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Use of the Asynchronous BlackBerry Technology in a Large Children’s Hospital to Connect Sick Kids to School Deborah I. Fels*, Peter J. Samersƒ and Margaret Robertsonƒ ƒ

*Ryerson University, 350 Victoria St., Toronto, CANADA Royal Children’s Hospital, 159 Flemington Rd. Melbourne, AUSTRALIA,

Abstract: Almost ubiquitous use and distribution of information and communication technologies throughout many parts of the world has revolutionized our ability to access, distribute and process information. One of the most common of these technologies is email. Students in many educational settings have access to and are expected to use email on a regular basis. At the Royal Children’s Hospital Educational Institute, email is used to keep children and young people connected to their school of origin for academic and social purposes. We carried out a pilot study to investigate the usability and usefulness of a wireless email solution, called a BlackBerry, for children and young people in the hospital. Results indicate that an email appliance such as a BlackBerry is most useful for children and young people who are in the hospital for a short stay and for those who are unable to use a full computer system for email. The BlackBerry required little, if any, training so children could use it as soon as they picked it up. Security issues such as device tracking and avoiding device loss presented the greatest concerns among all users.

Introduction Advances in information and communication technology (ICT) have radically changed the way individuals access, distribute and process information. Those with access to ICT are able to share, search and store digitised information at high speeds across distances that can span the globe. The capabilities of these new technologies can provide a viable alternative to traditional methods of educating children and young people in hospital by allowing them to ‘connect from the bedside’ to their school of origin, and to the digital world of information and interactivity. Traditional strategies for accommodating the educational needs of children and young people in hospital involve teaching at the bedside, in a ‘hospital classroom’, or by simply not addressing a child’s educational needs at all. The hospital classroom is usually a physical space where teaching resources such as art supplies, textbooks and computing resources are readily available. Within the hospital classroom model, trained teachers facilitate the student’s engagement with education by developing a learning plan for the individual child based on grade level, ability and level of health. There is usually little or no ongoing communication with the individual’s school of origin teacher other than some initial contact to gain an indication of his learning needs. In addition, the hospital classroom model does little to address the social aspects associated with school because there is infrequent or no contact with familiar classmates. Researchers (Katz et al., 1992; and Arroyos-Jurado, 2000) report that social factors are of critical importance for children in hospital. Research also shows that beyond the academic gains of social interaction, contact with peers provides significant non-academic benefits, particularly in social and communication skills, and in the development of greater self-confidence and independence (Lipsky, 1995; Thompson, 1994). Keeping children and young people connected to their regular academic and social network can also reduce difficulties experienced by children during school re-entry (Fels and Weiss, 2001). New technologies have created numerous ways of supporting bedside-to-school of origin connectivity. Options range from fax and telephone technologies to advanced computer-mediated video, although few have been attempted in this context. While there is a considerable body of literature showing that children and young people can effectively learn using synchronous or asynchronous computer-mediated technologies (Benbunan-Fich, R, 1999; and Veerman et al., 2000), exploring use of these technologies in a hospital-to-school context has had little attention. Studies also demonstrate that computer-mediated communication can help support social interaction in educational settings (Wilson

and Morrison, 2000; Kim, 2000) and within hospital settings (Holden et al.,1999). Other benefits of using communication technologies to connect hospitalised children and young people to their classrooms include: personal empowerment (when control of their life is in the hands of others); educational benefits of learning to use ICT; and the prestige and ‘fun’ factors associated with using sophisticated technologies. Of these communication technologies, email is the dominant asynchronous communication application used by teachers and students in schools. Palmer and Bray (2001) observed that while students’ level of access to the internet has remained relatively static in recent years, use of email has increased markedly. The ubiquity of email use in schools (e.g., all schools in Victoria are connected to a Wide Area Network) also means that most users are familiar with the functionality and software interface of the email application, and that a hospitalized child has others with which she can correspond. The advantage of email to empower users to create and send messages at their own place is well documented in the research literature (Sabieh, 2002). In a hospital setting where a child may not follow a regular schedule or be able to participate in school at some standard and set intervals, using email to communicate with school and friends is particularly attractive. In addition, email does not place high demands on network bandwidth and it can therefore be reliably available at all times even in situations of high network traffic). The Royal Children’s Hospital Education Institute (RCHEI) has deployed an innovative model for providing educational services to children and young people in the hospital, and for supporting their transition back to their school of origin and home. The foundation of this model is to provide a child in hospital with connection and continuity to his school of origin for the duration of her hospital stay. As an alternative to providing bedside teaching, the approach of the RCH Education Institute is to employ a wide spectrum of technologies to support connection and continuity such as email, video conferencing, synchronous chat, telephone and even fax (see Fels, et al., 2003 for a further description of this model). This paper provides a report of a pilot study that was carried out at the RCH Education Institute to determine whether a wireless email appliance, the BlackBerry, could be used to keep children and young people connected to their school of origin, and in what circumstances would using a BlackBerry be appropriate.

System Description BlackBerry™ is wireless, handheld appliance and server software providing access to email, text-based web browsing, personal device assistant functionality such as address book management and calendaring, and mobile phone services such as telephony and sms messaging. In Australia, the BlackBerry technology uses Telstra’s GSM/GPRS network technology for signal processing and distribution. The user interface consists of an icon and menu based display that is controlled by a thumbwheel mouse and a small keyboard (see Figure 1). The keyboard is designed to be used with the thumbs (thumb-typing).

Thumbwheel mouse

Figure 1: BlackBerry 5820 wireless handheld

The markets for the design and use of types of wireless devices are typically upper-level executives, and mobile professionals. However, our application of these devices involves keeping children connected to their school of origin through email contact with friends, teachers and classmates.

Research purpose and questions The purpose of the study reported in this paper is to determine whether a portable, wireless email technology would be feasible and effective for use by children and young people in hospital to stay connected to their school of origin. The research questions are: 1) is the BlackBerry technology usable by students 2) what types of students and in what situations is this technology most useful.

Method Five young people (three secondary students and two primary students) used a BlackBerry from one to ten days over a two week period. There were three female and two male participants. Ages ranged from twelve to eighteen years. One student was unable to complete the study due to destructive behaviour. The telephony functions of the BlackBerry were disconnected during this study. Three education advisors also participated in distributing, training and monitoring the use of the BlackBerry handheld devices during the study period. Student participants were asked to complete a 14-question questionnaire upon completion of the study. The questions were designed to collect the student’s impressions of the ease of use of the BlackBerry, comfort with the device and usefulness to them. Education advisors were interviewed to gather their opinions on ease of use, supportability and likes and dislikes of the devices.

Results Results of the student questionnaire and the education advisor interviews will be presented followed by a more detailed case report of one illustrative example. Student responses Although the number of participants in the study is relatively small, children and young people of different ages with varying medical and school needs were able to use BlackBerry. As recommended by usability experts (Neilsen, 1994), between four and six people are required to isolate most of the major usability difficulties with a user interface. Sufficient feedback from users was provided to answer our research questions regarding the usability and feasibility of using a small wireless email device such as a BlackBerry. All four young people reporting liking the BlackBerry handheld appliance or liking it very much. All used the BlackBerry system often to send and receive email. Two of the participants often used the Internet services provided on BlackBerry. All participants stated that BlackBerry was easy to use for sending, receiving and replying to email messages. They indicated that they either taught themselves or had help from an Education Advisor at RCH Education Institute to learn how to use the device and that it was easy to learn how to use. Two of the students were simply given the device and left to their own devices. In one case, the parents used the device to assist their child in sending email because the child had limited hand mobility when first admitted to hospital. These parents also used the device to communicate with the school themselves. Two of the young people mentioned that they would not like to have the device upon return to the hospital. This seems to conflict with the very positive responses to questions about likes/dislikes with BlackBerry and the frequent use of it.

These two students may have responded this way because they did not intend to return to the hospital or that their hospital experience was unpleasant in general. Education advisors’ responses All of the education advisors reported having a very positive experience with BlackBerry. The positive aspects of BlackBerry included its portability, flexibility, ease of set-up and use, and it is easy for the children to learn how to use. Two advisors recommended that a small, wireless email system could be very useful for a young person as an interim measure before a complete computing system could be arranged for use in the hospital, or when a young person was in the hospital for a short duration (single or chronic short term stays such as for broken bones or kidney dialysis). Finally, all advisors were concerned that the size and portability of the device would make it difficult to keep track of it in the hospital, and not have it lost or stolen. Two advisors liked the small size of the device and one suggested that this was a disadvantage for some young people. Two advisors suggested that the device had a high novelty and prestige factor which motivated young people to use it. Two advisors also reported that the keyboard was small and difficult to use of some young people, particularly those with intravenous drips in their hands. However, they also suggested that “thumb-typing” would become easier with practice for most students with complete hand function. Technical Issues The BlackBerry system requires email services to be provided through a Microsoft exchange server or Lotus Domino Server within the organization. The hospital’s mail system was built on a POP platform and in order to implement the BlackBerry solution a new Exchange infrastructure was required. Each student participating in this study was assigned a new email account purposely established for this trial. The need to publicize this new address with the study participant’s peer group presented some difficulties. Since students had not brought a contact list with them, locating the addresses of their friends was problematic. A way of easily importing an address list from another source is needed to facilitate initial contact. In the case of education advisers who had existing addresses, rules in their mail software were established to forward a copy of mail received at the existing account to the BlackBerry account. The existence of two mail accounts was confusing and it would have been preferable if the BlackBerry system could have been linked directly to the existing account. For users with webmail accounts (e.g., hotmail), the facility to forward to another account was not always available presenting further complications. Users then had to manage two different accounts. Some solutions to address the interaction between BlackBerry and other email accounts have been flagged for future software upgrades, and the effectiveness of these would need to be established at that time. In the hospital setting where users are transient, these account management issues are an irritation to users and administrators. In a large scale implementation, protocols would need to be established for the simple administration of these issues. A compelling example illustrating effective use of BlackBerry technology. A young person was admitted to hospital with severe facial and hand burns as a result of an accident at school. The young person and family were traumatised by the accident and by the fact that it had occurred at school. The relationship between the family and school was therefore strained. The young person did not have the use of one hand, and was unable and unwilling to type on a keyboard when first admitted to the hospital... Family members were less familiar with computing technologies. Space in the hospital room was very constrained. For these reasons, use of a laptop to connect to the young person’s school of origin was not possible. Instead, the young person was given a BlackBerry system which provided a non-intrusive email appliance that would be used to email friends and school. Family members were able to easily learn how to use the device and could assist the young person in typing email. Because of the portability and size of the device, family members could use it outside of the young person’s hospital room giving them flexibility of time and location for communication with friends and school. Finally, email provided the parents with a constructive, nonthreatening method of maintaining a connection with school.

The family and the young person were immediately able to function with email and stay connected. This provided them with some distraction from the trauma of the accident and with a level of technology comfort not afforded by other technologies.

Discussion This pilot study provided the RCH Education Institute some initial positive evidence of the need and usefulness of a wireless, easy to use email appliance such as BlackBerry for connecting children and young people to their school of origin from the hospital through email. In one particular case, the benefits to the family and young person were greater than expected. In this case, BlackBerry helped the family function by allowing them to easily and immediately communicate with school and friends. Security, device tracking, and avoiding device loss create difficulties for the management of this device in a large organisation particularly when one unit would be used by a range of people at different times. Suggestions such as a lockable cupboard in the hospital room and retractable locking mechanism were made by families and education advisors. Another concern is the size of the keyboard and “thumb-typing” as an input method. For children and young people with the complete use of two hands, this input method may be awkward at first but is easily learned. However, for individuals with limited hand function (permanent or temporary), thumb-typing and thus the device may not be usable (although a helper could assist the young person with typing if deemed appropriate). Use of the BlackBerry technology seems to be most useful for children and young people as an interim solution before they obtain or can use a full fledged computer for maintaining connections and completing connections (e.g., when a young person is first admitted to hospital). By having a wireless email appliance that is easy to set up and use, a young person can establish immediate connection to friends and school which may have positive health and well-being implications. It also appears to be useful for young people who are in the hospital for short durations where use of a full fledged computing system is not practical.

Acknowledgements We would like to thank Telstra for their generous support in providing access to BlackBerry and signal processing technologies. We also would like to gratefully acknowledge the input of Barbara Emblin, Jacqui Gibson, Nicole Bremner, and Paul Ive for organizing the use and distribution of Blackberry technology (handhelds and software) with young people and for providing feedback for this paper. Finally, we would like to gratefully acknowledge the families and young people who participated in this study.

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BlackBerry is a registered trademark of Research in Motion, Canada and is distributed by Telstra in Australia.

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