A floating concept and blurred teacher responsibilities: Local interpretations of health promotion work in Swedish upper secondary schools

Abstract

This study explores the discourse about health promotion and the role of the teacher in Swedish upper secondary schools. The material consists of student health plans from schools and local authorities that were analysed using discourse analysis. The results show that health promotion is largely an empty or floating signifier. The teacher is mainly in discursive shadow. When the teacher is in discursive light, their role in health promotion is connected to ordinary teacher tasks. Schools can set out what health promotion entails to a greater extent and clarify the role of the teacher.

Keywords:

• Recontextualisation
• empty signifier
• semantic mess
• attribution of responsibility
• removal of responsibility
• professional identity of teachers

1. Introduction

In Sweden, as well as globally, schools have been identified as important places for health promotion work (Matthews et al., 2015; Weare & Nind, 2011), but the term “health promotion” is vague and fuzzy (Woodall & Freeman, 2020). In 1985, Tannahill described the term as “a semantic mess” (Tannahill, 1985, 167) and, more recently, other researchers maintained that the confusion around the term had negatively affected the practical work because broad, unclear definitions can lead to uncertainty about what should be done (Lindström, 2018). In the Swedish Education Act of 2010, stress is placed on the responsibility of schools for health promotion work (Swedish Government Offices, 2019), but what is actually meant in concrete terms is left to school managers and schools to determine.

According to the Swedish National Agency for Education (2021a), the administrative authority responsible for supporting and governing schools, every professional within the school system must work to promote health. The Swedish Education Act (Swedish Government Offices, 2019) actually links promotion and prevention in the area of health to student health service staff (Chapter 2, Section 25), but a guidance document issued by the National Board of Health and Welfare and Swedish National Agency for Education (2016, 27) includes teachers in this. This document stresses that “Student health care work is carried out in all school settings, not least in the classroom where the teacher plays a central role” (see also the Swedish Schools Inspectorate, 2021). However, what this work involves needs to be defined in practical terms in the individual school.

The material that the present study is based on is what are known as student health plans (SHP). It is not obligatory to have a student health plan, but the work carried out by schools on promotion and prevention related to student health must be a part of the school’s systematic quality initiatives (Swedish National Agency for Education, 2021b). The term student health plan began to be used in the 2010s by the Swedish Schools Inspectorate, the Swedish government authority that oversees the school system. The Swedish Schools Inspectorate (2015, 2021) stressed the importance of having a plan for student health work. Therefore, many school managers and schools began to establish such plans and it is interesting and important to investigate how the assigned mission of the school system to work for health promotion is represented in these plans.

The present study investigates how the assigned mission of the school system to work in a health-promoting manner has been re-contextualised (Fairclough, 2010), that is, how it is defined, renegotiated and interpreted by school managers and schools. The Swedish school system is decentralised, which means that national guidelines and guidance documents are interpreted and put into action locally. Here, we investigate the discourse on health promotion work and role of the teacher in student health plans in Swedish upper secondary schools. How is health promotion work defined and what actions is it linked to, if any? How are the teacher’s roles and responsibilities, if any, towards health promotion work produced (in the analyzed documents)?

1.1. Previous research

School systems and school health work differ by country, so it can sometimes be difficult to compare research from different nations. A lot of the research that exists evaluates the effects of different programmes related to the physical and/or mental health of students (Langford et al., 2015; O’Reilly et al., 2018a, 2018b). In recent decades, such programmes have been popular, particularly in the Anglo-Saxon world, but also in Sweden. Researchers have evaluated and investigated programmes using different methods and perspectives (Bergnehr & Zetterqvist Nelson, 2015; Kvist Lindholm, 2017), but how health promotion work is interpreted discursively and the role of upper secondary school teachers in this have not been the focus to any great extent.

Studies investigating how teachers relate to the task of health promotion have shown both varying and similar results. Norwegian upper secondary school teachers have described how, when participating in a programme, they changed their teaching and worked much more to strengthen the self-belief and well-being of their students, which meant that the students became more positive in their attitude towards school. Crucial for this work was that the collaboration between the teachers worked well, that there were clear, written objectives and that these objectives were evaluated (Viig & Wold, 2005). Another study carried out in Australia and Malta also examined how upper secondary school teachers experienced a health promotion programme (Askell-Williams & Cefai, 2014). In this, it became clear that the teachers found it difficult to introduce the suggestions from the programme in practice, and more knowledge and resources were sought.

Teachers are not trained to work with health promotion initiatives, and giving this profession increased responsibility has been criticised (Askell-Williams & Cefai, 2014; Bergnehr, 2015; Watson et al., 2012). However, Jourdan et al. (2016) found that teachers in France maintained that health promotion work could be married with the role of teacher. Here, health promotion was linked to supporting students in their personal and social development, which was seen as a long-term job that occurred continuously during the everyday life of the school and the impact of which was difficult to measure (Jourdan et al., 2016). Other studies from other countries have shown that teachers view it as natural to support their students’ psychosocial development and well-being and define this as health promotion work (Graham et al., 2011). Creating a good relationship between teachers and students, as well as working with adaptations in their teaching, links teachers to the job of promoting the mental health and learning of their students (Maelan et al., 2018). These studies indicate that health promotion work is something teachers do as part of their normal duties in the classroom as a part of the teaching.

Not many Swedish studies on student health work have been carried out since the Swedish Education Act came into force in 2010, and those that have mainly focus on management staff, the school as an organisation, special initiatives, or the student health staff (e.g., school nurses, school doctors, school psychologists, counsellors) (Greve et al., 2021; Hjörne & Säljö, 2021). What became clear is that the term “health promotion” is difficult to define in practical terms for both school managers and schools (Bergnehr & Johansson, 2021). There is not much research to be found on student health plans except for one study by Hylander and Skott (2019). This study followed up on a continuing education course for school staff. The authors investigated how the promotion and preventative work were organised and implemented in schools 1 year after the course was completed. The student health plans were analysed, revealing large differences in content and design between different schools. Some of the student health plans mainly concerned student health staff, and the teachers were not closely involved. Therefore, these plans could not be viewed as joint documents. If, however, the teachers had taken part in the evaluation and reviewing of the plans, it could become a document that all followed in their work (Hylander & Skott, 2019). However, there was no investigation of how the health promotion work and teacher’s roles were defined.

2. Materials and methodology

The analyses in this study are built on 37 student health plans that were obtained during the spring of 2021 from municipal upper secondary schools in Sweden. The process began by contacting municipalities by email, providing information about the study and requesting student health plans from the upper secondary schools. The municipalities were deliberately chosen for variability in terms of both geographic location and size. In some cases, the student health plans were stored at the municipal level and attached immediately, but in most cases the municipalities referred the researchers to the individual upper secondary schools. The head teachers and student health services representatives at these schools were contacted. In total, 32 municipal schools in 23 municipalities were approached. Three of these schools did not have a student health plan, three did not reply, and one declined to take part. The process of obtaining responses was stopped when the material was rich and varied in terms of scope, content, and geographic spread.

The schools varied in size in terms of student numbers and municipality size in terms of population (large, medium-sized and smaller municipalities). Similarly, there was variety regarding upper secondary school programmes and how the student health plans were created; certain school managers created a joint student health plan for the municipality, whereas in other municipalities different schools had different plans. Even individual schools may have a number of student health plans that differed to some extent. A total of 37 plans from 26 schools in 22 municipalities were included in our analysis. In the material as a whole, the scope, structure (e.g., headings), and contents differed greatly. The shortest plan was 4 pages long, the longest 32 pages long. In total, the material consists of 578 A4 pages.

Before the analysis, the plans were numbered 1–37 and the schools given fictitious names. Municipal schools are subject to the principle of public access to official records; that is, the public and other interest groups have the right to information about what happens there (Swedish Government Offices, 2019). In this sense, student health plans are public documents. For ethical reasons, however, we only included schools and school managers who agreed to take part in the study. Moreover, schools/school managers in this text have been anonymised, as there is no reason to indicate individual actors because the purpose of the study is to contribute knowledge and discussion on how health promotion work and the role of the teacher are set out.

2.1. Analytical starting points and approach

The present study is based on theories of social constructivism and discourse analysis (Burr, 2015; Fairclough, 2010) in which social phenomena are understood and become active deeds by means of human interaction; people interpret, reinterpret, negotiate, and use various strategies to influence which interpretation takes precedence, thereby influencing how a phenomenon is understood. As humans, we are born into a language that conveys and communicates the way in which we view different phenomena, but this language, through which norms and values are given expression, includes resistance, conflicts, and negotiation and is, therefore, in a state of constant change (Burr, 2015). The discourse—the meaning creating language—about the given phenomenon contains contradictions; a phenomenon can be interpreted and understood in different ways (Burr, 2015; Fairclough, 2010). This investigation shows how a national and global mission is defined and negotiated locally: how it is given meaning, made visible, and made invisible (Fairclough, 2003, 2010).

The analysis was inspired by discourse analysis (Fairclough, 2010; Laclau, 1996/2007, 2003) and we analysed linguistic formulations, such as how different terms were used or not used together as terms only have meaning in relation to other terms, such as “health promotion” and “teacher” (Fairclough, 2010; Foucault, 1990).

General tendencies in the material as a whole appeared (i.e., dominant and less common ways of writing about the health promotion work of the school), and the teacher’s role became clearer. In addition, the analyses of linguistic formulations provided knowledge about how certain actors were represented and how health promotion work was (or was not) linked to specific actions. Similar to what Foucault calls “analytics of power” (Foucault, 1990), it became apparent what was given precedence and what was made invisible in certain particular plans and in the material as a whole.

For the detailed analyses, a number of theoretical concepts were used. The first is empty signifier, which Laclau defines as “a signifier without a signified” (Laclau, 2003, p.305). Empty signifiers are representatives of a collection of various demands creating an unfulfilled totality (Laclau, 1996/2007). They represent a utopia, something unreachable and can be considered hegemonic signs as they hold a considerable amount of power. They offer the opportunity to mobilize a range of different movements and to universalize particular interpretations of the signified at the same time (Laclau, 1996/2007).

In our study, this also means that no actions (no particulars) are linked to the term “health promotion work” to help fill it with shared meaning. This tallies with Tannahill (1985), who maintained that “health promotion” needs to be linked to actions in order to have meaning and be usable/interpretable.

Therefore, a distinction is drawn between an empty and a floating signifier. A floating signifier applies to a signifier where the content is not fixed, its meaning shifts depending on context and perspective (Laclau, 1996/2007). In previous research, health promotion has been highlighted as a term that is “floating”, that is unclear in meaning and in constant need of local interpretation (Tannahill, 1985; Woodall & Freeman, 2020). This makes the term difficult to use but interesting to study (e.g., Bergnehr & Johansson, 2021).

The term “discursive shadow” (Basic, 2019) is used when certain actors appear as unimportant or become invisible in the language, even though they might be expected to be significant in the present context. When actors appear as visible and important in the language and context, we say that they are in discursive light.

3. Findings

The Table 1 below shows in which plans the term health promotion was an empty or floating signifier, the x marking which signifier is present in the document. It also shows where the teacher was in discursive light or discursive shadow. When there is no x in neither the box for discursive shadow nor for discursive light, health promotion is described solely as a responsibility for the Student Health Services in that plan.

Table 1. Overview of the findings

Student Health Plan	Empty signifier	Floating signifier	Discursive shadow	Discursive light
SHP 1	x		x
SHP 2		x		x
SHP 3		x		x
SHP 4	x		x	x
SHP 5	x		x
SHP 6	x		x
SHP 7	x		x	x
SHP 8		x	x
SHP 9	x
SHP 10		x
SHP 11	x	x	x	x
SHP 12		x	x
SHP 13	x
SHP 14	x		x
SHP 15	x		x
SHP16	x
SHP 17		x	x
SHP 18	x		x
SHP 19	x		x
SHP 20	x		x
SHP 21		x		x
SHP 22	x
SHP 23	x
SHP 24	x
SHP 25	x		x
SHP 26	x		x
SHP 27		x		x
SHP 28		x
SHP 29		x	x
SHP 30	x		x
SHP 31		x	x
SHP 32	x	x	x	x
SHP 33		x
SHP 34	x		x
SHP 35		x	x
SHP 36	x
SHP 37		x	x

The findings section then continues with an analysis of health promotion work and what contents the term includes and does not include. Subsequently, there is an analysis of how the role of the teacher is set out in writing linked to health promotion work.

3.1. Health promotion as an empty signifier

It is common to find in the student health plans that health promotion work is undefined; the term is not linked to concrete actions and it becomes empty of meaning. An example of this is the following description: “The health promotion work of the school shall focus on long-term solutions in order to strengthen the mental, physical and social welfare of each student, with the aim of benefiting learning and health” (SHP 11). In this quote, the expression “the health promotion work of the school” is used; thus, it is the school which owns the work and will run it. However, it is not stated whether “the school” is all of the staff, some of the staff, or includes the students. It also states that the work shall “focus on long-term solutions” without specifying what these solutions are or who is responsible for creating them. No actions are given as examples of these solutions. The work is described as “benefitting learning and health”, but it is unclear what this health promotion work entails in practice and in what way the staff at the school should work.

Another example of when health promotion work is described unclearly is the following extract: “Health promotion for students involves working with ‘wellness factors’ to achieve health benefits. Health promotion initiatives are intended for everyone and are created based on the organisational level” (SHP 4). In the example, health promotion work is linked to working with “wellness factors”, but there is no closer definition of what these are. It also states that health benefits are then achieved, but not what these health benefits are or who decides whether they have been achieved. The reader discovers that health promotion initiatives are “created based on the organisational level.” It does not say, however, which actors are on that organisational level and bear responsibility. The text in this student health plan continues in the following way:

Valley high school bases itself on the strengths and abilities of its students. We work for an inclusive approach under which we believe that students learn best together. All support is based on what is best for the student so as to create learning environments designed from a regard for social, physical, and pedagogical factors. (SHP 4)

In the above quote, the school bases itself on the strengths and abilities of its students, but the reader is not told how this takes place in practice. The quote uses the inclusive pronoun “we”, but it is not stated who is included in this. It also says that “all support is based on what is best for the student,” but nothing is written about who decides what is best for the student or how this is done. The text does not include any key protagonists and what the health promotion work entails in practice is unclear. The concept, which is linked to health promotion work, may be said to be so broad and so all-inclusive that the meaning of health promotion becomes empty.

In some of the plans, there is an attempt to make the work more concrete in the form of bullet point lists and by calling the work “measures”. However, as demonstrated by the quote below, what these measures entail in practical terms and who should implement them is unclear.

  East high school’s health promotion work:

• Measures aimed at increasing achievement of goal fulfillment and learning.

• Measures to promote a meaningful, challenging, stimulating and safe learning environment.

• Measures which encourage a good atmosphere with good relations between students and adults. (SHP 19)

In the sentences above, there is no subject, and it is unclear who the actor is/actors are. Measures aimed at “increasing achievement of goal fulfillment and learning” can greatly vary in nature and could be carried out by members of different professions or by the students themselves. In the second bullet point, the keywords “meaningful”, “challenging”, “stimulating”, and “safe” are used, but all these concepts are broad, subjective, and subject to interpretation. The last point deals with relational aspects, stressing how health promotion measures encourage “good relations between students and adults,” but there is no concrete description of how this work might be carried out or what characterises good relations. It is generally difficult to put a finger on where and how the measures in the above quote should be carried out. All activities during the normal school day may be said to fulfil one or a number of these points. In the plans, health promotion work is often linked to other general concepts, which also become “empty”. In this way, there is a risk that health promotion comes to mean and include everything and/or nothing—the meaning becomes empty and undefined.

3.2. Health promotion as a floating signifier

In some individual plans, health promotion work is made concrete and does include actions, but the meaning of the term appears to be floating, as it is filled with different contents both in and between the plans. In the quote below, some of the 11 points that are labelled as “health promotion measures” are listed in a plan.

• An outdoor activities week at the beginning of each academic year, with workouts, nature activities and team building exercises within/between school years and staff.

• Anti-sugar campaign.

• Movement in the classroom (brain breaks).

• Increased opportunities for workouts by choices of optional physical and mental workouts once per week.

• Five sports days per year, e.g., cross-country relay, multisport, power walking.

• Talks about values (…) and about macho culture (…). (SHP 33)

These points have a clear focus on physical health (e.g., “outdoor activities weeks”, “sports days”, and “anti-sugar campaigns”), but with “teamwork exercises” and “mental workouts”, and words such as “values” and “macho culture”, health promotion work takes on a broader meaning. The third point, “movement in the classroom”, links health promotion work to the classroom. In the example, health promotion work becomes something with broad content that is associated with what happens in the classroom as well as activities outside teaching. This example shows how health promotion work is given an extremely broad definition even when concrete actions are specified—it becomes floating.

Thus, there is great variation in how health promotion work is interpreted, defined, and made concrete in the materials. The quote below exemplifies this variation. In this plan, health promotion work is linked primarily to “the student health service”.

The student health service works actively to give students and classroom teachers health promotion and preventative strategies, as well as structures in the organisation to reduce the proportion of students who feel anxiety and negative stress about their schoolwork. The student health service is responsible for providing knowledge about how each student can affect their school circumstances to achieve balance in their studies. The school health service provides information to all students in year one and their parents/guardians at the beginning of term (…) The special needs education coordinators in the student health service provide knowledge about study technology and run study aid programmes to all students in year one during the first term. (SHP 8)

It is the student health service that “works actively” on health promotion, and that the work includes giving both students and classroom teachers “health promotion and preventative strategies”. The quote continues by clarifying what this work involves in practice, such as “providing knowledge about how each student can affect their school circumstances to achieve balance in their studies.” The text below also prescribes providing “knowledge about study techniques.” Thus, in this plan, the health promotion work is linked to the student health service providing knowledge, information, and strategies that can foster the students’ general well-being in the school and specifically in their studies. In this way, the plan gives a concrete foundation to health promotion work by linking it to specific actors—the student health service staff—and to specific actions, such as knowledge and study techniques. The health promotion work is also linked to more abstract tasks that provide “structures in the organisation”. It becomes clear that health promotion work can be used in the student health plans to both define specific activities and formulate general visionary goals, but that it appears to be a term that is generally difficult to define and becomes floating, with a risk of meaning virtually everything or virtually nothing.

3.3. The teacher in discursive shadow

The teacher as an active participant in health promotion is generally invisible in the student health plans—the profession finds itself in discursive shadow. Most often, the teacher is not mentioned at all but appears indirectly as a participant in the formulations in which health promotion work is linked to “increasing achievement of goal fulfillment and learning”, “learning environment”, “the classroom”, and “teaching” (e.g., the quote from SHP 19 above in Health promotion as an empty signifier). To a large extent, the teacher is responsible for meeting learning goals, the learning environment, and what happens during teaching and in the classroom and cannot be anything other than a central actor when this term is used together with health promotion work, but it is unusual to see the teacher featured in the plans. The teacher is in discursive shadow.

A number of plans feature the headline, “Division of responsibility”, in which the responsibilities of different professions are listed, particularly the student health professions (i.e., nurses, counsellors, special needs education coordinators, etc.), but one plan sets out the teacher’s responsibility in the following way:

The classroom teacher is responsible for implementing early interventions and adjustments in their teaching. The teacher must be a guarantor of safety and stress-free work and must collaborate about students they have in common in order to flag any concerns over the student to the mentor. Classroom teachers are responsible for achieving learning goals in their courses. (SHP 20)

As the responsibility of the teacher is set out in a student health plan quoted above, the tasks may be said implicitly to be linked to promotion of the students’ health (e.g., “implementing early interventions”, carrying out “adaptations” to the teaching, to be a “guarantor of safety and stress-free work”, and to “collaborate about students they have in common”), but there are no explicit formulations about the responsibility of the teacher for health promotion actions. In general, the teacher is seldom linked directly to the school’s mission to promote health.

Another example of how the teacher is in discursive shadow is when “leadership and stimulation” are mentioned in the plans. A number of plans define leadership and stimulation as important parts of the health promotion work: “Leadership and stimulation is an important part of our student health promotion work” (SHP 4). However, no individual or group is mentioned in this plan as carrying out and being responsible for leadership and stimulation. A number of plans do, however, link leadership and stimulation with “teaching”: “Leadership and stimulation: This is what in everyday language is called teaching” (SHP 26). As teaching is the main task of the teacher, and leadership and stimulation are set out as important in the student health promotion work, the teacher indirectly becomes an essential participant in this work but ends up in discursive shadow. It appears that, in the context of the Swedish school system, there is not a natural tendency to link “teacher” with “health promotion”, the cause of which is surely that health promotion work has an empty or floating meaning; it appears to be difficult to define and to link to concrete actions.

3.4. The teacher in discursive light

In individual sections in eight of the plans, the teacher appears in what might be described as discursive light. This means that the teacher is clearly mentioned and allotted responsibility and tasks linked to health promotion work. When the teacher is in discursive light, “attendance” is a recurring area of responsibility. In one of the plans, we find the heading “SHT’s¹ areas of focus and measures for promotion and prevention work” accompanied by the following text: “Attendance is an important condition for the development, learning and well-being of students. Classroom teachers record daily attendance at their lessons throughout School 24” (SHP 2). The quote begins by clarifying that, “Attendance is an important condition for the development, learning and well-being of students.” As such, attendance becomes a term that is linked to well-being and health promotion work. The teacher becomes visible in the second sentence, where he/she is given the task of recording daily attendance at his/her lesson. This task can be seen as lying within the normal job description of the teacher, with or without a student health plan, but here it is set out as an aspect of health promotion. However, precisely how recording student attendance promotes health is not specified.

Other places where the teacher is mentioned and their responsibility set out are in relation to teaching. Once again, the role of the teacher in health promotion work is linked to the classroom and the activities that take place there. In the quote below, the teacher’s responsibilities are listed in four points:

Subject teacher’s responsibilitiesHealth promotion and preventative work

• Leadership and stimulation (described above)

• Accessible learning environment

• Responsive teaching

• Extra adaptations. (SHP 21)

The example above illustrates something recurrent in the material: “leadership and stimulation” and “responsive teaching environment” are directly and explicitly mentioned in relation to the role of the teacher in health promotion work when the teacher is in discursive light and indirectly in cases in which the teacher is in discursive shadow. Leadership and stimulation is defined in some individual plans:

As a teacher, you should adapt your teaching to the whole of your class and the individual needs and circumstances of your pupils. This might entail, for example, alternative forms of testing, well thought-through use of different ICT tools, and clarity of communication in lesson logs and instructions. (SHP 21)

The example above is addressed to the teacher, including the use of “you”. The specific wording “your teaching”, “your class”, and “your pupils” is a direct address to the teacher, signalling responsibility. One key word is “adapt”, which means that adaptation of teaching is linked to health promotion. The second sentence provides examples of what this adaptation might mean, including “alternative forms of testing”, different ways of testing the students’ knowledge. It also stated that “well thought-through use of different ICT tools” is an example of adaptation. ICT is an abbreviation for information and communication technology, meaning things such as computers, spelling programs, and digital reading services. These are tools that are almost inevitably part of the normal life of the teacher and used in most classrooms. Finally, there is “clarity of communication in lesson logs and instructions.” In this quote, as in the material in general when the teacher is in discursive light, strategies and input labelled as health-promoting are linked to things the teacher does and is expected to do. In this way, health promotion initiatives become nothing more than the normal work of the teacher; there is no extra responsibility.

In three plans, social or relational work is set out as an area of responsibility for the teacher. The quote below is an example of this uncommon feature, in which the term relationship is linked to the role of the teacher in health promotion work.

In health promotion work, it is the job of the teacher to establish a good and trustful relationship with his/her students so that it becomes a natural thing for the student to regularly talk with his/her teacher about issues regarding knowledge development and about issues of a social nature. (SHP 7)

In the quote above, the teacher is allocated the responsibility of “establishing a good and trustful relationship with his/her students.” However, it does not state which students, such as whether it is the students who the teacher teaches or the students in the school. What a good, trustful relationship entails may be seen as clarified with the wording, “so that it becomes a natural thing for the student to regularly talk with his/her teacher.” A health promotion task for the teacher entails working in a relational manner, and if the students regularly talk with this teacher “about issues regarding knowledge development and about issues of a social nature,” this is an indicator of the relationship being good and trustful.

The following quote exemplifies a relational aspect of the teacher’s role in health promotion work linked to the term treatment: “During team meeting time, carry out collegial guidance and discussions with the teachers on how we treat our students and how we address a norm-challenging pedagogy, led by SHT” (SHP 11). In this plan, the teachers are highlighted as a group in need of continuing education within health promotion work and guidance from student health service staff on “how we treat our students” and “norm-challenging pedagogy”. In this way, treatment and norms are linked to how teachers work for health promotion. Despite the fact that the teacher is the one who deals with the students each day, the need for continuing education in how they treat them is set out in writing.

4. Concluding discussion

This study investigated how health promotion work and the teacher’s role is interpreted in the student health plans in Swedish upper secondary schools. The previous research focussing on the health promotion work of teachers has primarily studied the Swedish compulsory school (e.g., Jourdan et al., 2016; Maelan et al., 2018). In addition, student health service staff have often been the focus of Swedish research, and the role of the teacher has been studied to a lesser extent, even if the importance of school management and all of the staff working for health promotion has also been stressed (e.g., Greve et al., 2021; Hjörne & Säljö, 2021). Thus, the present study contributes important knowledge about how the mission of health promotion and the responsibility of teachers is understood and defined, how this is done in the student health plans, and how it is done in upper secondary schools.

The findings of this study show that health promotion work in the student health plans often becomes an empty signifier (Laclau, 1996/2007, 2003)—meaning it is a term that is used without being defined or linked to specific actions. Thus, health promotion appears to run the risk of becoming “a semantic mess” (Tannahill, 1985, 167), where its meaning and practice is unclear and becomes lost (Lindström, 2018). When the term is linked to specific actions, we see a great breadth, and the meaning is revealed to be floating. This is in line with previous research that maintains that there is a lack of consensus about the meaning of the term and how it should be understood and practised (Woodall & Freeman, 2020). Other studies of how health promotion is defined and applied in the Swedish school system show the same tendency: It is often empty and, when it is defined, it becomes floating in the sense that the meaning may vary greatly and it is possible to link it in a great number of ways (Bergnehr & Johansson, 2021). It is true that, as an empty and floating signifier (Laclau, 1996/2007, 2003), the term can have its benefits and actually be a basic necessity when health promotion is to be adapted to different actions. In the case of the school system, it needs to be applicable to different types of schools, for children of different ages, and to the specific circumstances, challenges, and needs of each school. Yet, the risk is that health promotion work becomes so vague that nobody takes responsibility for it or understands what should be done. With regard to the student health plans, it could result in them becoming documents sitting on a desk somewhere rather than having any positive impact on student health work (Hylander & Skott, 2019).

Health promotion in schools as an empty signifier is not necessarily something negative, as empty signifiers fill an important role in society. They point to the gap between the particular and the universal and without it, social demands would be fixed in particularism and thus ineffective (Laclau, 1996/2007). The hegemonic struggle to fill “health promotion” in relation to school with meaning is intrinsically linked to other power struggles such as teachers’ professional responsibilities and the purpose and role of schools.

At the national level, the teacher is set out as a professional who should participate in the health promotion work of the school, but it is not always so explicit (Swedish National Agency for Education, 2021a). The findings of the present study show that the teacher is generally in discursive shadow (Basic, 2019) in the student health plans. Thus, it appears difficult for school managers and schools to apply national recommendations and guideline texts in their work or to link teachers with health promotion; though the two words are given, they possess no clear shared meaning. This could lead to the work of the teacher becoming invisible or to removing the teacher’s responsibility of working in a health-promotive manner (whatever that might be perceived as being and becoming in any given school). This could be viewed as a cause for concern because it has been demonstrated that the teacher is an important actor in the promotion of the health of students (Eccles & Roeser, 2011; Maelan et al., 2018, 2020; O’Reilly et al., 2018a, 2018b).

When the teacher is in discursive light, the role of the teacher is linked to the terms “attendance”, “leadership and stimulation”, “teaching” and “relational work”. These activities can hardly be viewed as anything but part of the teacher’s normal job description. It is the responsibility allotted to the teacher in the Swedish curriculum. It is different from giving the teacher responsibility to operate psychosocial programmes, which was relatively common in the beginning of the 2000s (Kvist Lindholm, 2015). Here, the health promotion activities of the teacher are instead linked to the core competence and the teacher’s job description.

However, it is extremely uncommon in the material for the teacher to be in discursive light. If policy makers where to emphasize the teacher in the documents as important to a greater extent, with his/her competence and knowledge of the students, it may have a positive impact on the practical student health work and possibly student health. A recommendation for pedagogical practice would be to clearly make the teacher a participant who, together with student health service staff and school management, could work to create a health-promoting learning environment and school. If the responsibility of the teacher in the health promotion work falls within the already existing assigned mission, it is neither controversial nor dependent on more resources (cf. Bergnehr, 2015) Rather, it is compatible with the teacher’s professional identity and something that teachers can relate to positively and willingly undertake (Jourdan et al., 2016).

A limitation to the study is that it cannot say anything about what actually happens in pedagogical practice. Questions do arise though, such as regarding how health promotion work happens in practice, teachers’ thinking around health promotion work and their responsibilities in the Swedish upper secondary school, and not least of all how upper secondary school students experience and take part in health promotion initiatives. These are important questions for future studies to examine.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1. SHP—the student health team.