Using AV1 robots to support pupils with physical and emotional health needs

ABSTRACT

The AV1 robotic device has a growing evidence base, both internationally and in the UK, for supporting pupils with physical/emotional health needs. The device allows pupils to access their school lessons remotely through telepresence technology. Previous papers have highlighted the growing relevance to the education field, although, to date, there is no published UK academic research. In consideration of this, the purpose of the present paper was to explore the views of school staff who have trialled the AV1 device in the UK. Semi-structured interviews were held with 10 staff members from different school settings before data were analysed thematically. Key themes related to potential for impact, opportunities/challenges, and wider socio-economic considerations. Implications are considered in relation to (1) future research and professional practice, and (2) the introduction of a proposed implementation framework to support practitioners when trialling the AV1.

KEYWORDS:

• AV1
• telepresence
• robotic avatar
• schools
• perspectives
• physical/emotional health

Introduction

The use of telepresence robots (TR) to support children and young people (CYP) accessing their education has grown in recent years. The UK (Fletcher et al., 2023) and international (Page et al., 2021) reviews highlight their growing popularity, particularly to support a variety of physical and emotional health-related needs, with CYP connecting to educational settings remotely via a robot and computer tablet. One prominent type of TR in use is the AV1 (Figure 1). In the UK alone, over 750 AV1s have been in circulation in the last two years, across 45 local authorities (LAs), following commissioning from the Department for Education (No Isolation, 2021).

Figure 1. The AV1 avatar. Image by Johnsrud and No Isolation (n.d.).

Given this exponential growth of AV1s across LAs, support professionals, such as educational psychologists (EPs), are increasingly likely to encounter these devices in their role (Fletcher et al., 2023) due to their application for CYP experiencing medical needs, anxiety, and emotionally based school avoidance (EBSA) (No Isolation, n.d.). Whilst devices like the AV1 are in circulation throughout the UK, there is, however, a lack of UK-based, academic research that evaluates their use. LA reports are emerging (Somerset County Council SCC., & No Isolation, 2022) but broader UK research is needed to inform professionals who may interact with the AV1. This research paper fills that gap, providing the first UK-based research paper exploring the use of AV1s to support pupils with physical and emotional health needs in the UK. Please note that whilst No Isolation supported this research project (for example, sharing recruitment materials), they did not have a direct relationship/oversight of the research project or data analysis. This paper was independently written by the authors, and the AV1 was chosen to be the focus of this research project given that currently, this is the most popular device in use across UK schools.

The AV1

Created by the Norwegian company, No Isolation, the AV1 robot allows CYP, who are hospitalised/at home, to connect with their school setting via a computer tablet. The robot sits in the young person’s seat in their class, allowing them to communicate with peers/adults (Johannessen et al., 2022) via 360° movement, a microphone, and a range of lights/digital expressions. Unlike other robots available, the AV1 provides one-way video only, allowing the young person to watch a live stream of their classroom, without staff/peers being able to see the young person’s face, as they may desire privacy due to their health needs. Research into robot designs shows that, compared to its market counterparts, the AV1 was well received by CYP due to its practical design, variety of functions, and accessibility (Søraa et al., 2021).

The AV1 robot appears to best align with Draper’s (1995) definition of telepresence, where technology allows a user to feel present within an environment without being physically present. Growing media interest in the AV1, both internationally (Børsting et al., 2019) and in the UK (BBC News, 2019), highlights the apparent awareness of the AV1 as a possible tool for support. In the UK, teaching articles (Hazell, 2018) are disseminating information about the devices to schools, emphasising both the prominence and growing popularity of these devices within the UK education system.

Applications and impact

Originally designed and piloted in university research for supporting physical health needs (Børsting & Culén, 2016), the application of the AV1 has evolved. The device is now used for a range of health needs, acting as an alternative education provision for pupils experiencing physical illnesses such as cancer (Weibel et al., 2020), or as an individualised intervention for pupils experiencing emotional health needs such as EBSA (Johannessen et al., 2022) where the device forms part of an eventual return to school transition (Johannessen & Haldar, 2020). According to a recent UK LA report, the leading use of the AV1 is to support pupils with mental health-related needs, such as EBSA (Figure 2), emphasising this development in its application.

Figure 2. The AV1 in Somerset, an LA piloting their use.

This figure was produced by Somerset County Council and No Isolation in 2022, illustrating the most popular applications of the AV1 within Somerset. From: “What is AV1 used for?”, by No Isolation, 2022, https://www.noisolation.com/news/somerset-county-council-report. Copyright 2022 by No Isolation.

International findings indicate that the technology has a promising use in supporting pupils with a variety of health-related needs due to providing access to education and social contact, thereby reducing the likelihood of pupil loneliness (No Isolation, n.d.). There is a current dearth of UK academic research, but findings from the Department for Education research project highlighted that 75% of pupils who used an AV1 increased their school attendance and showed improved engagement, self-esteem, relationships with staff/peers and emotional well-being (No Isolation, 2021). Similarly, an LA report concluded that in a project with 93 pupils using the AV1, 76% found that the AV1 positively impacted school attendance (Somerset County Council SCC., & No Isolation, 2022).

However, research to date is not entirely conclusive. For example, Johannessen et al. (2022) found that some participants reported either mixed or negative experiences of using the AV1; severity of the user’s health, lack of support from others, technical considerations or school approaches to implementation affected user experience. Several of these themes were also evident in a recent systematic literature review of robotic telepresence technology (Fletcher et al., 2023). An additional area of consideration relates to the need for considering multiple user perspectives and how this may account for contrasting experiences of the AV1. For example, recent international research has highlighted the scepticism of school staff relating to AV1 technology given that the function of the device directly challenges the traditional delivery of a school education (Johannessen et al., 2023). Given the large number of demographic groups who interact with the AV1 device, including CYP, classmates, parents, and school staff (Johannessen et al., 2022), research must therefore capture and consider the impact of views from all demographic groups. Such challenges must be acknowledged and considered, in order to effectively review the use of the AV1 and whether it should be considered as a form of support for pupils with a range of health needs.

Implementation and AV1

One explanation for these current, inconclusive findings, could relate to implementation processes, as similarly reported by Johannessen et al. (2022). Implementation science promotes the importance of acknowledging local and community level, ecological factors that can influence implementation success, alongside other key factors such as the importance of training and technology-related assistance (Durlak & DuPre, 2008). This is particularly relevant for the AV1 given that it is conceptualised as an assistive technology tool (Johannessen et al., 2022). Another area to consider is the importance of social validity. Whilst often under-represented in literature (Miramontes et al., 2011), social validity is an important area to consider given that implementation success/positive outcomes have been explicitly linked to staff confidence and belief that an intervention will positively impact on child outcomes such as attainment (Daniel & Lemons, 2018). This information highlights that the impact of implementation factors must also be considered when exploring the impact of AV1s.

The difficulty with implementation science, however, is that much of the research relates to a universal-level implementation, as opposed to group/individual level (Evans & Bond, 2021), which may not reflect the personalised use of the AV1. The AV1 device would likely be considered a Tier 3 form of intervention (Majeika et al., 2020), given its specialist use for individual pupils who are experiencing intense, day-to-day difficulties (Franklin et al., 2012; Suldo et al., 2019) and require provision/resources that are “ … beyond the scope of general education” (Sterrett et al., 2020, p. 134). What separates Tier 3 levels of intervention from more universal forms of support (Tier 1), is the need for vertical or horizontal adaptations. This refers to adapting an intervention, both prior to delivery (horizontal) or during/afterwards implementation (vertical), to accommodate contextual factors/individual user needs, without detrimentally affecting the core principles of the intervention itself (Sterrett et al., 2020). Considering this, universal-level implementation factors may not fully reflect the context of more specialist interventions like the AV1, an issue that has been highlighted in research around other interventions, such as Lego®‐Based Therapy (Evans & Bond, 2021).

Currently, existing international publications about the AV1 argue the need for further case studies and research to increase its evidence base (Johannessen et al., 2022; Weibel et al., 2020). Some universal-level implementation factors are being tentatively linked to the AV1, such as a lack of support from other professionals (Johannessen et al., 2022), the requirement for staff training around the technology (Weibel et al., 2020) or the impact of government policy/legislation around privacy laws (Børsting et al., 2019). However, the dearth of UK-based AV1 research suggests that there are likely to be AV1-specific implementation factors that have not yet been identified or are not reflected in universal-level implementation science.

Many complex interventions require more time and research before implementation theory can be fully integrated into their evaluation processes (Durlak & DuPre, 2008). This is acknowledged in other fields, such as medicine, where “adoption and assimilation” have been identified as distinct areas for professionals to consider, but only after feedback and further information has been gathered first (Greenhalgh et al., 2008). Whilst this suggests that AV1 research remains in its infancy in the UK, implementation factors are still important to identify in order to develop more sophisticated evaluation methods. Collecting implementation data in tandem with evaluation outcomes is still considered to be important to explore the relationship between implementation and outcomes (Durlak & DuPre, 2008). Consequently, in order to fully explore the implementation of the AV1 and its influencing factors, broader UK research about the devices is required first, alongside the collection of preliminary implementation information/factors.

Rationale and research aims

The research above highlights the complex nature of AV1 use but also identifies the potential, promising impact of the AV1 device to support CYP with emotional and mental health-related needs, as well as other learning difficulties. Whilst there is growing international research, there remains a UK gap and a requirement for considerations around implementation barriers and how this may inform future research. Despite the Department for Education funding projects with these devices (No Isolation, 2021), there is a limited evaluation of their effectiveness (Somerset County Council SCC., & No Isolation, 2022). Given the lack of UK research and the potential impact of implementation factors upon effectiveness, further research into the AV1s as a form of alternative education provision/intervention is warranted. This would also assist professionals, such as EPs, working with schools to implement AV1s (Fletcher et al., 2023). Consequently, the aim of the current research paper was to answer the following question:

What is the perceived utility and impact of the AV1 on key child outcomes such as attendance, attainment and emotional well-being in UK schools?

Methodology

Design

The present study adopted an exploratory qualitative research design which aimed to capture the unique experiences of school staff who had utilised the AV1s. Given the lack of research in the field, an open-ended approach enabled flexibility, guided by participant perspectives (Busetto et al., 2020), thus capturing the individual experiences of participants, both positive and/or negative (Willig & Rogers, 2017). The original project design aimed to capture both quantitative (attendance/attainment) and qualitative (user perspectives) data, including the views of CYP who had used the AV1. After several months of advertising, zero participants were recruited. Informal feedback from schools highlighted that they were concerned with placing additional duress on pupils who had only recently begun to trial the AV1 device. This indicated to the authors that, currently, UK research was not at a stage to solely focus on CYP and their views due to the early stage of AV1 implementation. Instead, the project was adjusted and focused on capturing user perspectives of school staff first, given their pivotal role within the early implementation of school-based interventions (Daniel & Lemons, 2018). Capturing school staff views would additionally allow for a comparison with the international research previously discussed, which highlighted some initial scepticism around the devices from a staff perspective (Johannessen et al., 2023).

Sampling and participant recruitment

Purposive sampling was used to recruit school staff with direct experiences/interactions with the AV1 robot (Etikan et al., 2016). Attempt was made to recruit from across the UK to gain a breadth of experiences; however, responses were only received from settings in England. Introductory emails were disseminated through contacts in multiple LAs; schools that had participated in UK news broadcasts about the AV1 were contacted and a staff member at No Isolation shared the authors’ introductory email to their own school contacts throughout the UK.

In total, 10 participants were recruited (Table 1), across 10 different schools in England.

Table 1. Overview of participants.

Participant	School Setting	School Age Range	Role	Area
A	Secondary	11–18 years	SENDCo	South East
B	Post-16	16–18 years	Teaching Assistant	North West
C	Junior	7–11 years	Class Teacher	South East
D	Primary	4–11 years	Head of School	Midlands
E	Secondary	11–18 years	SENDCo	South West
F	Primary	4–11 years	SENDCo	Midlands
G	Secondary	11–18 years	SENDCo	South West
H	Alternative Provision	3–19 years	Headteacher	South West
I	Primary	4–11 years	Class Teacher	East
J	Primary	4–11 years	Class Teacher	South East

Data gathering

Semi-structured interviews (SSIs) were used to maximise participation and gather the unique experiences of participants (Willig & Rogers, 2017). An interview schedule was designed to provide structure and prompts for participants, ensuring rich, detailed information was captured (Bearman, 2019). A broad focus of questions (for example, participant role, use of devices, perceptions, etc.) was developed from existing semi-structured interview research (Bearman, 2019) in order to accurately reflect the explorative nature of the project. However, several specific questions around implementation were included, informed by Durlak and DuPre (2008) to begin to capture key considerations around AV1 and its implementation within the UK, for example, how devices are currently used in school settings. The interview schedule was emailed to participants in advance, providing them with time to reflect on their experiences, reducing the likelihood of participant anxiety around the contents of the interview (Bearman, 2019). To further maximise access, participants were interviewed online; interviews typically ranged between 30 and 50 minutes.

Ethics

Ethical approval was given by the University of Manchester (10/01/2022). All consent forms/information sheets were sent to participants in advance; signposting to external professional services was also provided, should participants have felt emotionally impacted by discussing the sensitive application of the AV1 for supporting pupils’ health needs.

Data analysis

Thematic analysis provided a systematic process to thoroughly analyse and interpret participant experiences (Boyatzis, 1998). Braun and Clarke’s reflexive thematic analysis (RTA) approach was used (Braun & Clarke, 2022) because it aligned with the authors’ aim of interpreting, synthesising, and reporting themes relating to the experiences of participants interacting with the AV1. Data were analysed inductively and collaboratively, where codes/data of interest were discussed among the authors, informing reflections and developing a richer and more nuanced review of the data (Braun & Clarke, 2019).

Findings

Use of the AV1 varied greatly among participants, with some referring to one pupil who had used the device, whilst others referenced multiple pupils. Whilst specific numbers have not been attributed to each participant to preserve anonymity, a summary is provided here. In total, staff referred to approximately 37 different pupils who had used an AV1. Seventeen pupils had used the AV1 for physical health reasons, for example, cancer, whilst 20 pupils had used the device for emotionally based reasons which are typically related to either generalised anxiety or EBSA. Of the 10 schools represented in the research, six schools had used the AV1 solely for physical health reasons, two schools solely for emotionally based reasons and two schools for a combination of both physical and emotionally related reasons. Figure 3 presents the three generated themes and subsequent sub-themes that informed the following findings.

Figure 3. Thematic map of themes and sub-themes.

Theme 1 – the potential of AV1 to improve presence, participation and well-being

The majority of staff praised the AV1 as a tool for improving attendance of pupils given its ability to enable children to access their education remotely. Improved attendance related to both attendance within the classroom but also social situations such as playtime.

“They had reduced … . their timetable to about 25% of their lessons. They’re now back into all [lessons] bar PE … we’re looking at almost a full timetable of lessons … and they’re going to sit all their GCSEs. So that has been a huge impact for them”. (Participant G)

One staff member felt the AV1 did not support attendance but perceived that this may possibly be due to other needs of the young person (existing anxiety) as opposed to being a fault of the device itself. Several other staff (who used the AV1 with multiple children) perceived possible concerns from older pupils.

“ … if the robot is sat in school instead of me that highlights I’m not there and that highlights well, why aren’t I there? [referring to views of a pupil]. And I can’t cope with that, that makes my anxiety even worse”. (Participant J)

Most participants commented that the AV1 assisted with pupil attainment due to the device supporting their ability to continue with the mainstream curriculum.

“ … it’s [AV1] allowed their attainment to continue to move forward”. (Participant G)

However, a number of participants reported that the device was still at an early stage of implementation.

“I’d say for some we hope that it helps with their attainment, but I wouldn’t necessarily say that’s something that I can measure yet”. (Participant E)

A further example was given of how there were difficulties monitoring attainment in Maths, given that these types of lessons required continual feedback/monitoring of formulae/approaches used, something that was more difficult to monitor due to the pupil being at home.

School staff additionally referenced the benefits of the AV1 for supporting emotional well-being needs. Perceived benefits included improved self-esteem and confidence due to pupils contributing to lessons from the safety of their own home or pupils having a sense of control over their situation due to being in control of the AV1.

“ … it definitely built some self-esteem … . they’re a lot more confident and I do think it developed a sort of grit/determination side in them”. (Participant J)

Staff shared that this was particularly important for pupils experiencing physical health needs, such as cancer, where the AV1 provided them with a form of control when they did not have a full grasp of their health. Other participants identified the device may have provided pupils with stability and routine despite their health needs, whilst other staff perceived that the device supported pupils with feeling safe, specifically for those who may have felt unable to leave their home for emotional-based reasons.

“I think it gives them a bit of control … .if they get to that point where they don’t want to carry on in that lesson or they’re too tired, they just go off, so I think again, for some of the children with really gruelling medical conditions, they haven’t got any control in their lives … and for that, giving them a little bit of control is quite nice”. (Participant H)

Participants explicitly referenced how the AV1 enabled pupils to remain a part of the school community. This not only included access to day-to-day lessons but also access to social contacts and friendships within school.

“They are still, you know, part of the school day, they’re following the same routines, the same lessons, so they’re staying connected in that way”. (Participant A)

One unique example was given of AV1 use enabling a pupil to attend the school Christmas pantomime. This continued access to the school community was perceived to facilitate an easier transition back into school as pupils felt that they had not been away from the environment, something that was shared by several participants. The importance of promoting links to the school community was attributed by one participant to the leadership team and the need for a “top down” approach to promoting inclusion.

“The fact that they are keeping involved and keeping in touch with their friends, I think is brilliant, because for any child not being in school … they are going to form some kind of an anxiety about coming back … so just to keep them linked in place, I think it’s great”. (Participant F)

Staff reported that some parents were extremely positive about the AV1 enabling their child’s ongoing inclusion within the school community. A few participants shared, however, that social contact was not consistently a positive for AV1 users. Several staff members perceived that pupils may have found the AV1 a reminder of what they were missing in school.

“It allowed the child to have access, but their friendships were not the same level as friendships in person. And quite often, … . they would listen to what the other children had done rather than be able to sort of share things that had happened to them because actually, they hadn’t really done anything because they weren’t going anywhere”. (Participant I)

Theme 2 – (current and future) opportunities and challenges for the adoption of AV1s in schools

The general consensus around the AV1 was extremely positive from the personal perspectives/experiences of staff participants. Participants praised the technology as a tool for bridging contact between home and school for pupils who were unable to attend school physically. All participants stated that they would recommend the AV1 device to other schools/professionals.

“I think … . it’s a great tool and it’s a great resource for students who physically can’t be in school to feel a part of the school and a part of the community, part of the classroom, it helps the students in the classroom to remember that there’s another student at home … they can physically talk to them … it’s, again, more personable for the whole class really”. (Participant B)

“I just think … . It’s an amazing technology … the more we embraced it in the classroom, the more we got from it and the more the child was able to get from it as well”. (Participant I)

A small number of participants reported third-party (i.e. other staff members) experiences of the device increasing workload, for example, preparing worksheets that would be sent home for the pupil.

“I think the view from some members of staff is it’s a lot of extra work in that I would upload the slides and work onto Google classroom. And it’s just another layer of thinking that sometimes you just don’t have capacity for. I know some teachers’ views were yeah, it’s great for the pupil but also it’s adding more to our workload”. (Participant C)

Added workload also related to the co-ordination time needed to implement the device within a school. However, most participants reported that staff were largely positive around the use of the AV1 due to its positive impact on pupil well-being, engagement, and positive reactions from parents. Acceptance of the device was strongly linked to teachers adapting to the device over time.

“ … we haven’t had a single teacher that’s not wanted to have it. Teachers have probably had more questions … that it’s not recording, it’s just a livestream … they’ve all been really positive. And they want to be able to help the children learn however they can help them so they’re happy to facilitate whatever method that might be so yeah, teachers have been really good about it”. (Participant E)

Overcoming potential challenges of the AV1 (for example, staff acceptance) was largely linked to the importance of preparation and information sharing. This included alleviating staff concerns around privacy and data protection by disseminating information about the AV1’s security/encryption.

“I sent some emails round – whole staff emails – as did the head teacher and I think once the realisation came in that … . there are very tight consent forms and regulations around it … that’s when everybody’s attitude changed”. (Participant F)

Similarly, information sharing alleviated parental concerns by keeping them informed about the process/benefits of the device. When concerns related to technology-related difficulties such as how to use the device, nearly all participants praised the technological support/advice from No Isolation, thereby increasing staff confidence and acceptance of the device.

“The company are fantastic … I think we’ve got everything we need and anything I need, you know, I check in with them”. (Participant G)

Theme 3 – wider socio-economic factors leading to variability in equality of access to AV1s

Most participants discussed the impact of the device cost. For some, the device proved significantly cheaper compared to other alternative provision in the long term. For others, the decision to use the device was affected by school financial constraints. Several comments highlighted how school budgets were limited and the initial upfront cost for the AV1 participants was expensive, which was a key factor that schools considered when deciding to purchase the product. Positively, many participants referred to the use of charities and LA funding as a means of purchasing or renting the device to overcome this barrier. However, this funding dependency also impacted on answers around continuation of the device, because whilst participant experiences were largely positive, for some, the use of the device was dependent on whether the charity/LA funding would continue.

“We were lucky to get them … . they’re a great piece of equipment and they’re really worth it, definitely. But I suppose for a school to have, if you’re having to pay for it yourself, it might be a bit expensive but that’s the only thing with them”. (Participant A)

“But at the end of the day it [continuation of the device in school] will come down to the company, the charity or whoever it is that donated it to us or loaned it to us because we haven’t bought it”. (Participant C)

Most participants explicitly referred to Wi-Fi dependency as an important consideration of the device. Whilst the device itself does have 4 G in recent models, participants discussed that the design of their buildings often prevented 4 G, thereby requiring a secure and stable Wi-Fi. One participant gave the example of their school Wi-Fi not being high-quality due to their location within the country, thereby impacting on the device use.

“Although we do have Wi-Fi, it operates off kind of 4 G as well and mobile signal is not great where we are. So it was occasionally tricky to get it [Wi-Fi]”. (Participant D)

Participants also highlighted that:

“Some parents were a little bit frustrated with the techie side or with the school side, so the parent of the robot user was banging her head against the walls. If the family’s internet is poor, you’re not going to get it [the AV1] to work”. (Participant H)

However, most participants reported IT issues were resolved with school IT technician assistance and support from No Isolation.

“So yeah, there were a few technical difficulties to start with but once it was up and running, no problems at all”. (Participant F)

Discussion

This UK study, the first of its kind, has collated and reported the views of 10 different staff members relating to their experiences of the AV1. Aligning with international research (Weibel et al., 2020), these findings show promise that the device can support pupils to access their school environment and feel part of the school community. Key strengths of the device relate to (1) supporting academic achievement/engagement and (2) supporting the emotional well-being of pupils by facilitating social contact, again, a growing finding in international literature (Fletcher et al., 2023). Unlike the original purpose of the AV1, the findings highlighted that in the UK, the device appears to be used more for emotional-based reasons, aligning with existing LA reports (Somerset County Council SCC., & No Isolation, 2022). This suggests that an increasing number of UK settings are adapting the purpose of the AV1, with promising results, to support a wider range of pupil needs.

In consideration of the research question, these findings highlight the generally positive perception of the AV1 device, and its role in improvement of school attendance and emotional well-being. Key areas for consideration relate to specific examples of the device not being successful (for older pupils who did not like the attention) or wider IT-related difficulties. Specific examples of pupils not accepting the device align with existing AV1 research that reports of mixed experiences/successes (Johannessen & Haldar, 2020). Similarly, the discussion around IT-related difficulties is a consistent finding of settings which use TR (Fletcher et al., 2023).

Implications for research and professional practice

From the reported findings, it became apparent that there were key factors which require consideration for effective AV1 device implementation. Discussions around the cost of devices and Wi-Fi-related problems, for example, highlighted a current inequality in relation to access to TR as a form of alternative provision. These findings are widespread in research, with researchers proposing the need for systemic-level considerations, such as improving IT infrastructure across boroughs to enable all schools to have fair access to devices like the AV1 (Johannessen et al., 2022) and UK authorities having a duty to address digital inequality for all children (González-Betancor et al., 2021). Participant references to wider, systemic factors, such as the socio-economic considerations above, highlight that similar to other interventions, the AV1 device and its use are intrinsically linked with ecological factors that can influence implementation success (Durlak & DuPre, 2008).

Given the current dearth of UK-based research around AV1s, participant findings highlighted that implementation considerations must be made if the potential of devices is to be effectively explored, like the AV1, as a form of provision. To support this consideration, the authors mapped participant findings onto an ecological framework (Durlak & DuPre, 2008) to gain a better understanding of possible associations with implementation science and the impact of ecological factors (Figure 4).

Figure 4. Comparison of findings with the framework for effective implementation (FEI) (Durlak & DuPre, 2008).

Completion of the mapping exercise outlined in Figure 4 demonstrated that there were considerable associations between participant experiences and the impact of wider, ecological factors. Whilst the ecological framework used, like any framework, may not fully capture all considering factors around implementation (Durlak & DuPre, 2008), the exercise highlighted that considerations must be made around influencing factors and how the AV1 is effectively implemented.

Kislov et al. (2019) advocates for “theoretically informative implementation research” (p.6), which enables practitioners to remain evidence informed whilst also promoting the concept that evidence bases are not finalised and should be continually tested and adapted. This flexibility around implementation better aligns with the findings of this study, given that some comments from participants, such as staff/pupil reluctance to use the device, could be explained by other factors that require consideration during implementation. One such factor could be social validity. As previously discussed, social validity research has identified that school staff are unlikely to adopt an intervention if they do not feel it will improve pupil outcomes (such as attainment) or if it is not easy to implement (Daniel & Lemons, 2018). Whilst this study’s findings show promising social validity due to the perceived impact on pupil outcomes, further implementation of the AV1 should also consider social validity more explicitly, through staff, and also parent/pupil perspectives. Social validity research also highlights that in order to support staff acceptance, models of research should be developed that incorporate teacher views into implementation processes (Daniel & Lemons, 2018).

Whilst the application of ecological frameworks for implementation, such as Figure 4, could be considered for the AV1, the findings of this study highlighted the complex, multi-faceted experiences of participants. It could be argued that, if adopting a more flexible, theoretically informative approach (Kislov et al., 2019), a new implementation framework is required for the AV1, one that encapsulates both the impact of ecological factors (Durlak & DuPre, 2008) in addition to other concepts such as social validity and teacher experiences (Daniel & Lemons, 2018). Consequently, the authors have developed an implementation framework for the AV1 to guide practitioners, informed by implementation science and the experiences of participants in this study (Figure 5).

Figure 5. Proposed AV1 implementation framework.

This framework aims to capture both the experiences of participants and key areas of implementation science, such as ecological factors (Durlak & DuPre, 2008) and social validity (Daniel & Lemons, 2018). It provides practitioners with areas to consider when utilising AV1s, helping to assist with both effective implementation and the maximisation of staff acceptance (Daniel & Lemons, 2018). Informed from participant experiences and their links to ecological considerations, the inner segments identify six areas that will likely impact on successful AV1 implementation. The introduction of this paper highlighted that currently, implementation literature focuses on universal interventions (Tier 1) as opposed to Tier 3 interventions (Evans & Bond, 2021), likely due to the individualised nature of a Tier 3 intervention. However, social validity research argues that school staff require guidance and support when using new interventions/approaches, thereby increasing their confidence during implementation (Daniel & Lemons, 2018). Therefore, elaborative questions in Appendix A have been provided, informed by participant experiences and consultations with experts in the field, to guide practitioners during AV1 implementation. These questions aim to empower and inform professionals, whilst also remaining flexible/open-ended to accommodate for the individualised use of the AV1s.

The framework was designed to be non-linear, further promoting a flexible, theoretical, informative approach to implementation (Kislov et al., 2019) which better aligns with the findings of this study. A non-linear approach additionally accommodates research debates around fidelity and adaptation, which can promote positive outcomes during implementation (Durlak & DuPre, 2008). The inner segments provide fidelity, by defining participant and ecologically informed factors which must be addressed when implementing an AV1. The outer ring and open-ended questions (Appendix A) promote practitioner adaptation for their individual contexts. The AV1 itself does lend well to this balance of fidelity vs adaptation, given that the device provides some structure for practitioners via online, information guides (https://www.noisolation.com); however, the specifics of implementation (including who it is used with, length of use, etc.) are left to the professional judgement of the implementer/school setting.

As well as providing flexibility for practitioners, the outer ring attempts to incorporate this framework within existing school review processes, both within the UK and internationally. Whilst evaluation should form part of any intervention (Lendrum & Humphrey, 2012), incorporating this into existing school review processes should support professionals in continually reflecting around implementation success. For example, in the UK, this review process refers to cycles of Assess, Plan, Do, Review (APDR), as outlined in the Special Educational Needs and Disability Code of Practice (Department for Education and Department of Health, 2015), which professionals could incorporate the evaluation of AV1 implementation into these cycles. The decision to incorporate “supervision and safeguarding” into the outer ring is to emphasise the need for reflection and monitoring of the welfare/safeguarding needs of the child, ensuring there is no detrimental impact to their emotional well-being (United Nations Committee on the rights of the child, 2011). Supervision refers to any form of monitoring/supportive discussions that promotes continual scrutiny of the AV1 during implementation, such as between LA professionals and school staff. Whilst external support and supervision are an identified ecological consideration for implementation (Durlak & DuPre, 2008), the explicit links to APDR processes and safeguarding were devised by the researchers to ensure this framework had social validity for a UK context (Daniel & Lemons, 2018).

Additionally, specific considerations must be made around implementation and the use of AV1 devices for pupils experiencing anxiety/EBSA, given that this was the leading use of the device for participants in this study. Practitioners must consider how the AV1 device can be integrated into EBSA research, which argues the need for ecologically focused, multi-tiered models of intervention (Nuttall & Woods, 2013). The authors’ proposed framework lends itself well to trialling AV1 devices for EBSA cases (see Appendix B for an example of how the AV1 can be used within EBSA casework), given that common ecological factors form part of the framework design. Moreover, the highly individualised nature of a Tier 3 intervention (Majeika et al., 2020), like the AV1, would be congruent with best practice support for EBSA cases, given the necessity for EBSA support to also be highly individualised (Corcoran et al., 2022). To support this, settings must consider the use of professionals, such as EPs, when trialling AV1 devices, given that ongoing consultations with mental health professionals/psychologists are promoted when implementing any form of Tier 3 intervention (Berger, 2019).

The purpose of this paper is to provide contributory evidence to the development of an evidence-base for the AV1 from a UK context. Given the explicit links between participant findings and ecological factors (Figure 4), coupled with the important relationship between evidence-based practice and implementation (Damschroder, 2020), it is evident that professionals must consider implementation theory when utilising AV1 devices. The authors’ framework has been designed in consideration of this, whilst also ensuring that staff views are directly incorporated into its design (Daniel & Lemons, 2018). It is expected that this framework supports practitioners implementing AV1s both in the UK and internationally, given that many of the identified implementation factors echoed findings in other international research studies (Børsting et al., 2019; Johannessen et al., 2022; Weibel et al., 2020). Future research could trial the use of this framework during AV1 implementation, exploring whether this framework supports professionals, and accurately reflects and incorporates the direct views and experiences of LA professionals, school staff, parents and CYP (including classmates of pupils who use the AV1). Capturing views from other user groups would also strengthen the evidence base for the AV1 and its links to implementation science (Durlak & DuPre, 2008). Given that the framework is a combination of both research and theoretically informed principles, it will be important for future research to trial all aspects of the framework to ensure that they warrant being part of its design. Additionally, further refinement could be completed following consultation with experts working within the field.

Also as part of trialling this framework, future studies could also capture more quantitative outcome measures, such as school attendance/attainment data or psychometric data from tools such as the strengths and difficulties questionnaire (Goodman, 1997). Findings in this study highlighted how many participants were not yet at a stage to gather quantitative data around the AV1 devices, aligning with the methodologies of other research studies in this field (Fletcher et al., 2023). However, whilst the early implementation of interventions may rely on qualitative measures (such as semi-structured interviews) to explore outcomes, quantitative methods must eventually be explored to truly measure the extent/success of implementation (Smith & Hasan, 2020). Adopting a mixed-method design in future research could allow for further gathering of user perspectives, in addition to more formal, quantitative outcome measures to fully explore the AV1 implementation.

Limitations

Whilst this is the first UK academic study to explore the use of AV1s and report experiences of school staff, a potential limitation of this study is that it collected the views of school staff only. Whilst attempts were originally made to include CYP within the project, recruitment difficulties highlight that from a research perspective, AV1 implementation within the UK remains at an early stage, and future research is required to explore the views of different stakeholders, including CYP. However, in an earlier work (Fletcher et al., 2023) gaps were identified in relation to all stakeholder views, therefore a focus on UK staff in this paper had merit, given that it enabled explorations into specific challenges from their perspective. A collection of other participant experiences (such as parents/CYP), across a range of education setting types, alongside formal outcome data (such as attendance data) is required before generalised conclusions around the impact of the devices can be made.

Conclusion

This UK-based study explores the views of school staff using AV1s within the UK. Whilst concerns such as cost and IT difficulties have been highlighted, the general consensus is positive in relation to this technology. This paper adds to existing international research that is finding the AV1 to be a useful and effective form of alternative provision or intervention for CYP who have a range of physical and emotional health needs. The devices are perceived to have a mainly positive impact on academic progress, engagement, social contact, and emotional well-being. Considerations for future practice include the possible trial of the proposed implementation framework, as well as the need for further studies to consider EBSA specific implementation factors, evidencing outcomes and capturing the experiences of other key stakeholder groups such as CYP and parents.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings of this study are available on request from the corresponding author.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This work was supported by the Department for Education [National College for Teaching and Learning (NCTL)].

Appendix A:

Proposed AV1 Implementation Framework

Introduction

This framework has been designed to be used by any practitioner e.g., school staff, EP, LA staff, who are intending to implement the AV1 within their field/support the implementation of the device. The purpose of the framework is to provide a thorough and rigorous approach to implementation, accounting for potential areas of difficulty. This in turn, will help to increase the likelihood of the device being successfully implemented, leading to better outcomes for the pupils using the device.

Measuring Outcomes

How will key outcomes such as attendance and attainment be measured?

How will emotional-based outcomes be measured? E.g., pupil confidence, responsiveness to the device, engagement in school, interactions with peers etc.

What will these outcomes be used for? E.g., for research, to review the effectiveness of the AV1 etc.

Technological Set-up and Support

How will school/home be supported with setting up the device?

How will ongoing IT support be provided for all parties?

How will No Isolation be utilised as part of this IT support?

How will school/home adhere to the No Isolation user guides for the device?

Education and Social Considerations

How will lessons/teaching be adapted in consideration of the AV1?

What support will staff need to be able to make these adaptations?

What considerations will be made for more practical subjects such as Art/PE?

What support will home need in regards to teaching/adaptations?

How will social opportunities for the pupil be arranged using the AV1? e.g., playtime.

How often will the pupil use the device?

What considerations will be made for AV1 use during school holidays/outside of school hours?

Information Sharing

How will the AV1 be introduced to all parties?

How will concerns be alleviated e.g., around security and privacy?

How will parties be signposted to further information about the AV1?

What lines of communication will be established for all parties?

Financial Considerations

How will the AV1 be funded?

Will school require support around WIFI cost/WIFI strength?

Will home need to be supported around purchasing a computer tablet and WIFI?

What support can be provided around reducing financial costs for all parties? e.g., the use of bursaries.

Consent and Role Contracting

How will fully informed consent be gathered from all parties?

How will roles be identified and agreed? E.g., point of contact for support, those responsible for liaising with No Isolation etc.

How will the AV1 be contracted? E.g., the length of time using the AV1, the purpose of using it, social/education considerations etc.

How will the young person’s views/opinions be collected and involved through the entire process?

Appendix B:

Example AV1 EBSA Reintegration Plan

The diagram below was created by the authors to provide an example of the AV1 and its potential use within an EBSA case. The use of the AV1 could be trialled within EBSA casework, as part of a graded exposure therapeutic approach¹ which ultimately aims to reintegrate a pupil back into an education setting. Please note that this example is illustrative only, devised by the authors, and requires future research to explore its validity as a potential approach.

¹Graded exposure therapy refers to exposure-based therapeutic approaches that aims to gradually expose a pupil to the school environment, in sequenced stages to promote acclimatisation and reduce anxiety/phobia-related barriers to attendance (Elliott & Place, 2019).

²Ongoing review meetings should be routinely held between school/home to monitor the wider context around the pupil. For example, any changes within the family context (e.g., parental illness) or school context (e.g., bullying) should be reviewed, to further explore push/pull factors that may be contributing towards non-attendance. These factors can then be considered when planning support for the pupil.

Reference: Elliott, J. G., & Place, M. (2019). Practitioner review: school refusal: developments in conceptualisation and treatment since 2000. Journal of Child Psychology and Psychiatry, 60(1), 4-15. https://doi.org/10.1111/jcpp.12848