen interactions with all students (Cappella, Jackson, Bilal, Hamre, & Soule, 2011). Baisch et al. (2011) argued that school nurses contribute to students’ performance in school by reducing absenteeism related to health and freeing time for teachers to concentrate on didactics. Similarly, Kvarme et al. (2010) showed that improvements in students’ self-efficacy could lead to higher completion rates and better performance. None of these studies measured the direct relevance for student learning.

Interventions targeting teachers/school staff

We found eight studies evaluating school-wide programmes in which multiple (unnamed) professions were included in the intervention (see Table 4 for all studies included in this section). The central feature of these programmes was that they primarily targeted teachers and teaching staff, not students. The purpose of these studies was to assess whether changes in teaching staff would lead to lasting effects on students’ social and academic attainment. Many of these interventions were so-called social and emotional learning programmes, in which helping children build skills beyond academic knowledge (such as school climate initiatives, anti-bullying work and positive behaviour supports) was the main target (six studies). These interventions often used external resources that contributed to the professional development of school personnel to strengthen the school’s ability to ensure that the students met the learning objectives. We also found other whole-school initiatives in which collaboration among professions was the main focus of the intervention (two studies).

Table 4.

List of eight studies targeting teachers identified by the search procedure.

Citation	Change target	Study design	Sample characteristics	Type of intervention	Results
Bradshaw, Koth, Thornton, and Leaf (2009)	School organizational health (operationalized by school staff reports)	Group-randomized controlled effectiveness trials	Staff in 37 elementary schools (n = 2596)	Investigated a universal, school-wide prevention strategy (Positive Behavioural Interventions and Supports) for reducing disruptive behaviour	The studies showed positive effects on the overall organizational health of schools. School organizational health was proposed as a mediator of the effects on students’ performance
Cappella, Jackson, Bilal, Hamre, and Soule (2011)	Improve collaboration between mental health professionals and teachers for more effective classroom interaction	Mixed methods to assess the fidelity of implementation	School staff, mental health professionals and elementary school students	Developed and implemented a teacher consultation and coaching intervention	The project observed systematic and substantive barriers to collaboration between educators and mental health professionals and provided a feasible model for breaking down such barriers
Durlak, Weissberg, Dymnicki, Taylor, and Schellinger (2011)	Social and emotional learning	Systematic review meta-analysis	Literature review of school-based universal interventions (213 studies)	Effects of school-based, universal social and emotional learning (SEL) programmes	The findings showed significantly improved social and emotional skills, attitudes, behaviour and academic performance
Ertesvag and Vaaland (2007)	Preventing and reducing problem behaviour in school	Repeated measures design	Staff and students in three primary schools and one secondary school	Evaluated the effects of a prevention and problem reduction programme (Respekt)	The results showed that students reported a decrease in the four areas of problem behaviour. The effects were small to moderate
Hagelskamp, Brackett, Rivers, and Salovey (2013)	Coaching teachers in programme elements to improve the quality of classroom interactions	Cluster randomized controlled trials	62 schools, 164 classrooms and 90 teachers	Implemented a social and emotional learning programme (RULER)	The programme showed effects on emotional support, better classroom organization and more instructional support
Jenkins, Ronk, Schrag, Rude, and Stowitschek (1994)	Involvement of teachers in decision-making and planning to redesign services for low-achieving students	Experimental and control groups	Teachers (n = 72) and students (n = 1362) in 12 elementary schools (experimental) and teachers (n = 76) and students (n = 1062) in 10 control schools	Developed and implemented a multicomponent school reform process	The results showed positive teacher attitudes towards the change process, but no treatment effects on students’ achievement and behaviour
Kimber, Sandell, and Bremberg (2008)	Mental health promotion among students	Quasi-experimental longitudinal design	Students in grades 1–7 in 41 experimental classes; 14 classes served as the control group	Investigated the effects of a social and emotional training programme	The results showed that the programme had small-to-medium effects on mental health and other health-related behaviours
Nelson (1996)	Increase institutional capacity for working with students with disruptive behaviour to increase students’ social adjustment and academic behaviour	Pre-test and post-test. Experimental and control groups	Students in two elementary schools (n = 1362); two matched elementary schools served as control schools (n = 1062)	Investigated the effects of a school-wide programme designed to meet the needs of students who exhibit disruptive behaviour	The results showed positive effects on teachers’ perceptions of their ability to work with children who exhibit disruptive behaviour and on children’s social adjustment and academic performance

The literature search revealed one systematic literature review and seven primary studies targeting training school staff via programme elements. The systematic review conducted by Durlak et al. (2011) showed that social and emotional learning programmes in schools provided positive results on aspects such as social and emotional skills, students’ attitudes towards themselves and others, positive social behaviour and academic performance, and reduced behavioural problems and emotional stress. The effect measured on academic performance was found to diminish over time, however. A more recent study focused on educating teachers showed moderate-to-strong effect sizes for classroom quality (Hagelskamp, Brackett, Rivers, & Salovey, 2013).

Other programmes aimed to reduce the extent of externalizing and problem behaviour in schools. Bradshaw, Koth, Thornton, and Leaf (2009) showed positive effects for school climate, teachers’ affiliation and students’ focus on learning; effect sizes were small to moderate. For a similar programme, Nelson (1996) documented positive effects on the disciplinary actions of schools and teachers’ perceptions of their ability to work with children who exhibit disruptive behaviour, as well as the extent of shared goals among staff for working with children exhibiting disruptive behaviour. The study also showed positive effects on students’ social adjustment, academic performance and school survival skills. A decrease in problem behaviour (Ertesvag & Vaaland, 2007) and effects on mental health (Kimber, Sandell, & Bremberg, 2008) was also found in the Scandinavian context, although the effects were small to moderate.

Cappella et al. (2011) and Jenkins et al. (1994) strayed from the previous studies described in this section in that they did not implement a fixed programme in a school but applied a participatory development process to increase collaboration among professions. Cappella et al. (2011) focused on developing collaboration between teachers and mental health professionals by employing a participatory research design. These authors argued that collaboration between mental health professionals and teachers is important for improving teacher–student interaction generally and for increasing effective classroom interactions for students with behavioural difficulties specifically. This study proposed a model for improving collaboration between teachers and mental health professionals and did not measure effects on students.

Jenkins et al. (1994) studied the effects of a democratic decision-making process characterized by teachers developing consensus regarding the school’s goals and the means of achieving those goals. The results showed positive teacher attitudes towards the change process, new approaches to organizing instruction and more mainstreamed instruction. Despite the positive changes observed among teachers in studies that emphasized developing collaboration among different professions, the studies did not find or address effects on students’ learning and development.

Interventions in SNT project schools

The SNT project was designed as a research and development project in which schools were invited to find answers to how they could develop interprofessional collaboration practices. The objective was to gain knowledge of how different kinds of models of collaboration worked in practice. The project aimed to stimulate the municipality and principals to take an active role in the developmental work together with school staff and collaborating partners. A key element in the design was that educational staff and collaborating partners participated in the decision-making processes to develop new and better practices in student-oriented work. Because the participating schools had different demographic compositions, different challenges for interprofessional collaboration and different student populations, the schools chose different strategies for developing interprofessional collaboration.

Two of the participating schools decided to use the resources available in the SNT project to hire a social work assistant part-time in school. Both the schools hired social worker assistants without the relevant education; however, the social worker assistants were engaged young men in the community whom the students respected. The social worker assistants’ role in the schools was loosely defined as helping teachers address day-to-day challenges, thus freeing time for teachers to concentrate on teaching and being an available adult that students could contact during school. The social work assistants had a slightly more independent role than TAs in school, in that they were hired to focus on the student environment more generally.

A third school already had a social worker, with a qualification in social work, working in school full-time. The school chose to make efforts towards better collaboration between the social worker and the teachers. The social worker in this school had a loosely defined role in the school, but she had more time for, and professional experience with, collaboration with teachers than the social work assistants did.

Experiences with the social work initiatives in the three schools were mainly positive, and most teachers expressed a desire to engage the social worker with ‘their students’. The challenge was that for the most part, the social workers worked on the principle of first come, first served. The teachers expressed that the social workers/assistants concentrated too much on individual students and not so much on the student environment as a whole. Because the social workers in all the three schools were generally free to develop their own practices in their schools, their roles and responsibilities varied. The social workers, especially the qualified social worker, also expressed difficulties in prioritizing their efforts to more prevention work. Both students and teachers contacted the social workers/assistants with challenges that for the most part filled up their calendar. Social workers/assistants found it difficult to reject or postpone requests from teachers and students.

The Principals in the three schools were only mildly involved in managing the work of the social workers/assistants. The qualified social worker was involved in a wider range of activities than the social work assistants in the other two schools. For example, she had counselling with students individually, and in groups; she had contact with parents, and contact with external services; she observed students in recess; she participated in school meetings and collaborated with the school’s nurse. The social work assistants mainly concentrated their attention on calming down situations and organizing activities in recess. They had a less independent role than the social worker in the way that the principal or teachers specifically requested their attention to certain challenges in the student environment.

This meant that having a social worker/assistant in school and the effects on teaching and learning were somewhat connected to the person in the position and not the position/profession itself. As for the social work assistants, we can connect the observations in our two case schools to research on teacher assistants, which finds that teacher assistants can be important resources in school, when they are given training and guidance relevant for their activities (Farrell, Alborz, Howes, & Pearson, 2010; Webster, Blatchford, & Russell, 2013). Although the principals and teachers were mostly satisfied with having a social worker/assistant in school, a clearer role and responsibility would maximize the quality of the work and reduce the likelihood that the work depends on the person who holds the position.

The literature review mainly found effects of targeted interventions when social workers intervened in particular problems (Allen-Meares et al., 2013; Early & Vonk, 2001; Franklin et al., 2009). In the project schools, the social workers/assistants conducted mainly targeted interventions; however, the lack of management from principals left space for conflicts of interests and difficulty in prioritizing efforts. The lack of prevention work that took place in the schools could also be managed by better clarification of roles. Ultimately, lack of leadership in the social work interventions did lead to poor implementation of the locally developed initiative.

Two of the schools in the SNT project chose to develop a more systematic collaboration culture in general, similar to Cappella et al. (2011) and Jenkins et al. (1994). Some of the teachers in the project schools reported a lack of collaboration with the school nurse, the Educational and Psychological Counselling Service and the Child Welfare Services in the municipality. The challenge with school nurses was defined as lack of time to collaborate and differences in student confidentiality requirements. nurses mainly worked at the school part-time, and only had time for legally required activities such as vaccinations and individual student conversations, so that preventive work was not prioritized.

Most of the schools also had challenges integrating the school nurse with the school staff. The teachers experienced that the school nurse, for the most part, worked in isolation with pupils and did not contribute to the integration of efforts. The implication of this finding was that double work and compartmentalization occurred rather than collaboration and innovation. Although the teachers, and sometimes the school nurses, claimed that the lack of integration was due to differences in student confidentiality requirements, the researchers observed substantial potential for better collaboration between teachers and school nurses. Assuming that school nurses could obtain more hours to work in each school, better collaboration routines could be discussed and developed.

Teachers often reported that collaboration was difficult with professions operating in the municipality with no office in the school, such as the Child Welfare Services. Generally, the explanation for this difficulty was a lack of information from these services regarding how teachers should handle situations in classrooms. More frequent contact with ‘external’ services was proposed to contribute to breaking down the barriers to collaboration. In the SNT project, we gathered external and internal school staff to participate in discussions to eliminate such barriers (in dialogue conferences). Engaging in discussions between services in municipalities was also found to be critical for collaboration practices in schools. However, the project was too brief to observe any long-term changes in collaboration practices, but both the teachers and the other professions did report better knowledge of each other and each other’s competences, which could mean that collaboration would be strengthened in the future.

One concrete initiative to overcome barriers to collaboration with school nurses and partners in the municipality involved a SNT project school asking all of its collaborating partners to attend and present their working methods regularly in school staff meetings. The activity was received positively by teachers; however, the school leader was unable to maintain this strategy for developing the interprofessional collaboration in school, resulting in the presentation activity happening just one time. The conclusion was that developmental processes need a strong leader or team to organize, manage and adjust initiatives during a project for the developmental process to be successful.

One of the project schools had such a leader dedicated to managing the developmental project during the project period. The aim of this particular school was to support and develop a new manager model implemented in the school, a model that facilitated closer collaboration between school management and teachers, assistants, students and parents. The school also aimed to develop systematic sharing of practices among teachers in such a way that teachers could develop their own practice in collaboration with colleagues, including the school nurse. We found that the principal and the staff were active and engaged in the development work to promote better collaboration between professions in the school. It is difficult to say whether the principal affected the motivation of school staff, or vice versa, but the school in question differed from the other case schools in terms of how the school staff approached development work, namely with higher levels of engagement (as shown by positive attitudes, time on task and body language).

The empirical data imply a need for better organization and facilitation of collaboration among all professions in school and external collaboration partners. One way to accomplish this is to start a development process in schools, and the best way to approach the development processes is to engage school staff and partners in discussing the challenges to collaboration and concrete plans on how to overcome those challenges. Utilizing the school’s available resources in better ways can lead to lasting collaboration, professional development and renewed and more effective efforts related to student-centred work. However, for such a dialogue-based strategy to succeed, the development process needs a leader or leader group with a clear and involved role.

Conclusion

Combining evidence from the literature review with qualitative analyses of five developmental processes, this study found that interprofessional collaboration in school is mainly constructed as (1) one non-pedagogical professional involved in interventions targeting students directly, (2) interventions that focus on teacher training (in a specific programme) by a non-pedagogical professional or (3) developing collaboration between teachers and other professionals in school.

The interventions targeting students showed that a requirement for interprofessional collaboration is often restricted to the involvement of one non-pedagogical professional in the intervention. The studies were mostly compartmentalized by profession (social work and school nurses) and professional themes. However, the effects of having a non-pedagogical professional involved were found to be positive (although small to moderate) on a range of different outcomes, such as problem behaviour, absenteeism, motivation, self-efficacy and academic attainment. This finding indicates that the professional component of an intervention is less important than the intervention itself. However, a large part of the research was conducted in a short amount of time, the programmes were of limited duration and the results were measured a short time after completion, rendering it difficult to know whether the effects would last. Studies that re-examined effects at a later stage observed either no effects (Reid & Bailey-Dempsey, 1995) or lower effects (Kvarme et al., 2010). Hence, due to the lack of long-term measurements, it is difficult to predict permanent effects on students’ levels of attainment.

A limitation of these studies is that there was no emphasis on the implementation of the intervention or on how other professions collaborated with the teachers inside or outside the classroom. The SNT projects showed a lack of effort to facilitate collaboration among different professions and thus a need to discuss expectations and define roles and responsibilities. There was a lack of professional knowledge and confusion about the professionals’ responsibilities and areas of expertise. Developing collaboration among professionals in schools may be an important element contributing to lasting effects on learning environments for students and early intervention and extra support for students in need (Ødegård, 2005; Galvin & Erdal, 2013; Willumsen & Ødegård, 2016).

Interventions that targeted teachers instead of students showed positive effects on teachers’ job satisfaction, and schools or class environments. These initiatives generally involved hiring external professionals to train the teachers in themes such as anti-bullying work and positive behaviour support, to strengthen the school’s ability to ensure that students met the learning objectives.

Few studies have investigated the effects of involving multiple professionals in a team-based collaboration with teachers. The most promising studies, however, were implemented in several different settings, lasted for more than 1 year, involved multiple agents and consisted of several components. The results showed positive teacher attitudes towards the change process, new approaches to organizing instruction and more mainstreamed instruction.

Interventions targeting teachers did not show positive effects on students’ academic achievements. However, interventions that involved the whole school were found to be the most promising for making sustainable changes. The argument is that school-based interventions are complex, in that they target teachers first and students second. One explanation for the lack of results regarding student outcomes, is that the benefits of school-based interventions require more time for effects to show than interventions that target students directly. However, these tend to fade with time (Ertesvag & Vaaland, 2007).

We generally found a lack of research describing how the effect was produced, which can partially be explained by the inclusion criteria in the literature review. The review was, therefore, unable to conclude whether a collaboration was effective and under what conditions and for what audiences. We thus used the SNT project to shed light on some of the challenges and positive drivers in developmental work, but there is a need for future research to combine different methods to identify effects and study the processes that bring them about.

Footnotes

Notes

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