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. 2023 Feb 23:1–13. Online ahead of print. doi: 10.1007/s11423-023-10209-0

Effects of robot-assisted digital storytelling on hospitalized children’s communication during the COVID-19 pandemic

Ching-Yi Chang 1,2, Gwo-Jen Hwang 3,4, Ya-Lien Chou 1, Zi-Yin Xu 2, Hsiu-Ju Jen 1,2,✉
PMCID: PMC9949694  PMID: 36855519

Abstract

This study proposed a robot-assisted digital storytelling approach to reduce hospitalized children’s anxiety about intravenous injections and to improve their therapeutic communication and therapeutic engagement. In order to verify the effectiveness of the robot-assisted digital storytelling approach, a randomized controlled study was implemented. A total of 47 children from a regional hospital were randomly assigned to an experimental group (n = 21) and a control group (n = 26). The experimental group adopted the robot-assisted digital storytelling approach in health education for intravenous injections, while the control group received video-based health education. The study results indicated that the proposed robot-assisted digital storytelling approach not only reduced the children’s anxiety, but also had positive effects on children’s communication about intravenous injections, emotions during hospitalization, and therapeutic engagement. As a consequence, it is suggested that educators and researchers consider adopting robot-assisted digital storytelling to facilitate nursing clinical health education for children.

Keywords: Communication, Digital storytelling, Emotions, Engagement, Robot-assisted learning approach

Introduction

Improving health education and alleviating fears in young patients are important and challenging tasks in hospital services (Koivula et al., 2002). In particular, during the COVID-19 pandemic, family members were not allowed to stay with hospitalized children owing to the safety consideration (Sengupta et al., 2021). To efficiently deliver health knowledge and to attract the attention of young children, attempts have been made to shift health education from traditional instruction to digital tool-based learning mode (Santos & de Lacerda, 2020). How to make effective use of information technological resources further complicates these challenges. As a result, facilitators or administrators of clinical medical care are forced to search for or learn to apply existing media tools to improve health education and reduce young patients’ fears or anxiety (Hasamnis & Patil, 2019). Compared with conventional paper-based health education, what makes it more complicated is finding a suitable and interesting interactive environment for health education, or introducing individual or group health education activities using existing technological devices.

In addition to maintaining the quality of medical care and paying attention to patient safety during the COVID-19 pandemic, maintaining the number of nursing staff, dealing with the shortage of nursing manpower, and reducing medical workload are public health issues with urgent concerns in various fields around the world (Maleki et al., 2021; Stokes & Iskander, 2021). In addition, assisting children who receive invasive treatment, such as intravenous injections (IV), is a difficult skill in clinical nursing practice, especially for young children who have limited communication competences and are afraid of needles (Hsu et al., 2022; Tsao et al., 2017; Fadlilah et al., 2022) pointed out that hospitalized children are prone to anxiety; if untreated in time, this anxiety might hinder the treatment process and increase the length of treatment, thus prolonging the inpatient days. Therefore, in clinical nursing practice, there is a need for interactive health education tools to assist in communication with children and in pacifying their mood during IV treatment (Canares et al., 2021; Wong et al., 2019; Tsao et al., 2017).

Researchers have tried using digital storytelling (DS) in the form of online videos to improve patients’ and their families’ awareness of the medical treatment process for serious diseases, such as cancer, to reduce their therapeutic anxiety (Akard et al., 2020; LeBlanc, 2017). DS has also been applied to nursing education in various training programs, such as taking care of newborns (Petty et al., 2020). Researchers have indicated that with video sounds and lively stories, DS has great potential to facilitate effective communication and enhance learners’ empathy in class (Yu et al., 2021). Integration of DS and technological tools can safely deliver health care learning content and create a caring medical environment, which is definitely important during the pandemic (Babal et al., 2020). In particular, when dealing with hospitalized children, it is important to reduce their therapeutic anxiety through the use of such auxiliary tools to promote communication and divert their attention from their fear of medical treatments (Kasimoglu et al., 2020). Previous studies have identified that the communication and emotional comfort for hospitalized children should be strengthened to reduce their anxiety (Arane et al., 2017; Azak et al., 2022; Malone, 1996). Although DS has been recognized by several researchers as an effective strategy for delivering content to young children, researchers have pointed out the disadvantage of using the conventional video-based DS approach, that is, the lack of interaction between videos and young children (Saxena et al., 2021; Yawisah et al., 2022). Therefore, it is crucial to improve children’s understanding of the treatment process as well as to promote their communication with medical staff by proposing an interactive form of DS.

Robotics is a technology that can interact with people in a highly accepted mode (Dorouka et al., 2020). Robot-assisted learning is an approach that employs the interactive function embedded in robots with learning materials for delivering knowledge vividly. Past research has verified that the robot-assisted learning approach could be an effective approach as it can generally create relaxing and joyful interactive learning with a cute robot (Chassignol et al., 2018; Chootongchai, Songkram, & Piromsopa, 2021; Rao, 2019). As a result, it has great potential to increase the engagement and emotional transfer of learners to reduce their anxiety (Roberts-Yates & Silvera-Tawil, 2019). In particular, it could attract children to spend more time interacting, transferring their emotions and reducing anxiety about hospitalization and illness (Lee et al., 2019; Moerman & Jansens, 2021). Therefore, the present study proposed a robot-assisted DS learning approach to facilitate children’s communication during nursing care to reduce their potential therapeutic anxiety by engaging them in interaction with robots to learn the content to be delivered via digital stories. To evaluate the effectiveness of the proposed approach, a randomized controlled experiment was used to answer the following research questions.

  1. Could the robot-assisted DS approach improve hospitalized children’s therapeutic communication?

  2. Could the robot-assisted DS approach reduce hospitalized children’s hospitalization anxiety?

  3. Could the robot-assisted DS approach improve hospitalized children’s emotional engagement?

Methods

Study design and setting

This study adopted a randomized experimental design, and implemented the robot-assisted DS approach in health education for IV led by medical staff. The experiment was carried out in the children’s wards of a regional hospital from January to May 2022.

Figure 1 illustrates the experimental design. A total of 111 hospitalized children were asked by the same researcher for their consent and willingness to participate in this study. Among them, seven children were not eligible based on the inclusion criteria and 52 children refused to participate; the reasons included children’s health conditions, no interest after understanding the experiment, and schedules that were incompatible with the implementation. The remaining 52 children agreed to participate in the experiment with their parents’ permission, given by signing the consent form. They were randomly assigned to two groups. The experimental group (n = 26) adopted the robot-assisted DS approach for health education, while the control group (n = 26) received video-based health education. All participants completed the experiment, except for five in the experimental group who did not complete the questionnaires.

Fig. 1.

Fig. 1

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Flow diagram of the experimental design

Characteristics of the participants

In this study, a total of 47 children completed the experiment. The average age of the experimental group was 7.24 ± 2.05 years old. There were seven children (33.3%) diagnosed with fever at admission; just over half of the children were male (52%). On the other hand, the average age of the control group was 7.38 ± 2.06 years old. There were six children (23.1%) diagnosed with gastritis and/or tonsillitis; just over half of the children were female (54%). The majority of children in both groups received IV at admission. None of the children who participated in this study had any experience of using robots before the experiment. Moreover, they had basic ability of recognizing numbers and simple Chinese words. Their listening ability enabled them to comprehend the stories and interact with the learning content. Table 1 demonstrates the demographic characteristics of the participants.

Table 1.

Characteristics of the participants (N = 47)

Characteristics Experimental group (n = 21) Control group (n = 26)
Age (years), mean (range) 7.24 ± 2.05 7.38 ± 2.06
Gender
 Male 11 (52%) 12 (46%)
 Female 10 (48%) 14 (54%)
Medication use
 IV 10 (48%) 13 (50%)
 IV + oral 9 (43%) 8 (31%)
 IV + inhalation 2 (10%) 5 (19%)
Admission diagnosis
 Fever 7 (33.3%) 5 (19.2%)
 Gastritis 4 (19.0%) 6 (23.1%)
 Cold 2 (9.5%) 3 (11.5%)
 Tonsillitis 4 (19.0%) 6 (23.1%)
 Vomiting 1 (4.8%) 0
 Bronchitis 2 (9.5%) 5 (19.2%)
 Enteroviruses 1 (4.8%) 1 (3.8%)
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Development of a robot-assisted DS system for hospitalized children

The robot adopted in this study has a screen as its face, which can show various emotional expressions, such as happiness, sadness and anger when speaking. Moreover, the screen on the robot can also be the interface of playing videos or apps. That is, children can interact with the robot via clicking on the items displayed on the screen. In addition, the robot can also recognize voices; therefore, the children can make choices or answer questions using voices. When presenting digital stories to children, the robot not only plays videos on the screen, but also uses voices and gestures with emotional expressions on the screen to interact with them. Therefore, the digital stories implemented in the robot are presented in the way of interactive videos with facial expressions and gestures.

In this study, the learning scenes in the robot were two digital stories. One of the digital stories is called Duck Abel, which is related to “hospitalization information and injections.” The other digital story is related to IV. For example, the IV story is teaching material for hospitalized children and their families. The story was about a sick child who was diagnosed by the medical doctor as needing an IV drip. In the video, the doctor explained why an IV drip is needed, such as to supplement sick children who have diarrhea, vomiting or fever with a large amount of fluids, so that they could quickly rehydrate and receive basic nutrition as well as the necessary medication from the IV. Furthermore, several scenes were used to let children and their families know that they did not need to be afraid of having an IV drip. For example, a young nurse appeared in the video and told the children that there was almost no pain when having the IV drip, and that it would soon make the children feel comfortable and strong. Furthermore, at the end of the story, the sick child recovered and felt happy.

The DS plots were based on the scenes in the hospital and the health education videos were designed for children. When children encounter invasive treatments, they often feel anxious and insecure. Therefore, the videos in this study were designed as cartoon animations to simulate the treatment process in order to reduce children’s anxiety.

During the digital storytelling process, there were some interactions between the children and the robot, as shown in Fig. 2. The interactive features allowed the children to select the story sessions they would like to know in more detail. In addition, some questions were raised in specified story time periods to ensure that the children had correctly comprehended the learning content.

Fig. 2.

Fig. 2

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Scenes of child-robot interactions

With the interactive scenes and storylines developed in the DS, the children were able to interact with the robot repeatedly during the care and treatment process. They could click on the screen on the robot or say keywords to the robot to make selections for deriving more details regarding the stories or answering questions. It was expected that such a friendly interactive design could distract their attention and reduce their anxiety in the nursing care or treatment process (see Fig. 3).

Fig. 3.

Fig. 3

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The treatment process and interaction with the robot

Experimental procedure

After the researcher introduced the research purposes of the robot-assisted DS approach, all children received the interventions in different scenarios. The experimental group conducted DS through the robot, while the control group completed the questionnaires after video-based health education. Although the two groups adopted different intervention approaches to health education, the content was identical. The two groups of children interacted with the same DS content. The only difference was that the experimental group interacted with the robot system, which used additional gestures and facial expressions when telling the studies via presenting the videos; moreover, the children clicked on the robot’s screen or used voice feedback to make selections or answer questions. On the other hand, those in the control group interacted with the same DS content using a tablet computer; that is, they clicked on the screen of the tablet computer to make selections or answer questions. Every child interacted with two digital stories, each for 20 min; that is, the total learning time for each child was 40 min.

As the children were young, both groups of children were assisted by an accompanying nurse and their families to fill out the questionnaires by observing their treatment process. To avoid affecting the experimental results, before the experiment, the nurses and families of the children received an orientation in which they were told not to interfere with the selections made by the children. In addition, during the experiment, a researcher was there to ensure that the nurses and families did not influence the selections made by the children.

Instruments

This study employed three questionnaires to measure children’s therapeutic communication, anxiety, and emotional engagement, respectively. The therapeutic communication questionnaire referred to Varni’s (1999) PedsQL (Pediatric Quality of Life Inventory), which incorporated the integrated generic core and disease/symptom-specific modular approach for pediatric chronic health conditions. The physician/nurse communication module was adopted for this study; it consisted of two items with a 5-point Likert scale, that is, “It is hard for me to tell the doctors and nurses how I feel,” and “It is hard for me to ask the doctors and nurses questions.” The higher the score, the more difficult it is for the respondent to communicate. The Cronbach’s alpha value was 0.83.

The Modified Yale Preoperative Anxiety Scale (mYPAS) was developed by Chow et al. (2016). It has good reliability and validity to measure children’s anxiety, and has been widely used in medical research (e.g., Aydın & Uyar, 2021). The category of emotional expressivity was adopted for this study; it consisted of four items with a 4-point Likert scale, including “Manifestly happy, smiling, or concentrating on play,” “Neutral, no visible expression on face,” “Worried (sad) to frightened, sad, worried, or tearful eyes,” and “Distressed, crying, extremely upset, may have wide eyes.” The higher the score, the more anxious the respondent was. The Cronbach’s alpha value was 0.80.

The emotional engagement questionnaire was adopted from Busselle and Bilandzic (2009), and aims to assess the level of children’s engagement, emotions, or immersion in the storyteller’s narrative in different health education activities. It consists of three items with a 7-point Likert scale, including “The story affected me emotionally,” “During the program, when a main character succeeded, I felt happy, and when they suffered in some way, I felt sad,” and “I felt sorry for some of the characters in the program.” The Cronbach’s alpha value was 0.84.

Results

The data were analyzed using SPSS 25 (Armonk, NY: IBM Corp.). To compare the two groups’ categorical variables, an independent samples t test was adopted.

Therapeutic communication and anxiety

An independent sample t test was performed to explore the therapeutic communication and anxiety; the results are shown in Table 2. The experimental group (mean = 3.24, standard error = 1.18) obtained higher scores on therapeutic communication than the control group (mean = 2.65, standard error = 0.56). There was a significant difference in therapeutic communication between the two groups (t = 2.09, p < .05), with a medium effect size (d = 0.64). Furthermore, the experimental group (mean = 2.92, standard error = 0.56) obtained lower anxiety scores than the control group (mean = 3.43, standard error = 0.81). A significant difference in anxiety could be found between the two groups (t = 2.43, p < .05), with a medium effect size (d = 0.73). As a result, it could be inferred that the robot-assisted DS approach was more effective in terms of improving children’s therapeutic communication and decreasing their anxiety during IV than the conventional DS approach.

Table 2.

Results of the t test for therapeutic communication and anxiety

Variable Group N Mean SD t d
Therapeutic communication Experimental 21 3.24 1.18 2.09* 0.64
Control 26 2.65 0.56
Anxiety Experimental 21 2.92 0.56 2.43* 0.73
Control 26 3.43 0.81
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*p < .05

Emotional engagement

An independent sample t test was employed to investigate the emotional engagement of the two groups’ emotional engagement; the results are shown in Table 3. The experimental group (mean = 6.24, standard error = 1.18) obtained higher emotional engagement than the control group (mean = 5.54, standard error = 0.58). There was a significant difference between the two groups (t = 2.49, p < .05), with a medium effect size (d = 0.75). Therefore, the robot-assisted DS approach increased children’s emotional involvement more during IV than the conventional DS approach. The medical staff were able to successfully assist children with their IV treatment.

Table 3.

The t test results of emotional engagement

Variable Group N Mean SD t d
Emotional engagement Experimental 21 6.24 1.18 2.49* 0.75
Control 26 5.54 0.58
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*p < .05

Discussion

The present study proposed a robot-assisted DS approach during intravenous administration for hospitalized children. A randomized controlled experiment was carried out to examine its effectiveness. On the basis of the results, the research questions were answered as follows:

  1. Children who adopted the robot-assisted DS approach during IV had significantly better therapeutic communication than those who received video-based health education. The use of interactive robot-assisted DS provided children with an alternative to health education; it also encouraged them to interact with the robot, listen to the stories, carry out game-based learning and explore the robot. On the contrary, the control group obtained information related to health education only through videos, which could be a reasonable explanation about why the experimental group had better therapeutic communication than the control group. This study successfully employed the robot-assisted DS approach to assist children in understanding the IV steps and to distract their attention. The results were consistent with Canares et al. (2021), who found that the use of an appropriate strategy during intravenous administration had great potential for medical staff to assist children with a smoother process. Hsu et al. (2022) also indicated that game-based learning tasks could significantly affect children’s emotions during IV.

  2. Children who adopted the robot-assisted DS approach during IV had a significantly lower level of anxiety than those who received video-based health education. A reasonable explanation was that the experimental group interacted with the robot to listen to the stories, while the control group watched the videos independently. The findings suggested that the robot-assisted DS approach could reduce children’s first-time hospitalization anxiety, since a robot as a peer could have conversations with the children, as well as allow them to read the materials and interact with knowledge related to the topic. This was in line with Fadlilah et al. (2022), who indicated that the newer things were, the lower the level of anxiety the children had. As a result, when children had a lower level of anxiety, they could cooperate to receive IV, thus shortening the injection time.

  3. Compared to children who received video-based health education, those who adopted the robot-assisted DS approach had better emotional engagement. The experimental results illustrated that the integration of health education knowledge and materials and an entertaining robot could increase the vividness and fun of storytelling in the environment, as well as engage children and transfer their attention during invasive treatments. The findings were consistent with Price et al. (2015), who stated that DS was beneficial for the participation of the children. Regarding daily health education in the medical environment, using a digital technology-based educational approach such as the robot-assisted DS approach could help children acquire the knowledge and content delivered by medical personnel, and allow them to engage in more interactive health education activities (Kasimoglu et al., 2020). Babal et al. (2020) and Zarifsanaiey et al. (2022) revealed that DS could stimulate the intrinsic interest and help them fully participate in learning activities. The findings of this study supported this argument since the integration of a robot and DS enabled children to have better learning and participation in activities.

In addition to the above advantages, the proposed approach was also crucial for promoting children’s interaction with the learning issues embedded in the robot-assisted DS system. Previous studies have disclosed the importance of facilitating interactive learning (Buedding & Schroer, 2009; Kasimoglu et al., 2020; Moerman & Jansens, 2021; Fossati et al., 2020); however, there is virtually no opportunity for children to have interaction in most clinical medical settings for health education. Take video-based health education as an example. It requires medical personnel to play the video, but it does not allow children to operate it or have direct interaction with it; nor can it encourage their emotional involvement in learning. In terms of the approach proposed in this study, children could interact with the robot through point-and-click behaviors via an interactive screen. This is in sharp contrast to video-based health education. In video-based health education, children are only allowed to watch videos directly with no opportunity for interaction during the learning process. Furthermore, this study also found that children had less fear and anxiety about the hospital environment after learning health education materials and reading interesting stories while playing with the robot at the same time. Since children may encounter different problems when operating the robot, they could interact with the embedded dialogues in the robot without worrying about the health education content being too simple. In addition, medical personnel and companions could design interactive personalized questions based on the health education content and embed them into the robot. In this way, the children could reduce their anxiety during IV, thus reducing the injection time and enhancing the hospitalization quality.

Based on the findings, it was substantiated that the robot-assisted DS approach effectively improved children’s therapeutic communication and emotional engagement, while also decreasing their anxiety during IV. In response to the challenges related to health education during the COVID-19 pandemic, these positive findings serve as a useful reference for nursing educators trying to apply digital technology (Fossati et al., 2020). As uncovered by Sentell et al. (2020), nursing educators must develop innovative health education strategies in response to the pandemic, to facilitate effective learning of patients and their families, and to enhance their health literacy and capacity. Therefore, the approach proposed in this study provided a good example of clinical application, which is suggested to be widely adopted by nursing educators in other fields. It can also be applied in other health education courses with different scenarios and issues, for example, explaining the surgical process and understanding the necessary examinations and important physiological monitors for the surgery. This approach can also be used with children who undergo radiation therapy for cancer, to teach them and their families coping skills or to cooperate with their companions to solve daily healthcare problems.

Conclusion

Numerous studies have corroborated that DS can support medical staff in taking care of patients and their families, reducing the therapeutic anxiety and stress, to facilitate their empathy, and improving therapeutic communication with patients. It has been regarded as a powerful approach (Briant et al., 2016). To achieve this goal, this study proposed the robot-assisted DS approach as a practical, professional, and interactive health education tool for children. A gaming scene was designed to simulate the clinical environment of IV; the present study adopted a random experimental design to explore its effectiveness. The findings showed that children who used the robot-assisted DS approach had better therapeutic communication and emotional engagement, as well as a lower level of anxiety, than those who used the conventional DS approach. The contributions of this study include proposing robot-based digital storytelling, which is an innovative attempt in hospital services, as well as conducting an experiment involving hospitalized children, who are rarely adopted as participants in existing studies. The findings of the present study could be a good reference to those who intend to improve the quality of nursing education and hospital service; in particular, improving health education and alleviating fear in young patients.

Although the results of this study revealed that the proposed approach was conducive to interactive learning, there are some limitations. The biggest challenge of robot-assisted health education in nursing activities is the cost of the robots and the additional time required to prepare the health education materials. In addition to the cost of a robot editor and the content production that can accommodate many or interdisciplinary health education materials, the labor cost should also be considered. Hence, it is recommended that quality health education issues can be shared with different robots for health education activities through a shared platform embedded in the robots, so as to increase the number of users. In addition, clinical medical personnel worked three shifts and were busy taking care of patients; they also had to spend a great deal of time preparing the professional health education content and learning materials for patients and their families corresponding to the scenes of the robot-assisted DS approach. Thus, it is suggested that effective editing strategies be adopted, such as collecting health education stories, photos, videos, or audio recordings with the authorization of patients and their families at ordinary times. In this way, medical staff can save the time for designing learning scenes in the robot-assisted DS system, and can apply it to the instruction of medical students through such a process. In addition, future studies are recommended to work with a digital technology team to edit and develop a robot-assisted DS package that can be used repeatedly, to meet the demand of clinical health education for medical staff. Another limitation was that only a small number of children were recruited in this study due to the pandemic. Future studies with a larger sample size and a longer intervention should be carried out to effectively evaluate whether the findings of this study can be replicated to different issues in medical care. Finally, it is suggested that children’s interactive learning behaviors in the robot-assisted DS approach be analyzed together with the interview results of their families, to further examine children’s therapeutic communication, emotional engagement, and anxiety, and to gain new insights.

Acknowledgements

This work was partially supported by the Ministry of Science and Technology of Taiwan under contract numbers MOST-109-2511-H-011-002-MY3 and MOST 111-2410-H-038-029-MY2. The study is also supported by the National Taiwan University of Science and Technology—Taipei Medical University Joint Research Program under the contract number TMU-NTUST-111-05.

Biographies

Ching-Yi Chang

is a PhD, RN, Assistant professor in the School of Nursing, College of Nursing, Taipei Medical University. Her research interests include mobile learning, digital game-based learning, flipped classrooms, medical education, nursing education, and AI in education.

Gwo-Jen Hwang

is a Chair Professor in the Graduate Institute of Digital Learning and Education, National Taiwan University of Science and Technology, Taiwan. His research interests include mobile and ubiquitous learning, digital game-based learning, artificial intelligence in education, and web-based learning.

Ya-Lien Chou

is an MSN, RN, Nursing Head Nurse in the Department of Nursing, at Taipei Medical University-Shuang Ho Hospital, New Taipei. Her research interests include mobile learning, flipped classrooms, medical education, and nursing education.

Zi-Yin Xu

is a nursing student, in the School of Nursing, College of Nursing, Taipei Medical University. Her research interests include mobile learning, flipped classrooms, medical education, and nursing education.

Hsiu-Ju Jen

is an MSN, RN, Nursing Director in the Department of Nursing, Taipei Medical University-Shuang Ho Hospital, New Taipei; and a lecturer at the School of Nursing, College of Nursing, Taipei Medical University. Her research interests include mobile learning, flipped classrooms, medical education, and nursing education.

Declarations

Conflict of interest

The authors declare no conflicts of interest associated with this research.

Ethical approval

The study has been evaluated and approved by the research ethics committee.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Ching-Yi Chang, Email: frinng.cyc@gmail.com.

Gwo-Jen Hwang, Email: gjhwang.academic@gmail.com.

Ya-Lien Chou, Email: 12483@s.tmu.edu.tw.

Zi-Yin Xu, Email: b405109069@tmu.edu.tw.

Hsiu-Ju Jen, Email: hsiujuj@gmail.com.

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