Hospitalized Adolescents’ Use of Mobile Technologies for Learning,Communication,and Well-Being

Abstract

Hospitalized adolescents experience significant needs beyond medical treatment. They require emotional support for anxiety and stress, educational support for learning, and social support to reduce isolation. This qualitative study explored the use of mobile technologies to connect students to their schools, classmates, and families in an effort to reduce their isolation and disrupted schooling experiences. We conducted in-depth interviews with 18 hospitalized adolescents aged 12 to 18, 29 teachers, and four parents about the affordances of mobile technologies. We found that mobile technology use in a hospital school was critical to engage adolescents in learning and keep them up-to-date with schoolwork. Mobile technologies should be available and accessible in hospital for adolescent patients for the purpose of meeting their learning, communication, and well-being needs. In particular, mobile technology should be used as a therapeutic tool to overcome hospitalized adolescents’ social isolation and improve their well-being.

Keywords

hospitalized adolescents mobile technologies learning communication well-being

Introduction

Advances in medical research and treatment of many chronic and life-threatening illnesses have resulted in increasing numbers of adolescents (age 12-18) living longer with these conditions (Shiu, 2001). These adolescents face many challenges as a result of their illnesses and hospitalizations. They become socially isolated from their families, classmates, and friends and from the routines of everyday life (Hopkins, Moss, Green, & Strong, 2014) and need strong academic and social support during recovery to help overcome their isolation (Bonny, Britto, Klostermann, Hornung, & Slap, 2000; Taylor, Gibson, & Franck, 2008). With increased availability of technologies providing access, communication, and interaction, integration of technology may offer opportunities for learning to hospitalized adolescents who would otherwise be disconnected from their enrolled schools (Ashman and Elkins 2009).

The research team was involved in implementing professional development about the use of mobile technologies which the school leadership introduced into the hospital school setting. Consequently, we were able to research the impact of specific technologies on adolescents’ learning, communication, and well-being.

A major challenge for hospital schoolteachers is to reduce the gap in learning opportunities between hospitalized adolescents and their peers to prevent these already vulnerable adolescents from the increased risk of being left behind (Maslow, Haydon, McRee, Ford, & Halpern, 2011). The typical stressors and trials of adolescence are exacerbated by the additional demands of hospitalization for life-threatening illness with its frequent concomitant changes to physical appearance, need for isolation, and fatigue (Palmer, Mitchell, Thompson, & Sexton, 2007). An emerging research base exists to support the therapeutic use of mobile technologies and web-based interventions in chronic disease management (Maor & Mitchem, 2015; Hamm et al., 2014). Little is known, however, about how mobile technologies and social media can support hospitalized adolescents’ educational, social, and emotional well-being and needs (Hamm et al., 2014).

A review of literature examining the use of technologies to address social and educational aspects of learning with hospitalized adolescents found preliminary evidence that technology was beneficial in supporting their education and social well-being and reducing any educational gaps (Maor & Mitchem, 2015). However, most studies in this review investigated technologies designed specifically for hospitalized youth and few took advantage of readily accessible social technologies. Currently, technology that affords communication, flexibility, accessibility, and multifaceted usage exists through mobile Web 2.0 technologies (Cavanaugh, Maor, & McCarthy, 2014); therefore, research examining the use and adaptability of mobile devices for adolescents in hospital context is needed.

Review of Literature

Hospitalized Adolescents’ Needs

Adolescents who are hospitalized for chronic or serious health conditions experience significant needs beyond medical treatment, including emotional support for anxiety and stress, academic and educational support for learning, and social support to reduce isolation. Prolonged absence from school can cause severe barriers to learning (Martinez & Ercikan, 2009) and thus high anxiety and stress to the child. Students may be concerned about keeping up with coursework they are missing and completing school expectations. According to St. Leger (2014), education professionals prioritized the well-being of young people with chronic health conditions rather than academic performance by maintaining their connection to school and friends and providing support to their families. It was noted, however, that maintaining social connections could be challenging when faced with long absences from school. The risk of decreased motivation to continue with schoolwork while experiencing isolation can have a critical effect on children and add to learning difficulties. This was amplified by Maslow et al. (2011) who reported that young adults who were growing up with chronic illness face greater threats of worse educational and vocational outcomes.

Children who experience repeated hospitalizations tend to undergo trauma not only physically but also emotionally and socially (Hopkins et al., 2014). Limited contact with families, lack of normal school-life routines, and new rules and limitations further create a negative impact on hospitalized adolescents’ well-being (Hopkins et al., 2014). Well-being is considered here as a multidimensional construct incorporating all domains of individual functioning including physical, psychological, social, and cognitive/educational (Moore et al., 2011). Being away from family and peers increases children’s isolation and disrupts friendships and family engagement. For adolescents, when social engagement is critical for their well-being and confidence (Hopkins et al., 2014), this can contribute to significant unhappiness (Palmer et al., 2007). Maintaining connections and addressing educational needs not only improves quality of life and minimizes educational disadvantage, it also gives students a sense of normalcy and increased hope, reducing risk and the impact of isolation (Liu, Inkpen, & Pratt, 2015; Wilkie, 2011; Yates, 2012).

Use of Mobile Technologies

As a means of reducing isolation and disrupted educational experiences, researchers have increasingly explored mobile technology use to connect children to schools, classmates, and families (Gonzalez, Toledo, & Collaazos, 2014) and facilitate their transitions when they return to school (Fels & Weiss, 2001; Rae & Frankel, 1998; Stuart & Goodsitt, 1996). Technologies continue to become more affordable, accessible, and powerful, challenging educators to identify how best to connect students with their schools and facilitate the interaction necessary to promote effective learning (Wilkie, 2011).

Investigating patient reported outcomes of people with chronic pain who used social media as self-management, Merolli, Gray, Martin-Sanchez, and Lopez-Campos (2015) described a framework of therapeutic affordances through which social media may impact health outcomes. They have identified the following therapeutic affordances of social media: self-presentation (disclosure, control, and identification), connection (interaction, exchanging information, support, mitigating isolation, and geographic freedom), exploration (information seeking, learning, and reputability), narration (imparting knowledge, understanding, and emotional catharsis), and adaptation (variation in use in relation to condition status or individual needs; Merolli, Gray, & Martin-Sanchez, 2014). In the study of chronic disease patients, they claimed that much of the efficacy of social media may be justifiable via a closer examination of these therapeutic affordances (Merolli et al., 2015). Drawing on the self-presentation and connection affordances, Liu et al. (2015) found that pediatric patients often use various communication technologies to help them to retain a “sense of normalcy” (p. 1527). In our study, we wanted to examine the affordances of mobile technologies as perceived by students, teachers, and parents in relation to how these can best serve hospitalized adolescents in meeting their educational, social, and emotional needs.

Findings from Yates et al. (2010) showed that young people in hospitals are concerned with maintaining normal routines and consider access to social networking sites or mobile phones an essential component of being normal. In a synthesis of current findings on adolescents’ use of social networking sites and its impact on psychosocial development and well-being, Shapiro and Margolin (2014) found several positive influences that included enhanced peer relationships, more opportunities to engage with a wider range of groups and peers, and increased occasions for self-disclosure. In addition, other research has found that an increased sense of connectedness with school is a significant factor in a future sense of well-being for all young people (Jose & Pryor, 2010).

Previous studies have found that the use of video for social connection may improve social presence by providing an audio and visual connection, especially for remote students (Weiss, Whiteley, Treviranus, & Fels, 2001; Wilkie, 2014). However, the findings related to video use are not consistently positive. Some researchers also noted resistance on the part of the sick child to being seen and by parents concerned that their children might find visually confronting pictures of the sick child distressing (Ellis et al., 2013). Furthermore, hospitalized adolescents themselves have been unwilling to reveal their changed physical appearance to their peers (Liu et al, 2015). For the most part, keeping in contact using social media and mobile technology helped hospitalized students feel more confident about their reintegration into school and about their future (Hopkins et al., 2014; Yates, 2012).

Previous research on specially designed projects to connect hospitalized students with their enrolled teachers highlighted a number of practical and procedural challenges. For example, Cook (2005) evaluated a virtual classroom package called Manhattan and found that despite receiving training, it was too complex and time-consuming for teachers to use. Wilkie (2014) reported on the feasibility of using a variety of existing resources including email, videoed lessons, interactive whiteboard, and videoconferencing for interaction between senior secondary students and their mathematics teachers to achieve academic continuity. Findings in this study highlighted students’ desires to stay connected to their schools and focus on academics with teachers expressing concerns about students’ ill health and reservations about their ability to cope with schoolwork. It seemed that students’ lack of motivation or perseverance was related more to lack of access to teachers than it was to their level of health. Wilkie (2014) noted the importance of providing hospital schoolteachers with time and resources (technical training and IT support) to implement and sustain the interaction with the student over time.

In a systematic review of the use and effectiveness of social media in child health, Hamm et al. (2014) noted that many studies showed the promise and utility of social media as an intervention, but this was not supported by the statistical significance of the results. Although previous studies looked at how patients use technology to communicate or share their experiences (Liu et al., 2015), few studies focused on adolescents in hospital schools using technology for learning, connection, and emotional well-being. Liu et al. also involved parents of chronically ill children to provide a deeper understanding of how these children stay connected with their peers.

Therefore, this article describes how mobile technologies affect a group of hospitalized youth in addressing their learning needs, feeling connected by overcoming isolation, and enhancing well-being. This qualitative research provides student, teacher, and parent in-depth perspectives on the following research questions organized under three themes:

Technology and learning: How does technology influence hospitalized students’ learning?

Technology and connection: (a) How does technology use influence hospitalized students’ communication with their enrolled school? (b) How does technology influence students’ social communication with friends and family?

Technology and well-being: How does technology influence hospitalized students’ well-being?

Method

This qualitative study was conducted in one Australian regional children’s hospital with three groups who volunteered to be interviewed: students, teachers, and parents. The goal was to present a richer, more nuanced description of the hospitalized students’ lived experience. The research consisted of three phases: (a) introduction to the hospital and ethics approvals from the University Ethics Committee and the Department of Education which has jurisdiction for the hospital school, (b) data collection, and (c) data analysis and interpretation.

The institution’s Ethics Review Board approved the research, and all participants gave informed consent. Hospital teachers (hereafter “teachers” distinguished from “home schoolteachers”) were introduced to mobile technologies through participation in a yearlong professional development and coaching program (McCarthy et al., 2017). A doctoral research assistant conducted semi-structured individual face-to-face interviews with 18 hospitalized adolescents (see Table 1 for demographic information about student interview participants), 29 participating teachers, and four parents. The hospital teachers were recruited initially during a whole school professional development presentation in which the first author discussed the aims of the research and explained the expectations of participants. Teachers who participated were interviewed for approximately 1 hour each in the offices of the hospital school.

Table 1.

Student Interview Participants.

Student	Age (years)	Year/grade	Time in hospital	Most challenging aspect of stay
S1	14	9	2-3 days	“hooked up to two drips, can’t move”
S2	12	7	6 days	“boring, nothing to do”
S3	13	8		“miss school friends”
S4	15	9	2 days	—
S5	14	9	4-5 days	“miss friends and school”
S6	17	12	Few days	“no Internet, the schedule, would rather work at night”
S7	15	9	1 day	“bored-waiting around. Miss friends”
S8	15	10	3 days	“boring, no Wi-Fi or internet”
S9	15	10	2 days	“being bored. Miss friends from school”
S10	15	10	7 weeks	“isolation from everyone. Miss people from school”
S11	13	7	1 day	“boring”
S12	12	7	1 day	“pain. Miss being with friends from school”
S13	16	10	5 days	“bored”
S14	14	8	3+ weeks	—
S15	16	11	1.5 weeks	“miss friends, normality and routine”
S16	13	8	4 weeks	“not being at home, not seeing my friends, not being in school”
S17	15	10	3 days	“miss hanging around my mates”
S18	14	10	5 days	“miss the Internet to contact friends”

Teachers identified hospitalized students if they were considered physically and emotionally well enough to participate. After explaining the goals of the study to the students, the researchers sought their parents’ consent for them to take part. If students agreed, signed consent was obtained from parents and adolescents. Only four parents volunteered to take part in the interview process because of their difficulties in finding time to be interviewed. Students were interviewed in the classroom or by their bedside, and parents were interviewed by their children’s bedside for approximately 30 minutes.

We asked participants how they used mobile technologies in the hospital setting; whether and how they were used and whether they helped in student learning; whether and how they were used to communicate with enrolled schoolteachers and classmates, friends, and families; and whether and how they had helped them in general in dealing with the challenges of the hospital stay. Each stakeholder group was also asked additional questions specific to their role in relation to technology and learning, communication, and student well-being. Furthermore, the interviews allowed for additional prompts and detailed descriptions of personal experiences. Interviews were audiotaped and transcribed verbatim.

Data Analysis

All 54 interview transcripts were entered into QSR NVivo qualitative analysis software. Each of the researchers read separately all transcripts to generate an initial list of codes.

For the first research question of technology and learning, we identified codes such as “schoolwork,” “normalcy,” “mobile technology,” “home teacher,” “home school,” “pressure,” “connect,” and “resources.” For the second research question of Technology and connection, we identified codes such as “access,” “portal,” “Wi-Fi,” “social isolation,” “missing friends,” “long-term,” “social media,” and “enrolled school.” For the third research question of Technology and well-being, we identified codes such as “support,” “normalcy,” “routine,” “escape,” “distraction,” “connection,” “enjoyment,” “social isolation,” “anxiety,” and “therapeutic tool.”

Once we identified and agreed on our codes, we nominated emergent themes by independently sorting codes into categories, reflecting perceptions expressed by participants in all interviews about the use of mobile technologies in the hospital school. At this stage, all data were transferred to NVivo to facilitate further analysis. The two researchers then met to compare and agree on the identified codes. We then revisited the transcript interviews several times to ensure accuracy and consistency of code application by independently coding each interview. When disagreements occurred, the two researchers met to discuss the code and reach agreement; this ensured stability (reliability) of coding (Creswell, 2007).

In the first stage, we identified the codes manually using open or initial coding (Emerson, Fretz, & Shaw, 1995), related to the project’s broad aims of exploring the use of mobile technologies with adolescents in hospital school in relation to their learning, communication, and well-being. Some issues identified by students, teachers, and parents, however, emerged independently as important themes for each researcher. For example, we did not ask specifically about normalcy or the use of mobile technology as a therapeutic tool in the interviews. Instead, these were themes that emerged repeatedly during analysis suggesting support for the multiple ways that mobile technology supports individuals with chronic and life-threatening illnesses.

Finally, to illustrate our findings, we retrieved specific excerpts from the interview transcripts, relevant to each theme and representing the three stakeholder groups. This entire process helped us to analyze the data to answer our research questions with high level of authenticity reflecting the participants’ voices.

Table 1 provides a summary of the demographic information about student interview participants. As part of the interview, the students self-identified the “most challenging aspects” of their stay.

Results

In each section, excerpts from the participants’ interviews illustrated the themes that emerged from the qualitative data to answer the particular research question.

Technology and Learning

The following themes emerged from the question, how does technology influence hospitalized students’ learning: importance of education and keeping up with school, technology’s affordances for the hospital setting, new ways of learning, and infrastructure issues.

Importance of education and keeping up with school

Almost every student commented on the importance of education and stressed the need to keep up with peers in relation to their learning and its importance in later life. This concern to keep up with education while in hospital was confirmed by the hospital teachers who were clearly aware of the pressure students placed on themselves. A teacher described communication via mobile technology as an “amazing gift” that students can keep in real contact with their schools. She added about the technology value for the hospital schoolteachers:

. . . it’s also very useful to be able to immediately plug in to what’s happening at school because a lot of our students are very focused on what’s happening at school and for example if they were doing a particular short story and I give them something else they’ll go “but . . . I want to do exactly the same as they’re doing at school.” (T-07-interview)

When asked, “Do you feel much pressure to keep up with schoolwork?” a typical student response was: “I do, I kind of pressure myself to do well” (S-13-interview). In fact, the importance of keeping up with schoolwork appeared to be more valuable to students than their teachers highlighting students’ desire to be treated normally and without regard to their illness.

Technology’s affordances for the hospital setting

While students were focused on immediate task of staying on track with their learning by doing the same assignments as their peers at the enrolled school, teachers were interested in and engaged with a wide range of issues related to technology and learning. Teachers usually solved the differences in interest by focusing their help on schoolwork assignments and reserving the use of more creative, interactive activities to those students who were totally disengaged:

. . . the one thing that will easily connect and engage them is the use of technology so the iPads are becoming increasingly useful. (T-22-interview)

Other teachers spoke to additional affordances of mobile technologies that lent themselves to the unique hospital context and provided needed resources to students through connection and exploration. An advantage of technology is the way it can compensate for some of the limitations that hospitalization brings through the connection affordance:

It’s the resources, whether it’s software or programs . . . because in a hospital situation where the kids don’t get out, some of the programs that you can access are just so valuable because they [the programs] are out there and they can take you to where you can’t be, to learn about things. (T-11-interview)

A different teacher talked about how useful they were for students to choose how to present themselves for drama and oral productions (self-presentation affordance). This teacher referred to the ability to record students’ performances and share the recording via drop box. This overcame the problem of students having trouble standing up in front of a classroom or delivering a speech. As one teacher indicated,

. . . we can often use this just to record their voices, or film them performing . . . So that is a way to send back the assessment that you never could before. (T-07-interview)

New ways of learning

Teachers also identified other affordances of technology, such as connection, adaptation, and exploration. They noted that the ability to connect individuals, seek and share information, learn, and collaborate has changed the way that students are learning with other students. The teacher noticed that the students were more responsible for their own learning, and there was more collaboration among them, which according to the teacher, created engagement and immediacy for the students:

. . . They’ll perhaps come in and say “I need to go in on my class wiki . . .” or they’ll say “I think we got given a new essay topic this morning, I’ll just message my friend” . . . and they’ll message it back. Their friend will even take a photo of the class notes and immediately send it to them. So, that impromptu sharing created an engagement and immediacy. (T-07-interview)

Having access to relevant information and resources had a motivating effect on teachers and the students they supported. In particular, teachers needed to create meaningful learning opportunities for students in this often emotionally, physically, and psychologically challenging situation. Being able to draw from these relevant resources helped teachers to increase the interest and enthusiasm of even the disengaged and reluctant students. The adaptation affordance allowed teachers to adapt the technology to the students’ emotional and physical condition. The use of mobile technologies in a pedagogically meaningful way requires careful consideration of a multitude of issues, and it was evident from our interviews that teachers had some important issues. A common concern was the need to balance the creative, engaging aspects of mobile technologies with some of the more traditional, less creative skills:

. . . we did an experiment the other day on growing polymers and the kids were growing them, and working out what was going to happen but they were documenting each step with the iPad and taking photos along the way and putting that into a document and writing it up. (T-13-interview)

A second issue that all teachers noted was that of access. A teacher commented on the risk of leaving the iPad with the students without supervision:

That comes with problems because if you are leaving an iPad which is hooked up to the Internet with a kid in bed who is not being supervised, they have to sign off that they won’t go to inappropriate sites, but they’re unsupervised and that poses some issues. (T-12-interview)

Infrastructure issues

The hospital provided Wi-Fi access during the school day when the teachers were present and able to monitor access. When asked what would help to prevent the student from falling behind on schoolwork, one student responded, “If they had Wi-Fi, you could get onto Connect¹ and connect with all your teachers and ask for more work or ask what they’re doing” (S-02-interview). This was reinforced by another student who indicated, “Hospital Wi-Fi would be good. I’ve had to bring in my own Internet hub to be able to contact my friends” (S-10-interview).

With increased use of technologies in education, many enrolled schools have portals through which students can access information about each of their classes and continue to participate and stay up-to-date with their schoolwork while in hospital. Yet, not all schools had the same technology infrastructure and within each school not all teachers participated to the same degree. At one enrolled high-tech school where each student was provided a personal iPad, a student noted that only two schoolteachers uploaded materials and directions to the portal. Not only were there sometimes issues with teachers not using the portals, but often the portal itself required the use of a particular application, which might not be available on hospital equipment. The time restrictions on Internet access influenced students’ ability to both complete their schoolwork and connect socially. This underlines the difficulty in meeting two distinct needs enhancing the argument for better implementation and fewer restrictions on Internet access.

One student commented,

I had to do this big assignment on developmental theory for childcare and because I was only allowed internet during certain periods of the day I found it was so hard to concentrate on it because I’d want to just sit in my room and do it in my room so I could just focus on it without having interruptions, but because I had to be in the classroom on limited internet, it was just kind of difficult. (S-6-interview)

Technology and Communication

The following themes emerged from the question, how does technology influence hospitalized students’ communication with family and friends: technology use and its impact on social isolation and communication changes brought about by mobile technologies.

Technology use and its impact on social isolation

Given that students overwhelmingly identified “missing friends” as the most challenging aspect of being in hospital (see also Table 1), it is not surprising that they used mobile technologies mostly to connect with friends and family:

It’s kind of like you’re out of hospital even though you are still here, it makes you feel like you’ve got leave and you’re able to still see them. It makes you feel like you’re a part of their [peers] lives even though you’re not really seeing them much so that’s good. (S-10-interview)

Another student talked about feeling less socially isolated because he did not feel as left out because talking to friends was like talking to them in person:

. . . it just makes me feel more included, like even though they’re going out without me I can still talk to them online rather than not talking to them at all. (S-5-interview)

Teachers also understood the importance of mobile technologies to support social connections for their students who were often isolated—especially those who were hospitalized for long periods of time. One teacher working on the oncology ward with long-term hospitalized students noted that she encouraged the use of Facebook even though it was against regulations:

I encourage them to Skype to other kids on the ward because they can’t even associate with them. We do try to connect them via Facebook . . . we will say “so and so is in Room 1 and they can’t come out, Facebook them and introduce yourself” and they do. Because these kids are going through the same thing, it’s a support system. (T-18-interview)

The importance of being able to talk to friends is critical to this age group, so much so that one student noted, “I went through all my data (on the iPhone) this month and it’s been . . . five days . . . because I’ve been talking to my friends so much that it’s gone through a lot” (S-5-interview). In fact, parents also agreed with their children about the importance of being able to connect socially and complained about the lack of Internet/Wi-Fi connection.

Negotiating the balance between open access and providing reasonable boundaries to protect hospitalized adolescents appeared to be of concern to both teachers and students. The lack of Internet access outside schooltime created problems for social and educational communication, which led parents and students to complain about the cost of providing their own Wi-Fi access. Some students also commented on the less beneficial aspects of constant connection via social media:

It makes me feel isolated and makes me feel, like, alone [laughs] but sometimes it’s good cause, you know, you get away from all the, like, drama and stuff that your friends are causing, but at the same time it’s bad cause you just want to talk to your friends and see what they’re up to. (S-6-interview)

Students demonstrated self-awareness and perceptiveness with regard to social media and its downsides perhaps more than adults give them credit for. The same student also commented on the distracting nature of social media: “Oh yeah I’ll just check that cause I’m not doing too much at the moment, just get sucked into the void of social media . . . I call it a black hole; you keep getting pulled back into it” (S-6-interview). This student talked about taking steps to avoid this by turning off notifications. Another student talked at length about the prevalence of and personal experience with cyber bullying. When asked whether it would be worse if there were open Wi-Fi access at the hospital, this student responded, “I reckon it would . . . the bullying side of things would be worse because people in here have, say, eating disorders or something . . . so they could be called names” (S-2-interview).

Communication changes brought about by mobile technologies

A significant theme that emerged from teacher interviews was how technologies have changed communications with the enrolled school. This now occurred more quickly, and teachers were using their own mobile technology devices:

That has made life much easier in terms of communication, and much more immediate. I suspect that teachers have now their emails on their phone or iPad because we’re often getting responses within a couple of minutes. (T-07-interview)

Some teachers used the iPads to get to know the students and to initiate face-to-face conversations with them. This seems best represented by the narration affordance allowing the user the opportunity to talk about their experiences. As one teacher commented in an interview,

It is all about developing a rapport, and because the iPads and apps are generally interactive, you can have more discussion and build more rapport. So it is not always what they are doing or not doing, it is how they are doing it, and developing that rapport and connecting with them. (T-22-interview)

Technology and Well-Being

The following themes emerged from the question, how does technology influence hospitalized students’ well-being: technology as a physical therapeutic tool, technology as a psychological therapeutic tool, technology as a social therapeutic tool, and technology as an educational therapeutic tool.

Given that well-being is a construct comprising many dimensions of individual functioning including physical, psychological, social, and educational, it is possible that the support provided by technology could contribute to each student’s well-being. The main theme from our analysis highlighted using technology as a therapeutic tool for these four dimensions of well-being. The interaction of technology’s affordances—those features that allowed users to distract, engage, connect, or learn at any time or place—provided support for the hospitalized adolescent during this difficult time. According to Merolli et al. (2014), the adaptation affordance allowed individuals to use technology in different ways depending on their condition at the time.

Technology as a physical therapeutic tool

Students who were in pain and under medication were not always able to focus on academic learning, and it was not their first priority as described by one student:

I’ve just been more focused on my pain and stuff. It’s [studying] not a huge priority as my brain is frazzled from all the medicine and stuff. It just doesn’t really work well . . . It would just get me even more stressed out. (S-13-interview)

Recognizing this, a teacher in the oncology ward described how technology could be used as a distraction at times when students were feeling unwell. The teachers suggested that they could use different apps and explore:

And that’s all right with me if they’re not really feeling well, but just to engage them in some way. They go through their stages and they don’t have control of what’s happening to them medically. (T-11-interview)

In fact, for some students, schoolwork was a distraction from pain and a way to focus on what was still normal:

One of the boys I’ve got at the moment actually expresses that his schoolwork is his escape from this [being in hospital] . . . It’s one thing in his life that can remain normal. He’s an exceptionally academic boy anyway but yeah it’s his escape. (T-18-interview)

Technology as a psychological therapeutic tool

Apart from supporting communication and learning, many students spoke about how technology helped to distract them as “it just keeps you occupied” (S-7-interview). Although this might not appear to be a direct indicator of well-being, another student explained that “it can, when you’re not feeling the best, just to kind of calm you down, and just to basically look at things like that . . . take your mind off things” (S-14-interview). Parents, too, noted this feature of technology. One parent responded to a question about whether technology helped her child’s well-being and she mentioned her son’s enjoyment with technology:

Yes, because he can do whatever he wants. He watches a lot of YouTube, a lot of gag strips type things, and a lot of gaming . . . and then there’s where they take the mickey out of it, and they’re sitting there with the headphones, giggling like a little maniac in their own little world. (P-01-interview)

This same parent described how it helped her son’s mood, “If he finds something, especially when he finds a new game, and or something that’s taken his interest, like when he first started drawing [on the iPad]—it just took all his focus away from what’s happening” (P-01-interview). Another parent also emphasized how the connection through technology helped her son’s mood:

One of the teachers [enrolled school teacher] texted him and actually kept in contact with him and saying, “Hey, how are you?” And that just kept him going, “Oh wow, I’ve got to keep on top of this, you know. Even the teacher thinks I’m special enough to talk to, and they’re not supposed to do that.” (P-02-interview)

Technology as a social therapeutic tool

Another example of technology supporting communication, and this, in turn, supporting well-being, was described by a student who, when asked how she felt about technology, said,

A lot better in myself because I know I can talk to my friends on it, and family obviously, because my family’s overseas . . . I’ve got all my Aunties messaging me . . . I haven’t told any of them and it’s spread around because of technology . . . . (S-5-interview)

A mother was willing to relax rules she enforced at home to help her daughter’s social connection:

They need to connect to friends because I know she’s not on Facebook because I don’t allow that . . . but . . . the first thing she wanted to do when she knew she was staying in, was tell her girlfriends where she was and what’s happening. (P-02-interview)

Technology as an educational therapeutic tool

For one teacher working with adolescents with mental health issues, she was particularly interested in how mobile technologies allowed her to help adolescents create eBooks—work they otherwise would not have completed and that they were proud of. The teacher described how it helped their well-being:

What I do see and feel, is the pleasure that the kids get from producing something in a normal setting . . . because they have high anxiety or their academic levels are so low that they would never be in a position to produce something that they’re actually really proud of, and so it’s more about their feelings of accomplishment and self-esteem . . . . (T-03-interview)

This teacher described the use of the iPad as “a therapeutic tool” for these students and the ways it influenced them to become re-engaged in learning and in the school environment. Another teacher reinforced this approach and noted,

I work with teenagers and a lot of them aren’t engaged with schools so it’s just about engaging the young people. I’ve found the most useful apps are the creative type, so things like iMovie where it can help to build a relationship with the young person, find out about them or tap into something that interests them. (T-10-interview)

This was further emphasized by a teacher who believed, “It’s more about the therapeutic nature of what it can achieve as opposed to transference of skills” (T-03-interview). In each case, the teachers discussed the importance of helping students to achieve more than they are typically used to achieving, be proud of the product they created, reduce their anxiety levels, and be ready to return to school.

One of the few mothers who agreed to be interviewed summed up her son’s situation when he was discharged from a long-term hospitalization. Her words captured technology’s influence on hospitalized adolescents so poignantly:

This has made me think how hard we try to get our kids to live real life when at home, but how we try to entertain them using so much of it [technology] when they are stuck in bed. How a photo on our phone or iPad can cause us to smile or have a meltdown, or even allow us to share the journey he has travelled with his surgeries to get to where he is now. It has made me think just how much we would have to carry around to do the same things if these devices had not been invented and how heavy our bags would be. How many lessons would go unlearned because the appropriate items were not available (dissect a frog)—how much less contact we would have with family and friends if we had to use only landlines and wait till we knew they were at home to answer the call? (P-03-interview)

Discussion

Our primary interest was to examine the influence of mobile technologies on hospitalized students’ learning, communication, and well-being. Our findings supported the research of others (Liu et al., 2015; Merolli et al., 2014), that the affordances of technology appeared to mitigate many of the challenges experienced by hospitalized adolescents. Consistent with Liu et al.’s findings, the hospitalized adolescents in our study also identified the affordances of mobile technology to maintaining normalcy at a time of great disruption and social isolation. While students remarked only on technology’s benefits in terms of connection and its capacity to distract, teachers were cognizant of and reported a much wider range of affordances. These included the affordances of self-presentation, connection, exploration, narration, and adaptation identified by Merolli et al. (2014). The multiple ways in which mobile technologies may contribute to the potential improvement in learning, communication, and well-being for hospitalized adolescents appears to be related to these affordances acknowledged by teachers and, to some extent, students. Students appeared to focus mostly on connection and adaptation affordances, which addressed their priorities of keeping up with their studies, maintaining connection with friends and family, and being able to distract themselves when needed. In contrast, all five therapeutic affordances emerged from the teachers’ interview data. This illustrated the difference in teacher and student priorities as well as perhaps the student’s actual needs based on their physical and emotional conditions.

Technology and Learning

Hospital school education has changed. Where hospitalized adolescents once were disconnected from school and anxious about falling behind and missing out on schoolwork and activities, technology has allowed their education to continue almost uninterrupted. Interestingly, the literature reported that hospitalized youth perceived their needs differently than did their teachers. Adolescents in hospital placed value on their interactions with teachers, academic continuity, and opportunities to learn while teachers were concerned mainly about their health (Wilkie, 2014). This view of students was also expressed in another study by older groups of adolescents who wanted to stay up-to-date with schoolwork (Nisselle, Hanns, Green, & Jones, 2012). In contrast to these findings, in our study, perhaps as a result of the more immediate interaction and connection with regular schoolteachers, hospital teachers were cognizant of the pressure students placed on themselves to keep up with their schoolwork and wanted to support students to alleviate this.

Furthermore, all stakeholders agreed that enhanced communication using technology had clearly changed hospital school education. Hospital teachers were more able to help hospitalized youth continue with their schooling, focus on academic learning, and prevent social isolation because of the affordances provided by Web2.0 technologies (Maor & Mitchem, 2015).

Technology and Communication

While technology and open access offered many opportunities to support hospitalized adolescents’ social connections, the implementation and operation of such access presented a conflict for teachers between their duty of care and desire to reduce social isolation (Lambert, Coad, Hicks, & Glacken, 2013). A major theme that emerged was the importance vulnerable youth placed on being connected through social media to family, friends, and school while hospitalized. Adolescents and parents suggested that the feeling of not being left out and being able to interact socially was critical to this age group. Previous research by Hopkins et al. (2014) supported this finding. Access to Facebook and other social media was officially restricted for safety reasons; therefore, outside of school hours, Internet access was unavailable. But social connection was important for these isolated adolescents, and they found creative workarounds (Wilkie, 2014). What are possible solutions to this ethical conundrum? Some teachers could enable long-term hospitalized students to use social media (Facebook) under supervision to reduce their isolation, and parents could provide the means for this to happen outside of school hours. As noted by Lambert et al. (2013), the responsibility toward patients in children’s hospitals makes it necessary for a more customized and targeted approach. Identifying how to establish access policies that appropriately safeguard vulnerable populations while not limiting the potential for users is difficult for both teachers and students and requires further consideration.

Technology and Well-Being

We were primarily interested in the hospitalized adolescents’ social, psychological, and educational domains of well-being (Moore et al., 2011). In particular, we were interested in how mobile technologies could help in reducing the isolation and disrupted educational experiences of hospitalized students. All stakeholders identified positive aspects of mobile technologies that supported well-being, and it was evident from our study that teachers and adolescents, to a lesser extent, embraced the many affordances of technology (Merolli et al., 2014), such as connection and adaptation, to help overcome educational disruption and social isolation caused by hospitalization. When an adolescent was experiencing pain and educational demands, the teacher chose to use the mobile device as a “therapeutic tool” to distract the individual from pain during this traumatic and challenging time. In a similar fashion, when adolescents were struggling emotionally or were disengaged, teachers used the devices to initiate conversations, re-engage the student in something of interest to them, or create their own production in an eBook. Sometimes, the adolescents self-selected the device to distract or calm themselves down. This power to self-select and vary usage mode, dependent on condition or mood, is described as the adaptation affordance of social media and Web2.0 technologies in Merolli et al.’s (2014) and Merolli et al.’s (2015) list and one that has substantial support in the literature (Hamm et al., 2014). This therapeutic affordance of the mobile device to engage and distract used by both teachers and adolescents and reinforced by parents warrants further investigation.

Limitations

There are significant practical, ethical, and methodological challenges associated with collecting data from hospitalized adolescents. As other researchers have noted, these issues affected the research design and our ability to reflect on the adolescents’ lived experiences.

Given the complexity and unpredictability of their treatment schedules, length of hospital stays, and adolescents ability/wellness to participate in different types of data collection, some data collection was hampered. Our challenge was in recruiting participants in this unpredictable environment. Although the number of adolescent participants was viable and enabled us to conduct interviews and answer our research questions, the number of parent volunteers was small, and their contribution was limited. The ethical dilemmas and organizational and practical challenges involved in this study have been noted by other researchers who were interested in providing hospitalized students the opportunity to share their experiences and needs (Maor & Mitchem, 2015; Coyne, Haynes, & Gallagher, 2009; Wilkie, 2011).

Conclusion and Implications

We conducted in-depth interviews with adolescents and their teachers and parents to understand their perceptions about how mobile technologies could support them while in hospital. Our findings from qualitative analysis suggest that hospitalized adolescents were primarily interested in using mobile technologies to enable them to continue their learning; keep up with their peers; maintain a level of normalcy; and communicate with their schoolteachers, families, and friends. While teachers were also interested in introducing them to the creativity and therapeutic affordances of mobile technologies, they recognized and acknowledged their students’ pragmatic issues, such as reducing the gap in their learning to ease anxiety. Future research should consider the disparity between teachers’ and students’ priorities when designing curriculum or advising policy makers in the hospital school setting. It was impressed on hospital teachers that they needed to support these students in their school curriculum before introducing additional activities or apps outside of required work.

Parents and teachers discovered that mobile devices played a critical role in re-engaging adolescents in their academic learning and in distracting them from pain during what could be a traumatic and challenging time. Technology was also used as a therapeutic tool to reduce adolescents’ anxiety and contribute to their mental well-being. The concept of technology as a therapeutic tool in its many dimensions should be further researched in hospital settings to extend Merolli et al. (2015) framework of therapeutic affordances of social media.

In sum, this study examined how mobile technologies provided a variety of affordances to support hospitalized adolescents, and the researchers concluded that mobile technologies are crucial to meet three needs of hospitalized students: learning, communication, and well-being. As a parent commented, mobile technologies play a significant role in making many aspects of our life easier and more engaging; for hospitalized adolescents, mobile technologies are critical in providing access and making possible learning, connection, and distraction. Future research should focus on developing measures for assessing the extent to which adolescent well-being is improved and the conditions under which mobile technologies could be most effective in a hospital learning environment.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received financial support for the research, authorship, and/or publication of this article: This project was resourced by the Young and Well CRC (youngandwellcrc.org.au). The Young and Well CRC is established under the Australian Government’s Cooperative Research Centre Program.

ORCID iD

Dorit Maor

Notes

Author Biographies

Dorit Maor is an associate professor in the School of Education at Murdoch University, Perth, Western Australia. Her teaching and research expertise is in the area of eLearning, in particular the integration of innovative pedagogies with new technologies.

Katherine Mitchem is a professor of special education at the Department of Special Education, California University of Pennsylvania, Pennsylvania, United States. Her teaching and research expertise is in the area of mobile technology to support students with special needs.

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