Introduction

Existing research indicates that most teachers clearly recognize that mental health promotion is a part of their professional role and responsibility (Graham, Phelps, Maddison, & Fitzgerald, 2011; Roeser & Midgley, 1997). However, teachers are bound by limited training, time and resources, which makes it very difficult to address the challenges of mental health promotion alone (Hornby & Atkinson, 2003). Therefore, inter-professional collaboration is of critical importance to meet the mental health needs of students (Berzin et al., 2011; Burke & Paternite, 2007; Franklin, Kim, Ryan, Kelly, & Montgomery, 2012; Viggiani, Reid, & Bailey-Dempsey, 2002). Furthermore, as school is the most common point of entry for accessing mental health services and the only arena capable of reaching all students on a daily basis, the role of teachers and schools becomes essential in collaborative work on mental health promotion (Langley, Nadeem, Kataoka, Stein, & Jaycox, 2010; Lynn, McKay, & Atkins, 2003; Ringeisen, Henderson, & Hoagwood, 2003; Stephan, Mulloy, & Brey, 2011; Stormont, Reinke, & Herman, 2011). This paper aims to investigate teachers’ perceptions of their role in inter-professional collaboration on mental health promotion, and what they perceive to be their main challenges to such collaborative work. Data are provided from Norwegian K-12 teachers through a sequential mixed method design, which uses three focus groups followed by survey research.

The Norwegian Context

In Norway, the mental health service system in child and adolescent mental health consists of health care services such as school nurse and medical doctors, municipal mental health services such as Educational Psychology Services (EPS) and specialized mental health services such as Child and Adolescent Mental Health Services (CAMHS), located at region hospitals (Norwegian Minstry of Health & Care Services, 2005). In addition, the child welfare service is included as part of the mental health service system. The majority of mental health services are located outside of school, except from school nurses and EPS, which are normally present at school on regular, if not daily, basis. According to numbers obtained from the Norwegian Ministry of Education and Research (2009), 2 % of K-12 schools have EPS located in school as part of the school organization, 23 % have EPS present at school on regular basis, 52 % have a regular EPS contact, but no regular in-school service, and 21 % of the schools lack even a regular contact. School nurses represent approximately 50 % of all full time equivalents in school health services, whereas medical doctors represent 5 %, and school psychologists only 1 % (Kjelvik, 2007; Statistics Norway, 2013). In reality, this means that an average lower secondary school has school nurse present only 2–3 h per week, and very few schools have access to campus school psychologists. However, school counsellors/social teachers are present at most schools on a daily basis, but these are teachers, not mental health professionals, and only 50 % have additional education in psychology, sociology or other subjects relevant to mental health (Norwegian Ministry of Education & Research, 2009).

Inter-professional Collaboration at Different Levels of Intervention

Mental health promotion encompasses both the promotion of good mental health in general and the prevention of mental problems and illness (Greacen et al., 2012). Inter-professional collaborative work to promote student mental health would, therefore, include a wide range of intervention strategies at universal, targeted/selected and indicated levels (Askell-Williams & Lawson, 2013; Franklin et al., 2012; Levitt, Saka, Hunter Romanelli, & Hoagwood, 2007). Given this conceptualization of mental health, Wells, Barlow, and Stewart-Brown (2003) categorize universal intervention primarily as the promotion of mental health, and targeted/selected and indicated intervention primarily as the prevention of mental illness.

The ultimate goal of universal intervention strategies is to promote positive mental health for all students, for example, by providing anti-bullying programs and by making efforts to enhance the psychosocial environment. This includes class-based interventions as well as interventions to change the school ethos and raise the collective awareness on mental health issues amongst students and teachers. Reviews of universal intervention programs clearly show their effectiveness (Durlak, Allison, Taylor, Weissberg, & Kriston, 2011; Wells et al., 2003), but it is of great importance that teacher training in program implementation is followed up by support from school administration and mental health professionals (Andersson, Bungum, Kaspersen, Bjørngaard, & Buland, 2010; Langley et al., 2010).

Targeted/selected intervention strategies are directed at student cohorts with known risk factors that make them vulnerable to the development of mental health difficulties. Collaboration at this level primarily involves mental health professionals offering assessments of problems and suggestions for different types of school-based interventions. Mental health professionals can also be involved in the consultation and training of teachers, such as in their work with classroom management techniques and the implementation of behaviour plans. As Reinke, Stormont, Herman, Puri, and Goel (2011) pointed out, it is important that mental health professionals keep teachers well informed about the existence of different evidence-based interventions and, thus, enable them to make informed decisions in the classroom. As the students’ mental health problems become more severe and persistent, indicated intervention strategies are needed. This level of intervention involves specialist services such and intensive interventions; in the most severe cases, these are given as residential psychiatric treatments. Even though the teachers are not directly involved in therapy sessions, they play an important role in helping the students to reintegrate into school after treatment. There is also evidence that psychological well-being and academic achievement are strongly interrelated, and by helping students to improve their academics, teachers can complement and strengthen the effects of psychotherapy (Baskin, Slaten, Sorenson, & Glover-Russel, 2010). Thus, based on the understanding of mental health promotion as involving interventions at the universal, targeted/selected and indicated levels, the teacher role in inter-professional collaboration has many aspects which correspond to the levels of intervention. However, this paper gives special attention to teachers’ role in the referral process and their gatekeeping function in identifying and assessing the students’ need for help, in agreement with Ball, Anderson-Butcher, Mellin, and Green (2010) who point out that teachers have a critical role in inter-professional collaboration as key professionals in the identification and referral process.

The Gatekeeper Role in Collaborative Work

A wide range of research shows that teachers serve an important role as gateway providers/gatekeepers, in that they are front line professionals who identify students’ mental health needs and, if necessary, make referrals to mental health services (Nadeem et al., 2011; Stiffman, Pescosolido, & Cabassa, 2004; Williams, Horvath, Wei, Van Dorn, & Jonson-Reid, 2007). This role is based on teachers’ unique position, in which they can discover problems at an early stage, due to their day-to day contact with students (Langley et al., 2010; Ringeisen et al., 2003; Stephan et al., 2011; Stormont et al., 2011). Thus, teachers are active observers of students’ mental health on a daily basis.

As Weare and Markham (2005) argue, mental health problems are widespread, and if the focus of inter-professional intervention is reduced only to the targeted/selected levels, many students with minor mental health problems or no known risk factors will be ignored. Therefore, it is necessary for those in the gatekeeper role to possess good knowledge about warning signs, risk factors and indicators of mental health difficulties, but many teachers face challenges in filling this role, due to their inadequate educational training in mental health promotion. This makes teachers feel professionally unprepared, as they do not possess the necessary skills to make informed decisions about what is age-appropriate behaviour, what are normal variations in mental health and what is abnormal and needs intervention and help (Atkinson & Hornby, 2002; Kidger, Gunnell, Biddle, Campbell, & Donovan, 2010). According to the survey data referred to by Weist and Paternite (2006), 70 % of teachers expressed an interest in additional training in this field. Survey data collected from a Norwegian context has found that teachers receive minimal knowledge about mental health through their professional training (Ekornes, Hauge, & Lund, 2012). Similar findings from an international context are reported in Koller, Osterlind, Paris, and Weston (2004).

A possible consequence of poor preparation and training is that teachers become an underutilized resource in inter-professional collaboration on mental health as long as they feel ill-equipped to engage in this work (Powers, Bower, Webber, & Martinson, 2010). Following this, there is a risk of so-called “drain”, in which collaboration exists primarily in name alone and is dominated by rhetorical communication and formal protocols, as opposed to shared decision-making and the mutual exchange of information (Feinstein, Fielding, Udvari-Solner, & Joshi, 2009). Based on focus group data collected from inter-professional team meetings, Ødegård (2005) also raises the question of whether teachers are seen as true collaborative partners to be systematically included in treatment programs, or whether they are considered to be just important information providers for other services.

Identifying Possible Challenges to Collaboration Through a Contextual Organizational Perspective

A significant number of research papers identify difficulties in inter-professional collaborative work due to organizational and contextual issues, such as the lack of time and resources, vaguely defined roles and problems with communication between the professions due to confidentiality issues and different professional vocabularies (Ball et al., 2010; Choi & Pak, 2007; Hall, 2005; Holmesland, Seikkula, Nilsen, Hopfenbeck, & Arnkil, 2010; Lynn et al., 2003; Ødegård, 2005). Teachers are often unfamiliar with the psychiatric classifications, and mental health terminology that are used by mental health professionals (Gott, 2003; Kidger et al., 2010). These profession-based differences, combined with different practices regarding confidentiality, could cause problems with information exchange and communication (Feinstein et al., 2009). From a teacher perspective, inter-professional communication is further complicated due to other services’ lack of understanding of and knowledge about the school context (Burke & Paternite, 2007; Rowling, 2009). Like Rothi, Leavey, and Best (2008) pointed out, teachers unanimously state their need for ‘hands on’ training provided by mental health experts, something that requires contextual understanding in order to give feasible and relevant advice.

Finally, time constraints are an important contextual factor (Powers et al., 2010). Limited time resources in mental health services can lead to slow case processing, which leaves teachers and students to their own devices, while they wait for help and support. In school, time constraints lead to frustration and feelings of insufficiency due to the perceived gap between individual students’ need for support and teachers’ opportunity to provide it within their busy day-to-day routines (Poulou & Norwich, 2002). Additionally, teachers perceive that the logistical demands of collaborative work in mental health often come at the expense of instructional tasks (Jordfald, Nyen, & Seip, 2009). Altogether, many challenges to inter-professional collaboration are rooted in and affected by such contextual factors as time resources, service access and other services’ presence and involvement in classroom settings, and it is, therefore, important to recognize and identify the impact of these factors.

Aims and Research Questions

Various researches have explored the roles of school nurses, school social workers and school clinicians in inter-professional collaboration on mental health (Berzin et al., 2011; DeSocio & Hootman, 2004; Langley et al., 2010). This paper takes the perspective of teachers, their perceived role and their perceptions of what they consider to be the challenges of collaborative work. Based on this, two main research questions were developed:

  1. 1.

    How do teachers perceive their role in inter-professional collaboration in mental health promotion?

  2. 2.

    What do teachers perceive to be the main challenges to inter-professional collaboration in mental health promotion?

The first question addresses the teacher role and what teachers perceive to be their main tasks and responsibilities in inter-professional collaboration for mental health promotion. The second question addresses possible barriers to inter-professional collaboration as seen through a contextual organizational perspective, which focuses on how service access, time resources, perceived professional competencies, practices of confidentiality and school leadership issues affect collaborative efforts.

Methods

The present study adopts a sequential mixed method design (Creswell, 2012), utilizing focus group interviews followed by survey research. The reason for using a mixed method approach is to provide a more holistic picture than qualitative or quantitative approaches can give separately or individually. Additionally, the two data sources provide complementary and divergent information about related aspects of the same phenomenon (Tashakkori & Teddlie, 2008). In order to achieve interpretative rigour of the two strands of the study, the data are constantly compared and contrasted with one another, as well as with existing theories and the present state of knowledge in the field. According to Teddlie and Tashakkori (2009), design quality is comprised of four aspects: design suitability, design fidelity, internal consistency and analytic adequacy. In this paper, brief narrative descriptions of the construction of the focus group protocol and survey questionnaire are given in order to make the design quality of the study more transparent and reliable.

Sampling and Sample Characteristics

Three different focus group interviews with a total of fifteen teachers from grades 8–13 were conducted in December 2011 through January 2012 in three different municipalities in the western part of Norway. The schools were located in both urban and rural areas. Eleven women and four men in total volunteered to participate and gave their informed consent after having received written and oral information about the study at a meeting for teacher practice supervisors. The sample characteristics are displayed in Table 1.

Table 1 Focus group sample characteristics
Full size table

Group members were from the same school, which made the groups homogenous in their organizational context, and the group members were familiar to one another, which was intended to inspire reflection on everyday experiences and more open sharing of attitudes and opinions (Kitzinger & Barbour, 1999; Williams et al., 2007).

The survey data were collected from April to June 2012, in three different counties in the western part of Norway. In total, 51 state schools were selected by simple random stratified sampling, and the total number of respondents were n = 1575. The response rate was 49 % (n = 771). All participants received e-mail information about the study and were granted confidentiality protection. Table 2 gives an overview of the independent (background) variables and the number of respondents in each category.

Table 2 Survey sample characteristics
Full size table

Measures

The focus group protocol and its interview categories were mainly derived from a review of existing research and literature on school mental health. Based on this, the protocol contained a total of eight themes; (1) conceptual understanding of mental health, (2) perceived competence in mental health, (3) tension between policy and profession, (4) school organization, (5) inter-professional collaboration, (6) collaboration with parents, (7) school culture and (8) future perspectives. In this paper, the theme of inter-professional collaboration was selected for further analysis. Even though the interview guide was semi-structured, the theme of inter-professional collaboration contained four explicit questions:

  1. 1.

    When you suspect that one of your students is having mental health problems and not coping well, is it easy or hard to provide early help and interventions? Can you suggest some possible reasons for why it is so?

  2. 2.

    Is the teacher role clearly or vaguely defined regarding your professional responsibility towards students with mental health difficulties?

  3. 3.

    Do you consider yourself as central in following up with students also after referrals are made and other professionals are involved?

  4. 4.

    How do you perceive your ability to help students within the classroom context?

Three out of four questions were closed-ended, indicating a highly structured approach to focus group interviewing. This offers the researcher a better opportunity to follow the same order of topics and questions from group to group and provides basic control over the content and direction of discussion (Morgan, 1997). Given the sequential design, in which focus group data guided the construction of survey questions and items, a highly structured approach was regarded best suited to obtain design quality.

The survey measured different aspects of the teachers’ role and responsibility in mental health promotion and the questionnaire contained a total of 10 Likert scale questions (84 items), three open response categories and 10 background variables. Out of these, eight individual items, one question measuring the quality of collaboration and one open response category measuring teachers’ perceived barriers to collaboration were selected for analysis in the present paper. These individual items do not amount to reliability-tested indexes or scales, indented to measure defined constructs, but provide descriptive data on different thematic aspects of collaboration. The eight items are presented in Table 3.

Table 3 Eight individual survey items with Likert scaled responses
Full size table

The survey item construction, with regard to inter-professional collaboration, was inspired by recent research from an effect evaluation of mental health training programmes in Norway (Kaspersen et al., 2009), paying attention to teachers’ perceptions of their access to mental health services and their need for inter-professional collaboration as well as its outcomes. Furthermore, the quality of inter-professional collaboration was frequently discussed by the focus group participants. Based on the sequential and explorative nature of the design, this issue of quality was, therefore, included as a survey question, which asked teachers to assess the quality of collaboration with different services/groups of professionals on a Likert scale ranging from 1 = very bad to 5 = very good. The open response category explored teachers’ perceived reasons for poor quality of collaboration.

Procedures

The focus group interviews were conducted, tape-recorded and transcribed by the author. The coding was done in the NVivo.10 software, providing exact counts of all the mentions of a given code, both at the individual and group levels. The initial coding started out with seven main coding categories and 30 subcategories. Out of these, four main coding categories and 15 subcategories were selected for the purpose of this paper. These coding categories are presented in Fig. 1.

Fig. 1
figure 1

Overview of main coding categories and subcategories in focus group data

Full size image

The coding categories in Fig. 1 were created based on theoretical assumptions and existing research in the field, whereas the subcategories were mainly derived from ‘group-to-group validation’, in which the frequency and attention given to the issues served as the selection criteria for relevant coding categories (Morgan, 1997, p. 63). Thus, the analytical process was a combination of data-driven and concept-driven approaches (Gibbs, 2002), using abductive coding to combine deductive and inductive reasoning. The type of analysis applied can also be identified as constant comparison analysis, the main aim of which is to reduce data to codes and develop themes based on these codes (Onwuegbuzie & Combs, 2010).

The survey was piloted by six K-12 teachers, two from each school type. The questionnaire was also thoroughly reviewed by two different research groups and representatives from the national cooperative project of Mental Health in Schools. The survey data were analysed through simple descriptive statistics, showing the distribution of answers to the different questions. In addition, ANOVA and t tests were performed to identify variance between groups. When analysing the open response category, classical content analysis was applied. Here, the number of codes was counted in order to identify the most cited concepts throughout the data (Leech & Onwuegbuzie, 2008), and through axial coding, six main challenges to collaboration were identified. Recognizing the danger of decontextualization (Bergman, 2010), the statistical results were interpreted in conjunction with quotations displayed in full length in the paper.

An Integrative Mixed Method Framework

In order to obtain a quality design in mixed method research, integration of the different strands of the study is important in all aspects of the design (Tashakkori & Teddlie, 2008). Table 4 illustrates how the two data sources of this study are intended to address the two main research questions and how they provide complementary information (see also Table 3; Fig. 1 for a detailed presentation of survey items and focus group coding categories).

Table 4 Overview of research questions and source data
Full size table

Results

Based on the research design and integrative framework presented in Table 4, the results are presented by mixing qualitative and quantitative data in order to address the two main research questions of this paper, exploring teachers’ perceived role in and barriers to inter-professional collaboration in mental health promotion.

Exploring Teacher Role in Inter-professional Collaboration: ‘That is My Task I Feel—To Refer Them to Mental Health Services’

In the administered survey, teachers were asked to mark their agreement to the statement: The school is uniquely positioned to discover mental health difficulties at an early stage. The Likert scale ranged from 1 = strongly disagree to 5 = strongly agree, with a neutral mid-point. Teachers’ recognition of their unique position in the identification and referral system was clearly indicated, as 79.7 % of teachers somewhat or strongly agreed with this statement (M = 4.08, SD = .85, n = 757). However, focus group data highlighted teachers’ need to define themselves as educators, not psychologists. Thus, teachers seemed to perceive their main role in inter-professional collaboration in mental health promotion as that of the ‘gatekeeper’, whose responsibility is to identify and observe mental health needs and, if necessary, make referrals to mental health services. The following focus group quote is quite illustrative:

Let me put it this way; I don’t want to be my students’ psychologist. I am not a psychologist, but I do want to get them to take their problems seriously. That is my task, I feel, to refer them to mental health services….Because, pretending to be a psychologist and believing that teachers can cure students of severe depression and things like that, is not something I believe in. I believe all we can do is to keep our eyes open, observe and report to our superiors. (Female, 66, upper secondary school)

Related to this, the issue of teacher competence in mental health comes forth as teachers’ perceived ability to fulfil the ‘gatekeeper’ role greatly depended on their perceived ability to assess the nature and severity of problems. Survey data addressed the issue though three different items and the descriptive statistics are presented in Fig. 2.

Fig. 2
figure 2

Percentage distribution of answers to individual items measuring teachers’ perceived challenges to their competence in mental health

Full size image

As Fig. 2 indicates, the vast majority (68.6 %) of the teachers agree that it is hard to assess the severity of the students’ mental health difficulties. To some extent, it also seemed to be difficult for teachers to actually identify the issues and the need for help. These findings are supported by focus group data, in which the teachers, regardless of teaching experience, sometimes found it difficult to separate what they called ‘normal teenager mood swings’ from more severe problems in order to identify potential mental health issues and assess their severity. This competence problem was mainly attributed to limited professional training on mental health during their undergraduate preparation, like a young teacher described it:

I am thinking about the role you have as a newly qualified novice teacher. You are professionally trained in pedagogy and teaching, right? Not to look for what sort of mental health problems you might be faced with. ‘You feel you are on thin ice here, regarding all that sort of thing…. Because you don’t have professional expertise in that field. You’re just using normal common sense, when you can see that there is something wrong. But we can’t start making a diagnosis. We can only say what we think it might be. But we must sort of realize our limitations, and then make it clear that someone else has to take over. (Male, 34, lower secondary school)

Additionally, it can be difficult for teachers to discover mental health problems at an early stage, even if they consider themselves to be uniquely positioned to do so. Often, the students’ mental problems can be very well hidden for different reasons: for example, the parents’ fear of stigmatization. This situation is described by a female teacher (59) at a lower secondary school: ‘If you show your concern, there are parents that do not want us to…It is not often, but it has to do with being given a diagnosis and the fear of their child being stigmatized’. In other cases, the students are good at keeping up appearances and show few warning signs:

Sometimes it is obvious, and it is written all over them that there is something wrong. But with others, I have to say that perhaps I wouldn’t have noticed anything, if it wasn’t for their frequent absence from school…. Some are very good at hiding their problems, I think! (Female, 53, lower secondary school)

There are hidden mental illnesses that they would rather not divulge - and then they have a meltdown, and everything falls apart and you are completely shocked. ‘Cause it might be very clever students, and suddenly they just… (Female 63, upper secondary school)

In sum, the gatekeeper role is regarded as a prominent yet difficult role for teachers in inter-professional collaboration, as mental health problems can be hard to discover, identify and assess. This is not only due to limited teacher knowledge about warning signs and risk factors, but equally because problems can be very well hidden.

Exploring Perceived Challenges to Collaboration

In this paper, the gatekeeper role, as described above, and its respective demand for competency serve as a point of departure for exploring challenges to inter-professional collaboration, but the present data also identify challenging aspects of collaboration with regard to the implementation of interventions and how to follow-up with students in a classroom setting after referrals are made. In the open response categories in the survey, teachers gave multiple reasons for poor collaboration, indicating, from their points of view, what factors hinder the best possible provision of assistance to students with mental health needs. The results are presented in Fig. 3.

Fig. 3
figure 3

Teachers’ perceived reasons for poor quality of inter-professional collaboration based on open response answers in survey data. The number of respondents in open survey category was n = 196. However, due to the complexity of the answers, some of the responses were coded in more than one category, giving a total number of references n = 215. MH mental health

Full size image

Through axial coding, the single coding categories/nodes in Fig. 3 were collapsed into six analytical categories that identify the main challenges to collaboration: communication and confidentiality, time constraints, contextual presence, cross-systems contact, school leadership and teacher competence in mental health. All of the challenges were ranked by their importance, which was based on the number of references in each coding category. The six main challenges, their original coding categories and their illustrative quotes are presented in Table 5.

Table 5 Six main challenges to inter-professional collaboration—with illustrative quotations from survey data
Full size table

The six challenges identified above are elaborated on below, combining focus group data and survey data from the open response category. Answers from survey respondents are referred to throughout as ‘SR’, whereas answers from the focus group informants are referred to by gender, age and school type.

The Challenge of Communication and Confidentiality

Confidentiality was the issue most frequently mentioned as an obstacle to communication in inter-professional collaboration, in both the survey data and focus group data. The problem was independent of services. Confidentiality was frequently described as ‘unidirectional’, in which teachers gave extensive information about students without receiving any information in return. Thus, teachers often felt ‘left in the dark’ after interventions or treatment were initiated, making it difficult for them to follow-up with students through the day-to day routine. The expressions ‘hide behind the confidentiality’ and ‘bound by confidentiality’ are often recurring in the data, and the problem of information exchange was well described by one of the survey respondents:

Of course, as a teacher I do not need to know everything that is talked about, but I often feel like I’ve been dealt the poorest hand, knowing little or nothing, and therefore I’m not able to provide help when it’s really needed either as teacher or a fellow human being. (SR)

The importance of being informed to be able to help the students was also clearly stated by the focus group participants, and as a female teacher (59) in lower secondary school said: ‘It is not easy, because it’s so confidential. To my mind, if you are supposed to be something to a person, you have to be involved’. Although teachers clearly respect confidentiality, they also find the need for a pragmatic approach to it, in which practices of confidentiality are guided by what is perceived to be good for the students. The following quote is representative for this view:

We fear confidentiality a bit too. Sort of, what are the boundaries? Often, you need to discuss with others (…) I believe it is in the best interest of the student that we can discuss things with each other. Therefore, we choose to have more of a pragmatic approach to this. (Female, 42, upper secondary school)

The Challenge of Time Constraints

Second after confidentiality, the lack of time is the most frequently mentioned as a source of poor collaboration (Fig. 3). This is mainly due to limited resources, heavy workloads and the shortage of staff in school as well as in other services. As for mental health services, limited resources lead to case processing delays, which teachers find highly frustrating in case of urgent problems, and teachers often feel left to their own devices to cope.

Other services are very positive when we contact them and call for a meeting, and there is a quick response to initiate one. But of course, they too are short of resources, aren’t they? So the questions of what next and where to go from here are often up to us to figure out. We get some advice on how to do things, but in the end, it’s left to us to do something about it. This is a challenge! (Male, 38, lower secondary school)

The same teacher also elaborated on the conflict of interest in prioritizing between mental health issues and teaching tasks. He described it as ‘parallel driving’, juggling time spent on academic demands versus personal relations. Giving special attention to one student necessitates lessening attention to the other 20–25 students in class, and this dilemma is likely to cause a constant feeling of shortcoming. One teacher in the survey data actually felt that ‘not having the time you need to follow-up’ was the worst thing about being a teacher.

The Challenge of Contextual Presence and Understanding

As the quotes in Table 5 indicate, teachers are unanimous in their need for mental health professionals to visit their school more often and gain more understanding of the day-to day routine and daily life of students. A female teacher (53 years old) at lower secondary school described collaborative problems with CAMHS due to being in ‘two separate worlds’, in which CAMHS have not observed the student in the classroom setting and thus have a limited understanding of the nature of the problem. In general, the teachers call for more ‘hands on’ advice from psychologists and doctors on how to relate to students with mental health needs. In order to give relevant and useful advice, mental health professionals need to spend more time in schools. One survey respondent reasoned like this: ‘the other professionals often don’t know the child as well as those of us who work closely with them and they are therefore not able to give relevant advice’.

Additionally, teachers believe that inter-professional collaboration is strongly affected by service availability and state their clear concerns for the schools’ poor access to mental health professionals. For example, at one of the schools of the focus group sample, the school nurse was present approximately only 2 h per week. One of the teachers found this very unsatisfactory:

I miss having a much larger team of experts in pastoral care at the school. I just do not understand how it can be legal to have a school with over 400 students without a school nurse present at least two days a week or so… That mental health issues are not taken more seriously! (Male, 38, lower secondary school)

The survey data support that this is a representative situation for the schools in the study sample, as poor access to school nurse is frequently mentioned in the open response category as a major challenge to collaboration.

The Challenge of Cross-Systems Contact

This challenge is closely related to that of contextual presence and understanding but is more focused on weak professional traditions for collaboration, indicating that much of the contact between school and services like doctors and child welfare services, seems to be crisis-driven and not orientated towards collaboration at universal intervention levels. One survey respondent put the challenge plainly:

The only time we are in contact with the doctor is in the case of a crisis. There should have been better collaboration in terms of the doctors making themselves more visible to students and, for example, coming to school to inform about mental health. This is also the case for CAMHS and child welfare services. (SR)

With regard to the need for more collaboration at universal intervention levels, one of the teachers in the focus group data also suggested creating a ‘mental health mentor’ arrangement as part of inter-professional collaboration:

In the business world, they have mentors. I wish we could have had something similar here, where you could talk to someone, be observed and get feedback. We should have had professional mentors that could convey this kind of simple thing. (Male, 38, lower secondary school)

The key point is the teachers’ need for practical advice from mental health professionals in a classroom context as well as enhanced cross-systems contact beyond crisis management.

The Challenge of School Leadership

The essence of this challenge is that weak school leadership often represents a poor integration of mental health promotion in school routines and policy, relying too much on the individual teachers’ abilities and engagement to provide help when problems occur. A survey respondent made the following claim, pointing to the need for inter-professional collaboration to provide high-quality interventions: ‘The school relies on the teacher as a ‘hobby-psychologist’ and believes that is good enough. If we are to do any preventive work in school, this must be quality assured by properly qualified experts’. Focus group data support the claim of high pressure on the individual teachers, but underscore, at the same time, the impact that strong school leadership can have in supporting teachers in their daily efforts to promote student mental health:

There is a pressure upon us, and if you feel you can’t manage, the administration plays a very important role. I believe this is so much more important than having lecturers and projects and all other sorts of things. In other words, the daily follow-up is quite essential! (Male 34, lower secondary school)

This teacher also highlighted the importance of school administration to initiate and facilitate inter-professional collaboration, through creating what he called ‘tight bounds’ between the school and other services.

The Challenge of Teacher Competence in Mental Health

Finally, as the findings in Fig. 2 previously indicated, uncertainty with regard to what are ‘normal variations’ and what needs help is identified as a prominent challenge to teacher competence, and to their gatekeeping role in particular. If teachers make the wrong judgments here, it can hinder the student’s opportunity to receive appropriate help. Furthermore, teachers commonly express a fear of making things worse if they say or do the wrong things and are, therefore, reluctant to intervene. One of the survey respondents described the challenge: ‘In school, it’s the lack of expertise that makes collaboration difficult, both before and after referrals are made. You don’t know what to look for and are afraid of making things worse if you intervene’. This quote shows that the teachers’ need for knowledge not only regards warning signs and risk factors, but also encompasses evidence-based knowledge about how to implement interventions and follow-up with students after referrals are made.

Exploring the Challenges of Inter-professional Collaboration Further Through Descriptive Statistics and Analysis of Variance

The administered survey contained four items that measured teachers’ perceptions of: (a) knowledge outcomes of inter-professional collaboration, (b) the importance of inter-professional collaboration to enhance teachers’ ability to help students with mental difficulties, (c) their schools’ access to mental health services and (d) the overall quality of the cross-systems collaboration at their school. The descriptive results are presented in Fig. 4.

Fig. 4
figure 4

Individual and organizational aspects of inter-professional collaboration. Percentage distribution of answers to single items measuring individual aspects such as teachers’ need for support in order to provide help and their perceived knowledge outcomes of collaboration, and organizational aspects such as the schools’ access to help services and how well the school collaborates with these services in general

Full size image

The teachers’ perceived knowledge outcomes of inter-professional collaboration seem to be moderate as 34.8 % disagree and 41.8 % only somewhat agree that they have gained knowledge about the issue of mental health through collaboration with mental health services. Still, 39.7 % of the teachers agree or strongly agree that their ability to help students with mental health difficulties totally depends on receiving support from the mental health services. However, the schools’ access to these services varies and 45.5 % of the teachers only somewhat agree that their school has good access to child and adolescent mental health professionals. In spite of this, the vast majority of teachers (66.6 %) agree or strongly agree that their school collaborates well with mental health services. However, the respondents were also asked to give a differentiated account for their perceived quality of collaboration with the different groups of professionals involved in mental health services. The descriptive results are presented in Table 6.

Table 6 Teachers’ perceived quality of collaboration in mental health promotion with different services/groups of professionals. Percentage distribution of answers (%)
Full size table

As Table 6 indicates, the majority of teachers experienced the quality of inter-professional collaboration as good or very good, especially with regard to school nurses and Educational Psychological Services. The poorest quality of collaborative experiences seems to be with medical doctors, rated as good or very good by only 17.7 % of the teachers. In addition, a high percentage of the teachers (33.3 %) also reported having no experience with this kind of collaboration at all. The same situation somewhat applied to child welfare services, but here the quality of existing collaboration was generally perceived as better.

Finally, in order to explore the impact of different background variables on the items in Fig. 4, a series of one-way analysis of variance (ANOVA) was conducted with the independent variables of school type, school size, years of experience, educational background and participation in mental health training programs. For the background variables of additional education and gender, independent t tests were conducted. The one-way ANOVA, F(2, 170) = 4.13, p = .018, η 2 = .008, demonstrated significant between group differences in school size on the dependent variable of ‘Our school collaborates well with mental health services’. Post hoc comparisons using the Tukey HSD test indicated that the mean score for small schools (M = 3.97, SD = .68) was significantly different from that of large schools (M = 3.70, SD = .75). On the dependent variable of ‘Our school has good access to child and adolescent mental health professionals’, there were significant differences between groups on the independent variables of school type, F(2, 454) = 10.39, p < .001, η 2 = .025, and educational background, F(3, 754) = 4.71, p = .003, η 2 = .018. Tukey HSD indicated that the mean score for upper secondary schools (M = 3.49, SD = .87) differed significantly from that of lower secondary schools (M = 3.26, SD = .87) and primary schools (M = 3.16, SD = .76). Furthermore, the mean score for teachers educated at bachelor level (M = 3.28, SD = .85) differed significantly from teachers educated at master level (M = 3.51, SD = .89) and teachers with no formal teacher education (M = 3.76, SD = .77). Finally, ANOVA showed significant between group differences in school type, F(2, 458) = 5.95, p = .003, η 2 = .013, and participation in mental health training programs F(2, 757 = 17.90), p < .001, η 2 = .037 on the dependent variable of ‘I have gained knowledge about mental health through collaboration with mental health services’. The results from the Tukey HSD demonstrated that the mean score for teachers at primary school (M = 3.03, SD = .88) differed significantly from the mean score for teachers at lower secondary school (M = 2.78, SD = .98) and upper secondary school (M = 2.75, SD = 1.10). t tests also showed significant gender differences on this dependent variable, in the score for females (M = 2.91, SD = .98) and males (M = 2.69, SD = 1.01; t(557) = −2.84, p = .005) and in the scores for teachers with (M = 3.10, SD = 1.03) and without additional education in psychology and/or special education (M = 2.73, SD = .97; t(745) = −4.53, p < .001. However, the effect sizes (Cohens’ d) were small (d = .22 and d = .38, respectively). On the dependent variable: ‘My ability to help students with mental health difficulties totally depends on support from mental health services’, t tests showed significant gender differences in scores for males (M = 3.12, SD = .95) and females (M = 3.35, SD = 1.03; t(587.354) = −3.10, p = .002), but the magnitude of the difference was small (d = .23).

Taken together, these results suggest that teachers at small schools perceive the quality of cross-systems collaboration as better than teachers at larger schools do, and teachers at upper secondary schools report better access to mental health professionals than teachers at primary and lower secondary schools do. However, teachers at primary schools report greater knowledge outcomes on mental health through inter-professional collaboration than teachers at higher grades do. Similar significant positive knowledge outcomes were found for female teachers and for teachers who have participated in mental health training programs. Finally, the results indicate that females, more than males perceive themselves as totally dependent on support from mental health services in order to help students with mental health problems.

Summary of Findings

The gatekeeper role, which is responsible for the identification and assessment of mental health needs as a basis for referral to mental health services, is a prominent role of teachers in inter-professional collaboration. This role can be a challenging one, because teachers lack training and have been poorly prepared in the identification of warning signs and risk factors. Thus, the need for improved teacher competency in mental health promotion was identified as one of the six challenges to inter-professional collaboration. However, the single greatest challenge to collaboration was that of communication and confidentiality issues. Teachers often feel they are just providers and not receivers of information, which makes them feel ‘left in the dark’ after referrals are made and not fully included as partners in inter-professional interventions. Furthermore, teachers’ perceived quality and frequency of collaboration vary greatly across services, in which school nurses and EPS are given the highest ratings, while doctors and child welfare services are given the lowest. The availability and presence of mental health professionals in schools are a significant challenge, and teachers unanimously call for more in-service training and advice from these professionals—although they recognize the problem of resource availability in mental health services, which is similar to the challenge of time constraints in school. Finally, strong school leadership is regarded as essential to support teachers and to facilitate inter-professional collaboration to meet students’ different mental health needs.

Discussion

Challenges to inter-professional collaboration in mental health are well documented in previous research but are most commonly considered through the perspective of implementing mental health programs or through the perspective of school-based mental health services. This paper’s unique contribution to the research field is in the identification of the teacher role with regard to inter-professional work and perceived challenges to collaboration as seen from the teachers’ perspective. Based on data provided by Norwegian K-12 teachers, the teacher role in inter-professional collaboration is explored, and six main challenges to collaborative work are identified.

The vast majority of teachers recognize their unique position to discover child and adolescent mental health difficulties at an early stage. This makes the gatekeeper role prominent to them. However, teachers also realize that mental health promotion encompasses more than the assessment of issues, and they recognize the importance of inter-professional collaboration at all levels of intervention to prevent mental illness and to promote mental health for all students. In fact, 39.7 % of the surveyed teachers, and females significantly more than males, responded that their ability to help students with mental health difficulties totally depends on receiving support from mental health services. Further research is needed to explore these gender differences, but the main point is that teachers consider inter-professional collaboration as highly necessary in school mental health promotion. Therefore, as Langley et al. (2010) pointed out, to enhance inter-professional collaboration and provide the best possible interventions, we need to identify collaborative barriers and what factors that enhance the likelihood for these barriers to be surmounted.

Multiple Challenges to Inter-professional Collaboration

The present data identifies six main challenges to collaboration. These are the challenges of communication and confidentiality, time constraints, contextual presence and understanding, cross-systems contact, school leadership and teacher competence in mental health. Based on the contextual organizational perspective of this study, school leadership is considered to be an overriding challenge, which is important for facilitating inter-professional collaboration through the provision of clear guidelines for referrals, effective resource allocation, and day-to-day support for teachers in their efforts to implement interventions and meet the mental health needs of students. However, all six challenges somewhat overlap and interrelate, indicating the complexity of inter-professional collaboration.

In interview data reported by Rothi et al. (2008), teachers cited poor training and a lack of information as major barriers for them to engage in mental health promotion and follow-up with students with regard to their mental health needs. These barriers are mirrored in the findings presented in this paper, which show that many teachers feel professionally ill-equipped to identify early warning signs and to decide whether or not problems that they have identified need professional help. Teachers are also afraid of worsening the situation by saying or doing the wrong things. These results are well supported by international research (Graham et al., 2011; Kidger et al., 2010). Thus, when students start to develop mental health problems, teachers’ need for proper information, guidance and in-service training from mental health professionals increases. In the present data, teachers who have participated in mental health training programs report significantly better knowledge outcomes than other teachers. However, the overall knowledge outcomes from inter-professional collaboration seem to be rather moderate, as only 23.4 % of the teachers agree or strongly agree that they have gained knowledge about mental health through such work. Furthermore, primary school teachers report having significantly greater knowledge outcomes than teachers at higher grades, something which might be attributed to case that inter-professional collaboration takes place more widely in primary schools at the universal intervention level, in which the provision of general information on mental health issues is central. As students grow older, mental health problems become more persistent and severe, which calls for more collaboration at the selected/targeted and indicated intervention levels, in which confidentiality issues often are perceived to obstruct communication and information exchange. The findings in this paper show that teachers commonly describe mental health professionals as ‘hiding behind’ confidentiality and blame it for creating ‘firewalls’ between professions (Table 5). This is supported by findings reported in Holen and Waagene (2014), showing that confidentiality issues are a particular barrier for collaboration with specialist services such as CAMHS.

Obviously, as Ball et al. (2010) argue, teachers and mental health professionals have different expectations regarding confidentiality, which are based on their differences in work context and educational training. The present findings, however, clearly suggest that teachers have no desire or need to know everything about their students, but they do need to know something regarding students’ conditions in order to help them in the classroom. This ‘pragmatic’ approach to confidentiality is in line with the aim to improve quality of care and treatment as an important reason for sharing personal information (Baker, 2008). Therefore, as Feinstein et al. (2009) pointed out, it is crucial to clarify what can and cannot be communicated and, thus, define the possible areas of conversation. By doing so, confidentiality no longer needs to be equal to silence. However, this requires regular meetings between teachers and mental health professionals, in which the communication process itself can be discussed. In general, further research is needed to examine differences in inter-professional communication challenges that depend upon intervention levels.

Although regular and frequent meetings between teachers and social workers have clearly proven to facilitate communication and help effectiveness (Viggiani et al., 2002), the challenges of time constraints and poor cross-systems contact make regular communication difficult to implement. This is highly supported by the present findings. At the universal levels of intervention, limited time resources prevent teachers from engaging in mental health issues or giving priority to them in the day-to-day routine, whereas at indicated/selected and targeted levels, time constraints make it difficult, for example, to follow-up on students’ mental health needs and to attend inter-professional team meetings. Likewise, Forman, Olin, Hoagwood, Crowe, and Saka (2009) reported the dearth of time as a significant barrier for teachers’ engagement in mental health promotion. In addition, limited time resources in other services lead to case processing delays and leave teachers and students to their own devices long after referrals are made.

In general, as Powers et al. (2010) pointed out, teachers often feel isolated in their work with students’ mental health needs. As the present data clearly suggest, teachers call for more in-service support and training from mental health professionals, such as psychologists and doctors. However, they often find advice from mental health professionals to be unfeasible and irrelevant, due to these professionals’ limited presence in and knowledge of the school and classroom settings. As the survey data indicate (Table 6), teachers’ perceived quality of inter-professional collaboration seems to be affected by service access, and the services that are least present in schools, including doctors, child welfare services and CAMHS, are given the lowest quality scores. These findings are supported by Andersson et al. (2010), who found that organizational differences are likely to affect the quality of inter-professional collaboration. However, cross-cultural studies are needed to examine the differences in teachers’ perceptions of inter-professional collaboration as a function of the service delivery system.

Regarding the challenge of little cross-systems contact, the present data show that medical doctors are the professional group with whom teachers have the least collaborative experience and the poorest quality of collaboration. In general, doctors are described by teachers as difficult to contact, disinterested in preventive work, minimally involved in schools and only then in the event of a crisis. Similar findings were reported by the Norwegian Board of Health Supervision (2009), which found that doctors are often poorly represented in responsibility groupsFootnote 1 and that there are weak traditions for collaboration between schools and doctors. A partial explanation for this might be the tendency of schools to be too crisis-driven and to have too little of a focus on preventive work in inter-professional collaboration on mental health (Langley et al., 2010). However, research shows that teachers’ involvement in school-based interventions that aimed at breaking down stigmas and barriers is a significant factor in motivating students with severe mental health problems to seek help from doctors (Mariu, Merry, Robinson, Watson et al., 2012; Wilson, Deane, Marshall, & Dalley, 2008). Thus, greater contact between schools and doctors is warranted in order to provide the best possible help to students with mental health needs. Nonetheless, as Feinstein et al. (2009) pointed out, even if the importance of collaboration is widely recognized, many mental health professionals are unfamiliar with the nature of the roles of school staff and struggle to identify effective collaborative liaisons in schools. This would seem to call for better pre-service training of all professionals involved in mental health promotion, as to how they can better establish and maintain positive inter-professional relations. It is also important that the process of seeking help and establishing inter-professional collaboration is not relegated as the responsibility of individual teachers, but something that is supported at the organizational level as an integrated part of school leadership.

School Leadership as the Linchpin for Inter-professional Collaborative Efforts

Based on the contextual organizational perspective of this paper, it is important to discuss challenges to inter-professional collaboration in the light of school leadership and its role in facilitating collaboration. The present data show that support from school administration is of crucial importance for teachers in their efforts to promote student mental health and to deal with different sorts of student mental health difficulties. These findings are thoroughly supported by other research, identifying a lack of institutional support, unclear roles and minimal shared knowledge as major barriers for inter-professional mental health promotion in schools (Ball et al., 2010; Choi & Pak, 2007; Lynn et al., 2003; Ødegård, 2005). Therefore, weak school leadership, with regard to poorly articulated policies on mental health promotion and missing guidelines regarding the referral process, clearly represents challenges to inter-professional collaboration and increases the risk that interventions would become arbitrary and left to the individual teacher’s personal abilities and engagement. As Weare and Nind (2011) pointed out in their review of mental health interventions in schools, the effectiveness of interventions strongly depends on coordinated work with other services. Given that time constraints present a major challenge in both school and in other services, the effective allocation of existing resources, therefore, becomes an important leadership task.

Nonetheless, the most important aspect of school leadership in inter-professional collaboration on mental health seems to be schools’ ability to be proactive in their approach. According to Feigenberg, Watts, and Buckner (2010), proactive schools recognize how mental health affects students’ learning outcomes and are able to take action and intervene before these problems occur or escalate. In addition, as Rowling (2009) pointed out, leadership in health promotion includes providing formal means for mental health promotion in school documents as well as efforts to clarify referral pathways, support teamwork and strengthen school-based resources allocated for the prevention and treatment of mental health issues. Thus, as Weare and Markham (2005) argued, schools’ ability to consider several organizational aspects simultaneously, including ethos, communication, policies and relations with other services, are all key elements in a ‘whole school approach’ to mental health promotion. The importance of these aspects of school leadership is well supported by the findings presented in this paper, which indicates that school leadership serves both a symbolic function in raising awareness of mental health as an important issue in school context and a practical function in facilitating collaborative work through the provision of support and guidelines for referrals and interventions.

Conclusion

This paper has identified six challenges to collaboration: communication and confidentiality, time constraints, contextual presence and understanding, cross-systems contact, school leadership and teacher competence in mental health. These are all somewhat interrelated, and the main takeaway is the teachers’ need for support from mental health professionals as well as from the school administration, in their daily efforts to promote student mental health. The challenges also highlight the importance of mutual information exchange between teachers and mental health services as well as greater access to mental health professionals in schools. Additionally, it is of critical importance, based on teachers’ central gatekeeping role, to provide teachers with enhanced knowledge of warning signs and risk factors for mental health problems, as well as knowledge about evidence-based interventions and advice on how to follow-up with students in the classroom setting. This knowledge can, to some extent, be gained through participation in mental health training programs and in-service guidance, but there is still a need to strengthen the knowledge base on mental health promotion in the pre-service training of teachers. Finally, there is a need for a greater focus on the establishment of inter-professional liaisons and confidentiality practices in the educational training of all professionals involved in mental health promotion in schools.

Limitations of the Study

Although this study provides some insights into how teachers perceive their role in inter-professional collaboration and into what they identify as the main challenges to collaboration, several limitations must be taken into consideration when interpreting the results. First, as this study takes on the teachers’ perspective, it is a one-sided view of collaboration. Thus, the assessments of the quality of collaboration are not balanced with the views of the other parties. Second, the use of classical content analysis for the open response data, such as counting the number of references, calls for cautious interpretation regarding the most prominent challenges. The number of references in each node and in each category of nodes is affected by the coding criteria. Sometimes, an open response answer can be multifaceted and difficult to interpret and code. Therefore, in order to minimize the risk of decontextualization and the fragmentation of meaning, the node count is supplemented by full-length quotations. The use of a mixed method design also strengthens the interpretation of the open response data, as the focus group provide complementary information. Finally, there is a methodological limitation related to the representativeness and generalizability of the study. Those who are the most engaged in the mental health issues are also those who are most likely to respond to the survey in general, and to the open response categories in particular, which could alter the representation of the population in the study. Additionally, differences in how the mental health service system is organized in different countries affect, to some extent, how much the data can be generally applied. Nonetheless, the findings are likely to have international relevance, as they address universal challenges to inter-professional collaboration with regard to confidentiality issues, knowledge demands, time constraints and school leadership.