Participants

All hospital teachers working in Catalonia and not involved in the study as researchers (N = 15) were invited to participate. The principal investigator of the study was a hospital teacher in Catalonia but was excluded due to their involvement as an author.

Thirteen hospital teachers agreed to participate, representing 87% of the target population (or 81% of all active hospital teachers in Catalonia, if we include the principal investigator). At the time of the study, the entire target population were women. Due to the small size of the target population, the socio-demographic data gathered were limited to ensure anonymity. All participants were over 30, and more than half were older than 50 years old.

Six participants (46.2%) worked in HSs located in the city of Barcelona, and seven (53.8%) worked elsewhere in Catalonia. Teachers working in mental health units were not part of the target population since, as mentioned, care for students with mental health conditions in Catalonia is provided through separate educational units outside of HSs while following specific educational, procedural, and management approaches different from those of HSs. Participants did not receive any compensation or incentives for their participation.

Design

A mixed-method convergent parallel design (Creswell & Plano, 2018) was employed. A scoping literature review was first carried out to identify factors previously described to influence education in HSs. Based on these findings, an online questionnaire was developed, including close-ended questions and a comments section for each question. Quantitative data from close-end questions and qualitative data from written comments were collected and analysed in parallel while merging the results for an overall interpretation.

As described by Creswell and Plano (2018), this design is suitable when researchers aim to compare and contrast quantitative results with qualitative findings for corroboration and validation purposes. Furthermore, the combination of quantitative and qualitative methods allowed for the design of confirmatory and exploratory questions simultaneously (Teddlie & Tashakkori, 2012). While close-ended questions probed findings from previous studies, the comments section was added to further explore the participants’ perspectives. When applying this design, qualitative items do not result in a complete context-based qualitative data set. Instead, they can provide additional themes and interesting quotes that may validate and embellish the quantitative survey findings (Creswell & Plano, 2018).

At the time of the study and to the authors’ best knowledge, no survey for hospital teachers inquiring about factors that may influence education in HSs had been developed. Therefore, creating an instrument that could quickly capture the working conditions of hospital teachers and their perspective on factors that may influence education in HSs was an attractive pursuit. This pragmatic approach favoured the feasibility of an online survey over more time-consuming alternatives, such as in-depth interviews, to better adapt to the hospital teachers’ complex context and limited availability.

Instruments

The development and validation of the questionnaire constituted a fundamental aspect of this research. A scoping literature review (Armstrong et al., 2011) was performed to identify factors previously found to influence education in HS and serve as a basis for developing the questionnaire. Research articles and reviews in English and Spanish and up to 10 years old were retrieved in November 2021 from Google Scholar, Dialnet, Scopus, REDINED and ERIC bibliographic databases using the search terms “hospital school,” “hospital teacher,” “hospitalised students,” and synonyms. Articles were included through a multi-phase selection process (see Supplementary File 1).

Factors found to influence education in HS extracted from the literature review were grouped into three categories: pedagogical, socioemotional, and hospital context-related (see Table 2).

Pedagogical factors encompassed those directly related to teaching, such as lesson times, teaching methodologies, or coordination with education professionals in mainstream schools. Socioemotional factors were divided into a competency profile section, consisting of 21 attributes previously described as required for hospital teachers to cope effectively with circumstances within a hospital setting, and an emotional impact section, consisting of 14 items related to the emotional impact of working as a hospital teacher extracted from the literature review. Hospital context-related factors, in turn, included hospital characteristics that could influence the hospital teacher’s work, such as the transfer of information and coordination within the hospital or the need for specific hospital training.

Multiple-choice questions were used for pedagogical and hospital context-related factors. Some of these questions included non-mutually exclusive answers (e.g., in which educational stage/s do you teach?), allowing participants to select more than one answer. Conversely, 5-point Likert scale questions were employed for the socio-emotional factors. For the competency profile, participants were asked to rate each attribute in terms of them being “very,” “fairly,” “moderately,” “slightly,” or “not” necessary for the hospital teacher. For the emotional impact section, each item extracted from the literature review was translated into a first-person statement (see Supplementary File 2). Participants were asked to rate their agreement with each statement, selecting “totally agree,” “quite agree,” “indifferent,” “quite disagree,” or “totally disagree.” Since some statements referred to situations that not all participants may have experienced, the option “not applicable” was also included for this question.

This first version of the questionnaire was subjected to validation by four experts:

• Professor of Special Education and Hospital Pedagogy with more than 30 years of experience. Vice-Dean of the Education and Psychology Faculty at their university.
• National coordinator for hospital schools and homebound educational care at the Ministry of Education with more than 20 years of experience.
• Coordinator for an NGO supporting hospital schools with more than 20 years of experience.
• Hospital teacher with over 10 years of experience in HSs.

Based on their feedback, a revised updated questionnaire was then subjected to validation by two hospital teachers from outside Catalonia (see Supplementary File 3 for a summary of the expert validation process). The questionnaire was deemed validated with 70 items in total:

• Four items for socio-demographic data
• 18 items for pedagogical factors
• 35 items for socio-emotional factors
  • 21 items concerning the competence profile
  • 14 items concerning the emotional impact of working in a HS
• 13 items for hospital context-related factors

Participants were encouraged to provide comments by the following prompt: “You will find a space for comments in each of the questions; remember that this may enrich and clarify the answers given.” Further, following expert advice, participants were allowed to leave questions unanswered (see Supplementary File 4 for a description of the six items that received partial responses). An unofficial translation of the survey questions may be found in the supplementary materials (Supplementary File 5), and the original survey is available upon request from the corresponding author.

Procedure

All members of the target population were invited to participate via their education department institutional email accounts (accessed through the principal investigator), with a participant information sheet attached, in March 2021. Upon acceptance of the invitation, an online questionnaire allowing a response period of 10 days was sent to each participant.

Data Analysis

Quantitative data from the close-end questions were gathered using an Excel template and an SPSS data matrix. This required prior numerical coding of each item, data entry, transformation of syntactic data into numerical data, value labelling, and data cleaning.

The small sample size prevented estimation of correlation coefficients and restricted the potential for inferential analysis (Delgado, 2014). To achieve a confidence level of 95% for a population of 15 people, 100% of the population would have had to participate. For this reason, only descriptive statistics were employed.

Qualitative data from a total of 98 comments, comprised of, 2330 words, were analysed following thematic content analysis (Hernández-Sampieri & Mendoza, 2018). This analysis aimed to capture any additional themes from the comments. At the same time, illustrative quotes were selected to be presented along with the quantitative results.

Quantitative and qualitative analyses were conducted in parallel, and upon completion, results were combined for an overall interpretation. FJ conducted the analyses, and NZ validated them.

Consent

Participants were electronically presented with an informed consent form to be filed before the completion of the questionnaire. Completion of the questionnaire was anonymous, and no user data, including email, were stored.

Pedagogical Factors Influencing Education in HS

Hospital Teachers Coordinate With Education, Psychosocial, and Health Professionals as Needed Case-by-Case

According to education regulations in Catalonia, the mainstream school that the pupil typically attends must provide an individualised work plan for the hospitalised student. Furthermore, grades that go into academic reports are always given by the mainstream school and not the HS. For this reason, coordination among the two settings is vital.

Most participants (69%) described initiating contact with the student’s mainstream schools on the first day after meeting the student. Some participants (31%) reported only initiating contact if the anticipated duration of the hospitalisation was more than five days, while others (23%) did so only for hospital stays over 10 days. Most participants described using phone calls (80%) and/or email (85%) to communicate with mainstream schools; some (23%) also used video calls.

After first establishing contact with the mainstream school, the frequency of communications varied greatly among participants. Further, this item elicited the most written comments, as all participants but one (92%) commented on it.

“The frequency is very variable depending on the age of the pupils and the predisposition of the centre. An attempt is made to follow up with the centre according to needs.” (Participant 2)

“There are times when it is only necessary to do it once, at the beginning of the admission; at other times, it is necessary to do it every day.” (Participant 1)

In addition to coordinating with mainstream schools, hospital teachers may also need to coordinate with health professionals and psychosocial professionals, such as psychologists and social workers (either from the admitting hospital or external). When asked about regularly scheduled meetings for such coordination, 77% of participants reported having daily meetings with health professionals, while the frequency of meetings with other professionals varied greatly (see Figure 1).

Figure 1 

Frequency of HS Teachers’ Regularly Scheduled Meetings With Other Professionals.

Most Hospital Teachers Do Not Have Access to Specific Professional Training, and Some Lack Sufficient Supervision and Support

The Catalan Education Department offers free and recognised professional training for teachers on a variety of topics. However, results showed that 67% of the hospital teachers in this study reported not having access to professional training relevant to teaching students with a medical condition. Twenty-five percent reported having access to specific professional training outside of the offerings of the Education Department.

Among respondents, 69% reported having supervision and support. However, of these, 22% described such services as not quickly accessible and efficient. Some hospital teachers (15%) described not having sufficient supervision and support, and some (15%) abstained from responding.

In terms of how professional development was valued, 54% described their professional experience as hospital teachers to be a positive professional challenge, and 77% reported it to be a source of professional growth. All participants but one (92%) also described it as a source of personal growth. No participants agreed with the description of their professional experience as being exhausting.

A summary of findings from this section is provided in Figure 2.

Figure 2 

Pedagogical Factors Influencing Education in HS.

Socioemotional Factors Influencing Education in HS

Participants’ Views on the Attributes Required by Hospital Teachers Align Closely With Literature Findings

A 5-point Likert scale question probed 21 attributes described in the literature as being required by hospital teachers to cope effectively with circumstances within a hospital setting.

The responses of the participants were robustly aligned with evidence from the literature review (see Figure 3). Fourteen attributes were unanimously described as “fairly necessary” or “very necessary,” with none labelled as “not necessary” or “slightly necessary.” Flexibility and empathy were described as “very necessary” attributes by 100% and 92% of participants, respectively. The following attributes were also checked as “very necessary” by more than 75% of participants: “positivity,” “serenity,” “stress-reducing capacity,” “sensitivity towards the illness situation,” and “acceptance towards students’ and family’s emotions.”

Figure 3 

Competency Profile of Hospital Teachers.

*One participant did not respond to this item.

Statements From the Literature About the Emotional Impact of Being a Hospital Teacher Obtained Widespread Agreement From Participants

Another Likert scale question asked participants to rate their agreement towards 14 statements about the emotional impact of working as a hospital teacher extracted from the literature review (see Figure 4). For this question, participants were also allowed to select “not applicable” (as they may have not been exposed to the situation described in the statement).

Figure 4 

Emotional Impact of Working as a Hospital Teacher.

Once again, our findings showed strong agreement with the literature. No participants disagreed with any of the presented statements, and all items except one received ratings of “quite agreed” or “totally agreed” from more than 90% of participants. While the first five statements referred to situations that could be described as challenging, the remainder described positive feelings or emotions. However, no distinct pattern was observed among answers for these categories. Participants tended to agree with both challenging and positive experiences described in the statements.

The statements with the highest scores for “totally agree” were:

• “I feel satisfaction in being able to accompany students in difficult moments” (85%),
• “I feel that my role as a hospital teacher helps normalise the exceptional situation that a hospital admission is” (85%),
• “I share the joy of students and families upon recovery and discharge” (77%),
• “I feel moved when a student goes into palliative care” (77%),
• “I feel moved when a student starts an end-of-life process” (77%).

Hospital Context-Related Factors Influencing Education in HS

Despite Their Distinctive Uniforms, Hospital Teachers Are Not Always Easily Identifiable, Nor May the Hospital School Be Easily Found

In a hospital context, being able to identify hospital teachers and/or locating the HS is useful for students and families. Nevertheless, 62% of participants reported that the HS was not easily found. Ninety-two percent of hospital teachers reported having a uniform provided and maintained by the healthcare centre, while one participant stated otherwise. Almost half (46%) of the sample considered their uniform to be easy to recognise and indicative of their role, as distinct from healthcare personnel.

Not All Hospital Teachers Feel a Sense of Belonging Towards the Hospital

Eighty-five percent of hospital teachers perceived that the hospital paid attention to their professional needs. Of these, 55% reported that solutions were not always offered to meet their needs. On the contrary, 15% responded that their needs were only occasionally or rarely heard and that solutions were never offered. When asked about their sense of belonging towards the hospital, 69% reported feeling included and valued, while 15% expressed not feeling this way.

A summary of findings from this section is provided in Figure 5.

Figure 5 

Hospital Context-Related Factors Influencing Education in HS.

Additional Themes From the Qualitative Data

The findings from the qualitative data were presented previously alongside the quantitative results. However, the thematic analysis revealed an additional theme: lack of coordination between hospital schools.

“I think it is very important, fundamental, I would say, to be able to share our work with at least one colleague. Not to be alone in educational care, so as not to feel alone.” (Participant 3)

“I think it is important to mention the lack of closer coordination between hospital schools, to share ways of working, ideas, or to make a more detailed transfer.” (Participant 4)

The items that received the most comments are quantified below, as this may highlight those topics that participants felt more compelled to express their perspectives on:

• – Frequency of communication with the mainstream school: 12 comments
• – Class interruptions: 8 comments
• – Coordination with other professionals: 7 comments
• – Duration of lessons: 7 comments
• – Access to student information: 6 comments
• – Initiation of coordination with the school of origin: 5 comments
• – Coordination with the school of origin: 5 comments

Pedagogical Factors

Generally, teachers teach at a specific educational level and specialise in a specific subject. However, the entire sample in this study reported teaching both primary and secondary education, and 62% reported teaching any subject required. Altogether, it can be inferred from our findings that hospital teachers cater to a wide diversity of pupils, varying in age, stage, level, subject, learning style, and adaptations specific to a given disease situation, which coincides with the findings of Sukhanova and Sharikov (2020), Keehan (2019), and Äärelä et al. (2018). Congruently, 100% of participants described that the adaptation and methodologies used varied according to the student and the needs of the moment, suggesting the need for a high capacity for flexibility, which coincides with Benigno and Fante (2020), Capurso and Dennis (2017), Steinke et al. (2016), Burns (2013), and Carstens (2008). Furthermore, our qualitative data underscore how instructional plans are constantly adapted based on students’ needs. Ninety-six percent of the sample regarded class climate as an indispensable aspect to consider, the goal being an environment where the student feels comfortable, calm, relaxed and motivated, which coincides with Bustos and Cornejo (2014).

As Steinke et al. (2016) observed, the duration of classes often varies depending on the student, the day, and the medical tests to be performed, among others. Similarly, both our quantitative and qualitative results described a wide variability concerning the duration of classes, determined by the circumstances of the moment. Moreover, all participants reported experiencing interruptions during classes, which Benigno and Fante (2020) also mentioned as frequent in the hospital context.

The challenge of educating such a diverse student body makes it essential for hospital teachers to be restless professionals in search of new knowledge and skills, innovative methodologies, and creative use of resources, not to mention the need to be engaged in constant discovery of the latest information and communication technology, including the many resources offered online. Undoubtedly, these professionals must go beyond the teaching category to which they are assigned to look for solutions to expand their capacities and skills as teachers.

Ideally, the students feel a sense of belonging to the educational centre of origin, which the hospital teacher tries to maintain and promote. For this reason, it is important to direct efforts towards what Pini et al. (2019) referred to as the “interconnectedness of health, educational, developmental, and social aspects” of students in situations of illness. However, our results showed that the frequency of communication with regular schools varied greatly. Interesting, this item was the most commented (by 92% of participants). Qualitative findings stressed how the frequency of communications varied case-by-case.

A similar pattern was observed for instructional student plans; that is, they are designed in different ways depending on communication with the educational centre of origin. Dixon (2014) noted that the interaction and consequences of coordination depend on the staff at the educational centre of origin, giving evidence of success when the relationship is close and communication takes place with a person who is significant for the student. In light of this, the variability seen in our results is striking and might suggest a lack of equity and educational inclusion.

The aim of coordinating with the educational centre of origin, beyond academics, is to keep students in communication with their usual environment, as described by the Hospital Organisation of Pedagogues in Europe (HOPE; 2000) and Benigno and Fante (2020). Maintaining communication and friendship bonds can be of benefit for both students in situations of illness and their classmates (Observatorio Internacional en Pedagogía Hospitalaria, 2022). It can also allow the educational community to become involved and promote learning about illness as part of life (Jiliberto et al., 2022). Indeed, if the goal of educational continuity is to reproduce and compensate for what happens in the educational centre of origin, it is essential to include educational, social and cultural interactions that go far beyond the mere completion of academic work.

It is also necessary for hospital teachers to coordinate with hospital professionals to gather relevant information (Benigno & Fante, 2020; Carstens, 2008; HOPE, 2000; Keehan, 2021). The effectiveness of these interactions influences the quality and individuality of the interventions they deliver (Burns, 2013). Therefore, the disparity in coordination patterns seen in our study is striking, showing that it seems to depend on a given hospital, thereby reflecting variability in each hospital’s sense of the value and need for educational continuity.

Despite HSs being officially recognised educational centres, unlike regular schools, they do not receive annual budgets from the Department of Education. Consequently, and as previously reported by Steinke et al. (2016) and Işiktekiner and Altun (2011), we found a lack of financial provision by education authorities. This lack of annual budgets may limit the effectiveness of the hospital teacher. However, our findings reveal that in some cases this is compensated by the hospital upon request and subjected to approval. Furthermore, all participants reported using personal resources to carry out tasks that otherwise would not be possible, as also observed by Steinke et al. (2016).

Differences were also observed with regard to specific training for hospital teachers. Specifically, 67% of hospital teachers reported not having access to specific training, in line with previous reports (Benigno & Fante, 2020; McNamara, 2024). At the same time, 69% reported receiving supervision and support. Nevertheless, out of these, 22% reported that such services were not quickly accessible or efficient.

Finally, qualitative analysis revealed a lack of coordination between HS in Catalonia, which may seem surprising given the small size of this population and how feasible online meetings for coordination and cooperation purposes would be. Altogether, our results are in line with what Steinke et al. (2016) described as a lack of common structures, organisation, and funding of the different HSs.

Socioemotional Factors

Results indicate that participants’ perspectives on the competency profile of hospital teachers strongly align with the literature. Teaching in a hospital school setting requires professionals who are willing to cultivate flexibility, serenity, and empathy, as well as being positive and developing the necessary communication skills and emotional stability to be able to manage the diversity and complexity of situations faced in a hospital context. As mentioned by Plage et al. (2022), advocacy should be considered as an additional quality of hospital teachers, as an important safeguard of the right to educational continuity, equity, and inclusion of students in situations of illness.

Our findings regarding the emotional impact of working as a hospital teacher are consistent with those of Benigno and Fante (2020), Keehan (2019), Requena (2015), Bustos (2014), and Carstens (2008), in particular, the bond that is established with both the student and the student’s family. In these circumstances, where life-threatening events occur, the bond established between hospital teacher and student is often intense. Moreover, it can be incorporated into the family and maintained once the illness is over.

Further, our results revealed that hospital teachers perceive situations of deteriorating health and end-of-life processes as highly impactful, corroborating the findings of Keehan (2019), Steinke et al. (2016), Andreatta et al. (2016), and Requena (2015). Similarly, participants considered hospital teaching as a normalising agent for students and recognised the positive consequences this may entail, in agreement with Benigno and Fante (2020), Requena (2015), Burns (2013), and HOPE (2000).

The high satisfaction that participants reported regarding being a hospital teacher is noteworthy, coinciding with the findings of Benigno and Fante (2020), Keehan (2021), Steinke et al. (2016), and Işiktekiner and Altun (2011). Specifically, 92% of the participants consider teaching as a source of personal learning, which corresponds to findings by Bustos and Cornejo (2014) and Carstens (2008).

Our findings also coincide with those of Benigno and Fante (2020), Steinke et al. (2016), and Işiktekiner and Altun (2011) regarding the difficulty in coping with end-of-life situations and yet experience of sense of satisfaction regarding hospital teaching work. It seems that being able to offer a service that helps to alleviate a student’s suffering may be a trigger of satisfaction and personal growth for the hospital teacher. Perhaps, despite having to confront situations of suffering, the hospital teacher values teaching in this context as a way to be in contact with meaningful events that enrich their lifelong learning experience.

Hospital Context-Related Factors

As mentioned by McNamara (2024), Benigno and Fante (2020), and Ruiz et al. (2020), specific training for hospital teachers is necessary not only in the beginning but on an ongoing basis. For example, with regard to procedures specific to a hospital context, such as infection control protocol, results showed that only 23% of participants received such training upon taking their position.

Further, despite wearing uniforms, hospital teachers are not always easily identifiable. Less than half of the participants considered their uniform easy to recognise and indicative of their role as teachers. The implications of this may extend beyond practical aspects, as students may feel differently towards teachers than towards health professionals.

Not all participants reported feeling a sense of belonging to the hospital. Sixty-nine percent reported feeling included and valued, while 15% expressed not feeling this way. Perhaps the disparity in terms of resources provided by the hospital, coordination with hospital professionals, and supervision and support could explain these results.

What Happens Next?

Hospital educational care serves as a temporary resource with the goal of maintaining educational continuity and assisting with the student’s re-entry into their original educational centre after convalescence. However, as Barnett et al. (2023) noted, there is uncertainty regarding the efficacy of educational support interventions in enhancing academic performance, school engagement, or the transition back to school. For these reasons, as Ormiston et al. (2024) described, it is necessary to make improvements in the following areas:

• protocols for effective and efficient communication between the educational centre of origin and the hospital teacher,
• reintegration plans addressing academic, social, socioemotional, and medical needs, to be adapted as necessary, and
• enabling the hospital teacher to provide relevant information about the student’s medical condition to prepare the educational centre of origin for facilitating the student’s re-entry.

Altogether, our findings invite us to reflect upon how educational inclusion is managed in this context. Specifically, it may be useful to reflect upon the model that is guiding us, whether it is a medical model based on the individual’s deficit or a social model that acknowledges how social attitudes and barriers imposed by the environment lead to limiting individuals with diverse abilities (Koller and Stoddart, 2021).

Hospitalised students represent a small percentage of the student population attending mainstream schools. Being a minority may pose a challenge in terms of advocacy in itself. However, this is worsened by the fact that hospital students are usually spread out in different schools of origin upon discharge, limiting their chances of gathering and sharing experiences, and, in turn, possibly leading to an inability to recognise common needs or establish advocacy mechanisms.

According to Maslow et al. (2011), the reduction of inequalities, Sustainable Development Goal 10 (UNESCO, 2016), seems not to have been achieved, as young adults who experience chronic illness in childhood have poorer educational, vocational, and financial outcomes compared to their healthy peers – circumstances that can limit their potential of living an independent adult life.

Limits of the Study

Despite providing insightful results for an underexplored research area, this study is not without limitations.

First, even though the questionnaire was validated by six field experts, it could be argued that validation from psychometricians, statisticians, and/or survey methodologists was also necessary. However, expert validation was prioritised due to the specialised and situational nature of most questions. Additionally, the questionnaire was strongly tailored to the Catalan context, so its application elsewhere may require adaptations.

Second, although achieving an 87% participation rate relative to the target population, the sample size was too small to estimate correlation coefficients and allow for inferential analysis (Delgado, 2014). However, the focus was placed on descriptive statistics based on the study design, not due to this limitation.

Lastly, when reflecting on the thematic analysis, it is crucial to note that the qualitative data consisted of 2,330 words. Therefore, it is important to recognise that the scale of this analysis was limited compared to more extensive thematic analyses conducted on data from in-depth interviews or focus groups, for example.

Implications for Further Research

Our findings emphasise the uniqueness of the HS context. Therefore, advancing our comprehension of the factors that influence HS education is crucial for informing decision-making processes among stakeholders and shaping future policies.

To fully understand the HS context beyond the perspective of hospital teachers, future studies should explore the views of other stakeholders. First, of hospital students themselves, since it may not be possible to fully develop an understanding of the factors that influence education in HS without hearing their voices. As Spencer et al. (2023) asserted, the development of policies and the design of interventions should be based on the experiences of the individuals for whom they are intended to be implemented. Additionally, the experience of family members and/or guardians should be investigated, as well as the perspectives of other professionals, such as educational psychologists and social workers.