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\title{Ten Encounters between Students and a Special Education Teacher at a Finnish Hospital School -Outlining Hospital School Pedagogy}
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             \author[1]{Satu  Uusiautti}

             \affil[1]{  University of Lapland}

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\date{\small \em Received: 6 December 2015 Accepted: 2 January 2016 Published: 15 January 2016}

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\begin{abstract}
        


This article presents a description of a special education teacher?s work and how it appears as student encounters during a month-long observation period at a hospital school. The teacher?s pedagogical skills are tested when she has to bend to many directions. Every day is different, students form an extremely heterogeneous group, and every one of them has their special needs. Teaching at a hospital school is special education at its best and work requires especial flexibility, understanding, acceptance, and caring as well as endless trust in students? development regardless of their most difficult conditions. The article is based on Dr. Äärelä?s long-term experience as a special education teacher at a hospital school and her researcher?s diary of the everyday encounters in the teacher?s work. The month-long special observation period formed the data of this study. The findings are here presented as ten examples of student encounters. They are to illustrate the daily work at a hospital school and, thus, help to develop and support teacher training. The fundamental purpose is to lay foundation to the development of hospital school pedagogy.

\end{abstract}


\keywords{hospital school, teaching, special education teacher, hospital school pedagogy, teacher as researcher.}

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\section[{Introduction}]{Introduction}\par
eaching provided in hospitals are to secure the continuous education of children and youngsters even during illnesses. In Finland, the law of basic education establishes that the county in which the hospital is located must arrange hospital teaching to school-aged children. Hospital schools have a relatively long history but research has focused more on nursing and care than on the teaching work \hyperref[b4]{(Breitweiser \& Lubker, 1991;}\hyperref[b14]{Crossland, 2002;}\hyperref[b15]{Delbanco \& Parker, 1978)}.\par
Teaching is arranged for students hospitalized in, for example, child psychiatric, neurological, somatic illnesses, and phoniatrics wards. In Finland, most of the students are inpatients but after the new law of 2014, also outpatient students can attend classes at hospital schools. Teaching is arranged in 25 hospital schools in Finland (Vaativan erityisen tuen kehittämisryhmä, 2016). This study was conducted in one middle-sized Finnish central hospital. The teacher had been teaching various students in this hospital school for over ten years.\par
According to the Finnish Ministry of Education and Culture report about hospital teaching for students with intensive special needs, Finland has about 170 special education teachers in hospital schools. Hospital school teachers are usually special elementary education teachers but also special education teachers, subject teachers, and classroom teachers or elementary school teachers (Vaativan erityisen tuen kehittämisryhmä, 2016). Hospital school teachers work as the pedagogical experts in the multi-professional teams of special health care and are responsible for being in contact with students' own schools. Teaching happens as a small-group teaching and hospital school teachers often work in pairs with school assistants. 
\section[{II.}]{II.} 
\section[{The Nature of Hospital Schools}]{The Nature of Hospital Schools}\par
In Finland, students attending hospital schools usually follow the curriculum of their own schools when it comes to various school subjects. But for the school environment and pedagogical practices, the hospital schools have their own curricula (Perusopetuksen opetussuunnitelman perusteet, 2014; see also \hyperref[b17]{Dixon, 2014)}. The former is necessary because children remain officially as students of their own schools even if they were taught at a hospital school. When teaching follows the student's own school curriculum as far as possible, the future transition from hospital school to regular school will be smoother \hyperref[b41]{(McLoone et al., 2011;}\hyperref[b59]{Shaw \& McCabe, 2008;}\hyperref[b62]{Stuart \& Goodsitt, 1996)}.\par
In the hospital school, children are first and foremost patients of special health care. Their medical treatment has priority, while hospital teaching supports children's overall rehabilitation. This means that teaching provided at hospital school has to proceed within the limits of students' health. Learning goals and objectives are always determined individually and revised regularly because a student's health, condition, and length of medical treatment can change all the time. Therefore, cooperation with other nursing personnel and parents is especially important in a hospital school teacher's work \hyperref[b8]{(Choi, 2014}; Romaniuk, O'Mara, \& Akhtar-Danesh, 2014). learning and school attendance as well as support of goals in medical treatment \hyperref[b9]{(Clemens, Welfare, \& Williams, 2010;}\hyperref[b60]{Simon \& Savina, 2007;}\hyperref[b72]{Weiss et al., 2015)}.\par
Hospital teaching is pedagogically remedial teaching. Teachers are required of possessing special pedagogical expertise to support students and trust in their development and opportunities  {\ref (Ubha \& Cahil, 2014)} even when the chances to learn and study are the most difficult  {\ref (Lightfoot, Mukherjee, \& Slper, 2001)}. Students' backgrounds and school histories are often filled with various problems \hyperref[b64]{(Thies \& McAllister, 2001}  \hyperref[b42]{(Mescon \& Honig, 1995;}\hyperref[b52]{Reiss, Gibson, \& Walker, 2005)}, and the teachers and personnel from students' own schools \hyperref[b37]{(Lindsey, 1981;}\hyperref[b58]{St Leger, 2014)} have their important roles. The work shows special pedagogical and psychological expertise but also medical knowledge and expertise; hospital school teachers have to act as sorts of interpreters (to speak the language of "care and treatments") between special health care personnel and students' own schools \hyperref[b57]{(Shields \& Nixon, 2004;}\hyperref[b58]{St Leger, 2014)}.\par
In addition to the basic task of teaching inpatients and outpatients in hospital schools, hospital school teachers are expected to provide guidance and consultation help to schools the students would attend if they were not hospitalized \hyperref[b1]{(Ball \& Howe, 2013;}\hyperref[b7]{Chesire, Canto, \& Buckley, 2011;}\hyperref[b17]{Dixon, 2014)}, to create models and support methods to solve challenging situations with students (Mukherjee, Lightfoot, \& Sloper, 2000; Äärelä, Määttä, \& Uusiautti, 2015), and to be responsible for teaching of children with psycho-social special needs. Supporting students \hyperref[b6]{(Canto et al., 2014)} and paying attention to their special needs and learning difficulties \hyperref[b14]{(Crossland, 2002;}\hyperref[b19]{Epstein \& Wayman, 1998;}\hyperref[b63]{Taylor, Gibson, \& Franck, 2008)} necessitate such professional expertise and pedagogical approach that cannot be developed without understanding about the nature of hospital schooling. In all, hospital school teachers form quite a marginal group of special education teachers.\par
One of the typical features of hospital schools is the high turnover of students \hyperref[b16]{(DiVasta et al., 2008;}\hyperref[b65]{Tilus et al., 2011;}\hyperref[b71]{Van Leeuwen, 1977)}. Schools have approximately one new student per week while other students return their own schools as their condition allows them to do so. In addition, students have various treatments during school days which means that students come and go during the days, too. This kind of unpredictability is a central part of a hospital teacher's and other personnel's work \hyperref[b5]{(Callery, 1997;}\hyperref[b65]{Tilus et al., 2011)}. This special feature necessitates careful planning of educational entities \hyperref[b4]{(Breitweiser \& Lubker, 1991)}. In other words, teachers have to have various plans with plans B to each student. It is crucial to support and find methods to enhance students' positive development, stop the negative development toward exclusion , and teach students about their own responsibilities for seizing positive opportunities and enhance their well-being \hyperref[b77]{Uusiautti \& Määttä, 2016)}. 
\section[{III.}]{III.} 
\section[{Method}]{Method}\par
The purpose of this article to describe the multidimensional nature of hospital school teachers' work by introducing student encounters as a part of everyday work. This way, it is possible to show the unique features of hospital schools and the special expertise that is required of hospital school teachers.\par
To find answers to this research problem, a research period was conducted in one middle-sized Finnish central hospital that has a hospital school. The daily number of students in this school is approximately 30. Students are taught in four small groups: two of them consist of elementary-school-age students and two of middle-school-age students. If necessary, students can attend groups that suit their needs even if the group was initially for students of different age. For example, youth with school phobia find it less frightening to come to school if they are placed with younger students. All groups have school assistants with appropriate education. In addition, the hospital school has subject teachers based on demand. They teach either specific subjects (e.g., languages, handicraft) or individual students (e.g., those who are not able to participate in group teaching or those being provided teaching at their homes). This study took place in the students' group with mainly 9-13-year-old students.\par
Student groups are usually small because of each student's massive needs of special support. Most students come to the hospital school from the child psychiatric wards and polyclinics. Even nationally, over 80\% of students in the Finnish hospital schools are from psychiatric wards (Vaativan erityisen tuen kehittämisryhmä, 2016). Only children with intellectual disorders and autism are treated and rehabilitated elsewhere. Otherwise, school-aged children with special health care needs are directed in central hospitals and become students of hospital schools. The number of children with somatic illnesses has decreased due to increased outpatient care. Mainly, children stay longer at the psychiatric wards, but even there, treatment of outpatients are becoming more popular instead of long inpatient periods at wards.\par
The length of stay in hospital schools can vary from one teaching moment per day or during a few days (the moment can last e.g. 15 minutes if the student's condition does not allow more) to several-year-long attendance. Teachers can teach students also in their hospital rooms, next to beds, if they cannot leave their rooms because of treatments. Sometimes in these cases, teaching can happen via an online connection from students' own schools, too.\par
This study leaned on the idea of teacher-asresearcher approach (e.g., \hyperref[b0]{Altrichter, Posch, \& Somekh, 2005}; Mac an \hyperref[b38]{Ghaill, 2002)}. It is a case study in which the teacher observed her work and especially encounters with students for a predetermined time. Observations were written down in a researcher's diary and formed, in addition to the teacher's wide experience on hospital school teaching, the data of this study. The research period took place in the spring of 2015. The illustrations of situations with students are authentic and described as such in the researcher's diary. The teacher-researcher also wrote down utterances and short discussions after each event.\par
Eventually, the data formed a rich description of a teacher's work in a hospital school. It was analyzed with the qualitative content analysis method \hyperref[b13]{(Creswell, 2009)}. The analysis was data-based  {\ref (Malterud, 2001)} and thus focused on the emerging themes in the data. As the purpose was to study the multiformity of work, the analysis in this study focused on finding, on the one hand, varieties in students encounters and, on the other hand, illustrative examples of the special features of a teacher's work. Therefore, the analysis pursued drawing a picture that not only shows the ultimate fringes but also typical encounters in a hospital school teacher's work. Ten exemplary encounters were finally chosen as the illustrative results of this study. The eventual objective was to lay foundation to the development of hospital school pedagogy that pays attention to the special nature of teachers' work.\par
Certain ethical and reliability factors have to be considered always carefully in studies like this. As in child research in general (see e.g., Uusiautti \& Määttä, 2013), here also it was crucial to make sure that this research would not harm children in any way. Since the data were collected in the form of observations written down in a researcher's diary, the main issue was to secure the children's anonymity when reporting the findings. To do that, information about children's age and background is minimal. As the students change often in hospital schools, it is not possible to know who they are-that is why exact days of data collection period are not mentioned. In addition, the children were given pseudonyms and were selected randomly from an English name calendar.\par
Reliability of the research can be in this case evaluated as the researcher's ability to make relevant observations and mark them down correctly. It was also important that the researcher did not try to direct children's action or make hasty interpretations of the events \hyperref[b43]{(Mills, 2007)}. Therefore, to ensure reliability, a lengthy observation period was necessary: this way the researcher could obtain various kinds of situations and student encounters and become convinced that the descriptions of work are not just random but systematically collected during the specific period. When analyzing the diary data, the researcher has to be aware of his or her prejudices and earlier understanding of the research phenomenon. In this study, the teacherresearcher had been working at the hospital school for years and, thus, she had an experience-based understanding about the nature of the hospital teacher's work. This could hinder an objective analysis of the findings, but be an advantage too: an outsider would not probably understand the events and encounters as she did. To improve the reliability of the analysis, the findings, interpretations, and conclusions were discussed and revised within a research group that consists of the authors of this article. This is called researcher triangulation, and the purpose is not so much to seek consensus, but to understand multiple ways of seeing the data (see e.g., \hyperref[b73]{Wray, Markovic, \& Manderson, 2007)}. The results illustrate the events as they happen accompanied with further information and interpretation of the encounter. This way of presenting finding was to convince the reader about the truthfulness and richness of the data. 
\section[{IV.}]{IV.} 
\section[{Results: Encounters with 10 Hospital School Students a) A new student, Gerry, enters the school}]{Results: Encounters with 10 Hospital School Students a) A new student, Gerry, enters the school}\par
The school gets a new student, 11-year-old Gerry, who has been registered as an inpatient at the child psychiatric ward. During the month-long research period of this study, he attends hospital school. Based on the initial meeting with him and his background information, the teacher decides to place Gerry's desk near the teacher and the classroom exit. The desk has his name on top, like all other students have. Other students have been told the new-comer's name and grade earlier, and tension is sensible in the classroom. According to his records, the new student has plenty of difficulties in learning and behavior. Special education provided at his own school has not been enough and his has been temporarily suspended due to his repetitious aggressive behavior.\par
When arriving to his first lesson at hospital school, Gerry is grumpy and yells from the door at once entering the classroom: "Is this the place were crazies go to school?" He walks to his desk muttering to himself and loudly complaining about the location of his desk. 
\section[{Year 2016}]{Year 2016}\par
He places his back bag on the floor, crosses his arms, and looks angry. Before introducing everyone, the teacher replies to the student's important question by telling who, in general, attend hospital school-that is, all children who cannot attend their normal schools due to their condition or behavior. Then, the students introduce themselves.\par
Others present numerous questions to the newcomer but the teacher interrupts them. Gerry thanks the teacher and empties his back bag inside the desk. He starts his day by studying Finnish, which he has reported as his favorite school subject. Gerry's diagnose: depression-symptomatic behavioral disorder. 
\section[{b) From outbursts of rage to multiplication tables -Martin}]{b) From outbursts of rage to multiplication tables -Martin}\par
Martin from the 4th grade is against all school work. After signing in to the ward, he did not come to school for many days because he would always go berserk when the school day was supposed to start. When he finally comes, studying starts with two-hourlong days so that his nurse accompanies him in the classroom-not by his side but within sight. The goal is to stay at school for two hours without getting negative feedback from teachers. The first school subjects are math and biology and they are, according to Martin, his favorite school subjects.\par
The math lessons deals with multiplication tables. The teacher is surprised with the selection of theme because often students find themes that necessitate learning by heart repulsive. The teacher quickly notices that the multiplication tables are overwhelmingly challenging to this 10-year-old student, too. However, Martin does not want change the topic. He starts to cry and throw his things. Other students go to a classroom next door with the school assistant and continue their lesson with smaller students. Since the nurse is already in the classroom, no extra help needs to be called. The nurse watches the situation can calls for help if needed to secure everyone's safety.\par
The nurse helps Martin calm down by talking to him with a calm voice. At this point, the teacher goes to check the rest of the class to make sure that everything is ok with them. When the teacher comes back, the student has calmed down but is still crying and cursing. The nurse thinks that the lesson can go on because the student is likely to refuse coming to school. The student asks for a permission to go to a space reserved for calming down, a small room, so that other students would not see him crying. Moreover, the student wants to carry on studying multiplication tables. Studying continues in the small room that is equipped only with two soft beanbag chairs. The teacher takes there a table and a chair. The student is crying and solving multiplication problems. The teacher supports and help but the student would like to handle them by himself: "I can't learn these if you disturb me all the time here."\par
Martin achieves his goal: he attended school for two hours that day. The biology lesson was about forest birds and studying went well. He received positive feedback especially from the second lesson but also from the math lesson for being able to continue working by calming down after the outburst of rage. He also gained an insight when studying multiplication tables. Martin's diagnosis: Asperger syndrome. c) Luring the school refuser via the home building's ventilation hatch -Robert 12-year-old Robert has not attended school for several months. Personnel from his own school has contacted directly the hospital school to make sure he would get a place from the hospital school which has about one-month-long queuing time. These contacts happened already before this research period started. Now, he has been given a spot at the hospital school but he still has refused to come to school even for a tour.\par
The student has not been diagnosed with learning difficulties or other problems before he refused to go to school. According to his immediate adults, he has friends but had started to hanging back from shared activities. The student has not talked about school. He has just refused to go to school.\par
The students does not want to go to the hospital school or talk on the phone with the teacher. Eventually, his guardian presents a wish that the teacher would visit the child in their home. With the permission of the teacher's supervisor, they decide to do the visit. The child's condition was that his guardians should not be at home during the visit. The teacher arrives to the child's home at the appointed time. No one opens the door but there is a dog barking inside. The teacher waits, rings the doorbell again. Finally, she calls the student's own number that the guardian has given to the teacher. The phone is ringing inside the house but no one answers the phone. The teacher calls again. Now, the phone is dialing but ringing cannot be heard any longer. Therefore, the teacher knows that the child is inside the house. She sends the boy a text message: "This is the time for our appointed meeting. Would you please open the door." The reply is immediate: "No."\par
The teacher notices a nearby window that has the ventilation hatch open. Simultaneously, someone closes the blinds. The teacher has been observed through the window, and apparently, the student is at a hearing distance.\par
The teacher is talking through the ventilation hatch and explains what she knows already and why she is seeing the student right now. The teacher does not even know how the child looks exactly since she has only met the child's guardians at school and was shown a classroom picture from his school. The teacher starts to ask questions that can be answered with simple "hmmm". "You have a dog there, too?" "You go to the 6th grade, right?" After about fifteen minutes, the teacher dares to ask: "If I would come tomorrow at the same time again, would you let me in and I would see your dog too?" The student answers "hmmm". The teacher is happy and thanks. When getting to her car, the teacher notices that the blinds are turned open again. She waves at the window.\par
The following day's meeting goes well and the teacher meets a silent boy and an enthusiastic dog. The student comes to visit the hospital school the following week and decides to stay for the whole day at once. Especially, the small size of the class made him happy while disturbances, such as impulsive and occasionally loud classmates, do not bother him. He does not have difficulties in any school subject. Robert's diagnoses: school phobia. He had also been bullied at school. 
\section[{d) Teaching a youngster with cancer at home -Anna}]{d) Teaching a youngster with cancer at home -Anna}\par
This middle school student has been treated in a university hospital for cancer and is now entitled to home-based teaching. In the middle of hospital treatments, students whose studies become interrupted by low blood count or risk of inflammations can receive teaching at their homes.\par
The teacher plans studies for the eight-grader with her earlier hospital school teacher, rehabilitation advisor, and a teacher from the student's own school. Then, she agrees with the guardians about the plans and schedules for home teaching. Even a long-term illness should not prolong studies if the student's condition allows studying. While these students have less lessons that ordinary students, individualized teaching is often more efficient. Guidance and coordination of studies are important in home-based teaching. Students are given themes and tasks to study independently, too, but within the limits of their condition. Anna works diligently with the teacher and alone, and gets good grades from tests. Still, her mood is generally deflated and lessons are often hard. Cancer patients may have to vomit or they can fall asleep in the middle of studying due to their rough treatments. The teacher just has to patiently wait that the lesson can go on, if something like this happens.\par
In general, it is important to provide opportunities to participate in education also for those who have severe illnesses, such as cancer. School work provides content in days and gives other things to think about. Still, the fear of death may be strongly present, and the teacher has to face the family's fear and anxiety. Indeed, the hospital school teacher can become an important part of the family, even after the teaching period has ended. When teaching at homes, the teacher learns to know, for example, the family's pets and siblings, and often, the teacher is invited to the family celebrations as well. The devastating news of the young person dying after a long fight may become part of a teacher's day. Every time this happens, it touches deeply the hospital teacher, too. Anna's diagnosis: leukemia. 
\section[{e) Returning to own school from the hospital school -Paul}]{e) Returning to own school from the hospital school -Paul}\par
After having studied in a small group, Paul (11 years old) is rehabilitated and ready to return his own school. The student is nervous and would not like to return his school. However, being a special school, the hospital school is not meant to be anyone's permanent school and no one attends it longer than is necessary. Paul's return is planned as a two-month-long phased transfer to his own school so that he will spend a few lessons per day at his school at first, and then whole days, and finally a whole week. After that, they will have a meeting at the ward to evaluate his progress. The school assistant will accompany Paul at least for the first time and after that always when necessary. In this case, the assistant accompanied Paul every time despite the last week.\par
The students does not want to go to his own school and resists it. At the hospital, home, and hospital school, everyone talks about the importance of returning his peer group and how he has learned to recognize his challenges and how he has developed. His guardians have given his own school teachers permission to tell if they notice any changes in Paul's behavior and about challenges that they are facing and that have to be conquered-both Paul himself and everyone in his school, too. He will not be allowed to revert to his former troublemaker's role. In addition to himself, guardians, adults in his own school, and students are responsible for making sure this does not happen.\par
The student would not like to have his school assistant with him but this time, he cannot decide about it. Due to earlier unfortunate accidents, his former school does not want to take him back without a special adult to take care of him in the big school. This is also because he still has some challenging behaviors, although considerably less than before. The assistant stays in the back as much as possible, but clearly follows the student all the time. "What's up, homo?" is a greeting that Paul first heard at his own school. He had answered "And you?", and both students had continued walking. Visits to his own school are not easy, because the feel in informal situations and during breaks is expectant. What kinds of tricks the former entertainer student would come up with now? With the intensive, long-term support, his return is Year 2016 successful and those who expect crazy tricks give up. In the middle of one school day Paul had run home crying. Other had commented that after being for a long time in a mental hospital, he had become boring. Adults were complementing him not having become provoked for this, but just leaving the nasty situation. The student who said this inappropriate comment and others were spoken at school. They apologized their words in the next meeting.\par
The guardians, student, and other professionals had a meeting as planned after the days at Paul's own school. They analyzed the challenging situations and agreed about continuation and follow-up meetings. Everyone updated the situation, and especially Paul's teacher and school rector were prepared for the full transition to school in the following week. People at the hospital school arranged farewell party: Paul's favorite treats, a movie, hugs and wishes for the best. Even though not everyone wanted to hug, but surprisingly many did and several times. When leaving, the students whispers to the teachers: "By the way, I'm not ever coming back to this mental hospital." And he laughs. The teacher wishes the same sincerely, that he could spread his wings. Paul's diagnosis: behavioral disorder. f) A sixth-grader finding comfort from stuffed animals -Liza A 12-year-old girl Liza is playing with smaller children in the ward. He nurtures stuffed animals speaking in a very childish manner (echolalia). She is fretting always when she should go somewhere, including school. When she is urged to go to school, it becomes obvious that she cannot leave her stuffed animals alone. Thus, animals are invited to school, as well.\par
The student comes to school with her three stuffed animal friends. They all have names. However, she is unable to study, she is crying and squeezing the animals in her lap. Caregivers do not think private teaching would be beneficial because it would be important for her to be with her peers. Thus, the goal is to have her at school without disturbing others and to learn to tolerate staying at school. Only after less than a week, the student starts collaborating with the teacher according to her study plan. She is given small reading and writing tasks that she can do with her animal friends. Her writing is slow. She can read but not aloud, not even to her animal friends. Her stuffed animals have a place on the classroom shelf, and the student moves her desk close to them. Every now and then, she takes one of the animals in her lap and nurtures it by humming to it and swaying it.\par
Step by step, the student advances toward fivehour-long school days. Childish crying episodes and loud cries of distress are a central part of school days but become lesser. The student becomes distressed by, for example, hunger (even if she had just eaten), uncomfortable clothes, even the most careful negations by adults, and requests to do something that was asked, as well as surprising sounds, such as the start of air conditioning.\par
The student is moved to another place. Necessary information about her education are sent to the new school by the teacher's supervisor. The teacher attaches her contact information and waits for contact from the student's new school.\par
Liza's diagnosis: traumatized; suspect of sexual abuse. g) Super-diligent perfectionist with an eating disorder -Carol Carol, a 13-year-old seventh-grader, studies with smaller students because her treatments have continued at the pediatric ward. The student attends the hospital school during her treatments, and she has not had any problems in her own school. The students is meticulous and diligent in her studies, which is typical of people with anorexia. She wants to proceed fast and works hard after school, too. She wants to know exactly what others in her own school study while she attends the hospital school so that she would not leave behind in studies.\par
The students often dines together with her nurse, and sometimes, she is weighted even during the school days. She does not participate in group activities voluntarily, but does so always when asked. She speaks with a really silent voice and is careful with other students. During breaks, she spends time in the teacher's presence. Then, she talks about herself and her pet, asks about the teacher's family and pets, and mentions incidents that have happened during lessons. During these moments, the teacher has to be unhurried but still watch other students too. "This school is pretty different because students are so different. You couldn't so similar things at my school what you can do here. You teachers are different too." The girls describes the nature of hospital school well: a hospital school is also a place where children learn how to be in school, replace bad behaviors with good ones. Certainly, this is sometimes peculiar from a child's point of view. 
\section[{Carol's diagnosis: anorexia. h) A mute student as a part of small group -Steven}]{Carol's diagnosis: anorexia. h) A mute student as a part of small group -Steven}\par
A ten-year-old boy Steven had stopped talking at school. Six months ago he would still talk to his school assistant but then he stopped that too. At home, boy talks a little and the teacher hears school-related issues from the boy's guardians. They do not have any news to school. The guardian describes their family as an ordinary family but for some reason their child just stopped talking at school and in strange places.\par
The student is doing well at school otherwise, but he does not do oral practices. Therefore, it is difficult to control his learning of foreign languages. At times, the Year 2016 student stares at the teacher, and the teacher can only guess the meaning of these looks. Often in these cases, the teacher just gives space to the student. She can return to him when the look in his eyes has changed. At the end of one Finnish lesson, the student hands a note to a teacher. It says: "I'm not stupid. I know word classes. I just don't feel like writing." The teacher looks at the note and then at the student and smiles: "Thank you, it's nice to know this. I can't read your thoughts." The student pulls the paper back and writes quickly: "Usually, you can do it well."\par
The student goes to school, completes his tasks, and does his duties, but does not speak. The teacher's job is challenging. How to evaluate the student's learning in a balanced manner when writing is the only way of expressing himself? In the hectic everyday life at a hospital school, a mute student becomes easily ignored because he does what is required but does not disturb. The student also has therapy sessions, and sometimes, they are during lessons. The sessions are being marked as school lessons because he does not want to be absent from school.\par
Steven's diagnosis: selective mutism. 
\section[{i) Physical taming during a break -Jack}]{i) Physical taming during a break -Jack}\par
The student's state is evaluated every morning at the child psychiatric ward. It is necessary determine if he is able to come to school so that predictable difficulties and unnecessary interruptions of school days would be avoided. In other words, the purpose is to avoid the child's failure of doing his school work. At some point however, it is reasonable to come to school even if the morning had not started in the best possible way. The 10-year-old student has had the so-called bad mornings already for a week, and he has tried to become motivated to come to school, with the help of nurses. The goal is to be at school for the morning lessons and stay calm for the whole time.\par
Jack comes to the recess area with other students. They are not allowed to play soccer today because it has caused too many conflicts lately. They may play soccer on the following day if their surges of emotion have calmed and earlier grievances in the game have become forgotten. Jack is not happy about this solution because he likes soccer. His classmate comes to talk to him. "Fuck you", is Jack's reply. The nurse is nearby and intervenes in the situation. Before the nurse manages to say anything, Jack starts yelling and swearing, blaming that other students just stare at him. The nurse states that this is quite expected if someone speaks inappropriately. The student threatens to escape the hospital. At this point, other students are guided back in, and the recess alarm was rung a little bit ahead of time. The student would like to go to the lesson although he was still angry, but he is not allowed to enter the classroom with this state of mind and after this kind of behavior. More nurses are needed to calm the situation and hold on to the student who is relatively big for his age so that he would not be able to make good on his threat and run away.\par
Only psychiatric nurses have the right to restrict students physically. Teaching personnel can use physical power just to self-defense. In addition to school personnel, nurses attend to recesses. More eyes are needed to watch students, and in case of problems, teachers can go teaching if it is time to start lessons and others solve conflicts.\par
In the following morning, the student comes to school. Earlier day's events were necessary, because now the students came without bravado. The students were allowed to play soccer now, but Jack did not want to: "I lose my nerves so quickly when playing it. It's better not to play now because I want to do ok at school.  {\ref "} Step by step, the student accepts limits and obligations better and can bear responsibility for his own behavior. These are the best rewards to adults who have confronted him in power struggles. Jack's diagnosis: aggressive behavioral disorder. j) Violent and short-tempered student with substance dependence in a non-grade-bound education-Peter Peter (16 years old) who has faced plenty of challenges and attended several hospital school periods is now attending school for three afternoons a week. Still, he has abundant absences and tardiness. Mornings are impossible-he has tried to attend school in to mornings earlier-and Fridays and Mondays are especially challenging. The student comes to school from home, but he has stayed at the child psychiatric ward, too, several times. However, there has not been reason to resort to child welfare services, even though he has attended school irregularly especially when attending school from home and he abuses substances.\par
The student does not have learning difficulties per se, but clearly lacks study skills, such as attention and persistence in general, as well as learning to learn skills. He is not used to work hard and strive. He has wide gaps in knowledge. He has set the lowest acceptable grades as his goals and knows that it is called underachieving, but he is also aware of that he cannot do better at the moment. If he cannot complete basic education before he comes of age, it will be even more difficult to even complete it.\par
From the viewpoint of exclusion and dropping out, every time Peter comes to school is a victoryregardless of the state he comes. He has been and will be reported to child welfare officers many times because of his intoxication and low life management skills. At school, he studies in a goal-oriented manner every now and then. He always receives tasks to complete independently but he rarely does. His progress is slow, but as long as he wishes to complete basic education, hospital school provides a chance to Year 2016 obtain grades. "I'm sorry, I didn't hear the alarm clock. Do you still want me to school?" The student's being is fragile and nervous. The teacher remembers meeting the student when he was young; a vivid boy has become a withdrawing young man who abuses substances. He attends rehabilitation for substance abusers and a youth worker has been named as his support person. As long as he comes to school, even if late, he is not a drop-out. "Welcome, nice that you came", says the teacher. Nothing else is needed, because the teacher's words says what is the most essential.\par
Peter's diagnosis: potential drop-out, substance dependence. 
\section[{V.}]{V.}\par
The encounters with students of a hospital school draw a picture of the everyday work of hospital school teachers. Teachers meet students with the most different backgrounds. They all share the need for special support \hyperref[b28]{(Jackson, 2013}). Yet, teachers do not have the one and only method for encountering an aggressive student or a depressed student or a student with behavioral problems. Already attending a hospital school is an extremely big step to many of the students. They are worried about the new school environment and they have been branded as sick \hyperref[b48]{(Nash \& Schlösser, 2015)}. Thus, studying at a hospital school is not easy for students either \hyperref[b22]{(Ganz \& Pao, 1978;}\hyperref[b34]{Lian \& Chan, 2003)}.\par
The hospital school teachers' eternal challenge is how to have time to chart a new student's existing and possible learning difficulties, to progress with teaching according to the student's own curriculum, to practice social skills with the student, to group students in the class, and to rehabilitate and fill gaps in students' basic skills and knowledge. This is even more challenging now because hospitalized periods have become shorter (e.g., at the child psychiatric ward, a treatment period used to be from 6-8 weeks, now it is 2 weeks).\par
Collaboration between the hospital school and the student's own school becomes especially highlighted during the transition phases of coming and leaving the hospital school. Sharing of information is extremely important in both phases  {\ref (}  
\section[{VI Discussion}]{VI Discussion}\par
Hospital school teachers' work is demanding when they help various students to cope and struggle \hyperref[b11]{(Cousins \& DeLuca, 2016;}\hyperref[b20]{Ferguson \& Walker, 2014)}. Many hospital school students share experiences of maltreatment, ignorance, and lack of care, and their positive development has been hindered \hyperref[b55]{(Severson et al., 2007)}. Working with these students may give an impression that hospital school teachers' work is overwhelming. When reading the teacher-researcher's diary, one may wonder how the teacher can cope with her work and keep well herself.\par
However, the teacher's work is rewarding, too. Conquering students' problems gives inspiration and resources to work. The teacher finds especial joy in her work, when students show positive progress. Indeed, it can be the teacher who changes the direction of negative behavior and development . A hospital school can become a crossroads that leads to a new, better direction in life and being. But how can hospital school teachers do that? What is important in their work? The answer to this question is the beginning of the systematic development of hospital school pedagogy.\par
Hospital school pedagogy is based on many special features of special education \hyperref[b25]{(Gresham, 2007;}\hyperref[b29]{Johnson \& Semmelroth, 2014;}\hyperref[b30]{Kurz et al., 2014)}, but it also necessitates new pedagogical approaches that are applicable in the hospital environment \hyperref[b51]{(Reid, 2015)}. The question of how to help and intervene in problems in time can be crucial \hyperref[b18]{(Elliott, Huai, \& Roach, 2007)}, but solutions have to be considerate \hyperref[b32]{(Lane et al., 2015)}.\par
Technological novelties have been introduced in hospital school teaching as well, but they will hardly improve the hardest students' motivation totally \hyperref[b27]{(Hopkins et al., 2014;}\hyperref[b40]{Maor \& Mitchem, 2015)}. Neither seem distance and online classrooms to provide sufficient opportunities for the schooling of hospitalized children, yet \hyperref[b3]{(Bishop \& Gilinsky, 1995;}\hyperref[b59]{Shaw \& McCabe, 2008)}.\par
The core of hospital school pedagogy could be based on caring, positive, and encouraging teacherhood that pays attention to students' abilities and positive resources. We have created a 10-item list of this kind of a caring teacher's dos \hyperref[b77]{(Äärelä, Määttä, \& Uusiautti, 2016)}, that can be adopted as the foundation of hospital school pedagogy as well. They are: be present, listen, thank, collaborate with homes, teach everyone, enjoy your work, forgive, welcome the student to school, dare to intervene, and take care of yourself (Äärelä, Määttä, \& Uusiautti, 2016). To fulfill these dos in practice, the teachers may start by reflecting their action and encounters with students by asking questions such as: Am I available to every student and present in encounters?; Do I show with my acts and words that I care about your students -even the loudest one?; Do I ask how they are doing? Do I listen to their answers? Do I appreciate them?; Do I respect my students' parents Year 2016 and support them in their parenting task?; Am I genuine and fair, and consistent?; Do I recognize the challenges of learning?; Do I make sure that my students learn to learn -even the weakest learners, too?; Do I notice social problems in my classroom? Do I intervene in them 
\section[{Conclusion}]{Conclusion}\par
. in a constructive manner?; Do I maintain the feeling that my students are always welcome to school -even after cutting classes?; Do I provide positive feedback to my students?; Do I take care that no one is left alone and bullied?; Do I smile and use humor in my classroom? Do I understand humor?; Do I act as an adult in challenging situations? Do I set a positive example to my students?; Do I perceive my weaknesses and errors? Am I able to apologize when necessary?; Do I take care of my wellbeing and coping?; Does my action as a teacher show that every student is appreciated as thery are -not "after they have.." or "but they are?"?; and Do I fulfill my task as long and as widely as necessary?\par
Hospital school pedagogy leans on caring teacherhood and the ability to get various students with even loose attachment to school to tolerate schooling in order to complete basic education and to get a chance to advance to secondary education. Hospital schools can offer reconstructive experiences, and already one safe relationship with an adult can prevent the child from dropping out from school.\par
Hospital schools form an extreme form of inclusive education (Banks, Frawley, \& McCoy, 2015; Lakkala, Uusiautti, \& Määttä, 2014). When hospital school pedagogy is being developed, also inclusive pedagogy will develop-and vice versa. This kind of work is more and more important as the multiformity of societies and individual differences increase. Alongside this development, more research on the theme is needed as well.\begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-2.png}
\caption{\label{fig_0}}\end{figure}
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\end{document}
