Introduction

The quality of educational, health and social assistance is largely determined by the characteristics of professional practice, which depend on the qualities, attitudes and skills of professionals; the institutional context, as well as its social recognition.

The hospital teacher (HT) must be trained to perform his duties with maximum competence and guarantee the right to quality education in any of the contexts in which he can work, for which he requires specialization.

Hospital education, in turn, fulfills the mission of reducing the biopsychosocial impact of coping with a situation of unforeseen vulnerability that generates a lot of uncertainty and fear. Hospitalization gives rise to a series of risky circumstances that must be supported by educational spaces (^{ORTIZ, 1999}): feeling in a different place with unknown people; separation from the family; break with everyday life and school; uncertainty; greater passivity, even if there is more free time available; physical and emotional discomfort; concern about future projects. In this context, 4 focuses of attention are articulated: health, psychological, educational and social, whose professionals must coordinate and collaborate in an integrated care approach, centered on the person, where the boy, the girl, the adolescent and their family are the system shaft, as proposed by the international conference on integrated care (AGENCIA DE CALIDAD Y EVALUACIÓN SANITARIAS DE CATALUNYA, 2016), emphasizing collaborative work and multidisciplinarity.

A Conceptual Framework for Education in Disease

Education for children and young people with health troubles is an important part of the traditional hospital pedagogy. Although this name does not correspond strictly to the evolution that this discipline has developed, both by the target audience and by the areas of intervention, it gives identity to the profession. In an attempt to offer a comprehensive and up-to-date concept, we define it as: “A scientific, academic and professional discipline that studies and integrates quality educational and psychoeducational actions aimed at people with health troubles and their families, in order to guarantee the fulfillment of their rights, respond to biopsychosocial needs, develop their potential and improve quality of life” (^{MOLINA, 2020}). We consider the individual's entire life as a temporal cut because the disease can appear at any vital moment and, when it occurs, it can last for long periods or become chronic. We emphasize care centered on the person and the family, in order to improve the quality of life and enhance capabilities, which implies a resilient approach. However, the contexts of action are located both in hospital spaces through educational services inside and outside the classroom or school, as well as outside the hospital, be it the home, the substitute home or the regular school, provided that, in any educational context, one of the situations of diversity in students may be a disease. We could say that the educational action must be developed in all contexts where the person with the disease is found (MOLINA; BORI, 2013). On the other hand, we propose that the educational hospital service, as well as that offered in other contexts, be part of an inclusive educational system (fig. 1). We could say that the educational action must be developed in all contexts where the person with the disease is found (MOLINA; BORI, 2013). However, we propose that the educational hospital service, as well as that offered in other contexts, be part of an inclusive educational system (fig. 1).

Source: Adapted from ^{Ainscow (2020})

FIGURE 1: Hospital pedagogy is part of the inclusive educational system 

Professionalism and professional development of the hospital teacher

The conditions required for the good professional exercise of the hospital teacher are diverse and must be defined. We will show professionalism and professional development.

Professionalism implies contemplating the specificity of the profession, which, in the case of the teacher, is "the set of behaviors, knowledge, skills, attitudes and values that constitute the specificity of being a teacher" (^{SACRISTÁN, 1991}, cited by ^{OLIVEIRA, 2013}), while configuring the identity of the profession (^{OJEDA, 2008}). It means commitment to the profession and competence, that is, to act effectively. ^{Tejada (2002}) distinguishes traditional professionalism, in which the professional is a simple transmitter of knowledge and is based on technical rationality, alternative professionalism or developed professionalism, where the profession is dynamic and can change. The professional applies the reflection of his practice and acquires a role as a facilitator of learning. In this perspective, professional practice itself is a learning scenario, and the teaching and learning processes are “democratic, dialogical and ecological, in institutional contexts focused on improvement and growth, an organization that learns and develops” (^{TEJADA, 2002}, p. 65).

In the case of the hospital teacher, specificity is fundamentally defined by four factors: 1) the environment in which he exercises his profession (health and home, among others), 2) the functions he performs in addition to the teachers, 3) the methodology he applies and , 4) the characteristics of the population it serves. Other elements to be considered more and more identifiers in this profession are: the link with the regular school (coordination, collaborative work) and with health, psychology and social service professionals; addressing school issues according to the internship curriculum; personalized service due to the diversity of the students served (in addition to the usual ones, the health and emotional state); support and monitoring in the emotional management of families, among others (^{MOLINA, 2020}). In order to offer quality education, the professionalism approach developed is relevant in hospital pedagogy. The action in the hospital classroom is dynamic and changing, which requires continuous adaptation and flexibility.

The professionalism of the hospital teacher implies the acquisition of skills and abilities that allow him to integrate the reflection on his practice and contrast the theoretical and methodological foundations with his own individual and collective experience, so that it is a form of professional development. On the other hand, collaborative work in favorable contexts, as stated by ^{TEJADA (2002}), is what makes true professional development.

Professional development of the teacher is understood as a “set of factors that enable or hinder the advancement of the teacher in his professional life” (^{IMBERNÓN; CANTO, 2013}, p. 2). In a restricted sense, it refers to training as the only factor, but in a broader sense of the concept, training is combined with other factors, no less important, that significantly influence, such as working conditions, possibilities of promotion and recognition, among others. The hospital teaching profession requires decent working conditions, but mainly knowledge and social recognition, as it is a profession of great commitment and that brings great benefits to society. The teacher himself must be aware of this and be proactive in defending his professional identity.

^{Imbernón and Canto (2013}) consider that training can contribute to professional development; However, failure in other factors, such as an adequate salary, can negatively impact and render the profession precarious. This broader view of the concept of professional development must be understood as “any systematic attempt to improve work practice, beliefs and professional knowledge in order to increase the quality of teaching, research and management”. Quality education in situations of illness must be the goal to which the PH professional must advance. With that, for Imbernón and Canto (2013. pp. 4-5), we can apply to the hospital scenario five lines of action for the professional development of the teacher:

1. The theoretical-practical reflection on the practice itself through the analysis of reality; 2. The exchange of experiences between equals to enable updating in all fields of educational intervention; 3. The union of training with a work project; 4. Training as a critical analysis of work practices, such as hierarchy, sexism, proletarianization, individualism, low status, among others; and 5. Professional development that occurs predominantly in the educational center.

The network of hospital teachers is another challenge to be achieved with the objective to facilitate the exchange of experiences that lead to the joint construction of good educational practices in health contexts.

Although there is an abundant bibliography on the professional development and professionalism of the regular school educator, the same can not be said of the hospital teacher. Therefore, it is necessary to delimit and define this profession so that it has its own identity and is socially recognized for its role in guaranteeing the right to quality education for people with health problems. Therefore, it is very important to provide this profession with the necessary conditions that dignify it and put it in its proper place, namely: inserted in the inclusive educational system (^{MOLINA, 2020}). As stated by ^{Albertoni and Chiari (2014}), public agencies must establish links with each other to configure a support network for hospital education.

One of the most important factors that professional development requires, although as we have seen is not the only one, is training. This should be focused on the recognition of the specific professional character and its social valorization, starting with the professional himself, who must be considered an agent of social transformation. Likewise, it should contribute to the construction of hospital pedagogy, as a discipline and as a profession committed to society.

Competence profile of the hospital professor

The profile of the hospital teacher is built from the acquisition of the skills necessary for the development of their teaching functions and to the accompaniment in the teaching and learning process. This requires solid training, which, combined with professional experience, is an attitude open to knowledge, responsibility and commitment, the profession of hospital teacher. For ^{Bozu (2007}, p.4), "defining the professional profile of teachers means defining the functions, attributions, fields of activity and their professional skills". As for personal attributions, González-Simancas and Polaino-Lorente (1990) consider that the educator must be an imaginative and demanding professional, but at the same time flexible, prioritizing health over learning and the curriculum.

Professional competences for hospital education

We start from the complexity of the concept of competence itself, from which many definitions have been formulated. Rodriguez, Serreri and Del Cimuto (2010: p. 35-36) refer to the following aspects common to all of them:

a) Denote a know-how, of a correct integration between competences and knowledge or know-how; b) Show that this know-how is not something simple and linear, but rather a complex procedure; c) They also show that this complexity covers a wide range of competences, namely: cognitive, affective, social or psychomotor; d) The competence to know how to do, that is, to know how to perform an action, refers to a set of specific situations or contexts, and not necessarily to any situation (situated competence).

Emphasizing competition as an inclusive process, define it as “a complex wisdom resulting from a process of integration, mobilization and management of capacities, competences and knowledge used effectively and in situations with a common thread”.

This conceptual perspective is of special interest for its application in hospital education. It means that the educator, in order to be competent, must have a set of professional skills necessary for the effective development of his / her own functions. These functions, as a whole, they require a multidimensional approach that integrates cognitive, emotional and social skills, in a specific context different from the regular teaching function, such as the hospital.

According to the same authors (^{RODRÍGUEZ MORENO; SERRERI; DEL CIMMUTO, 2010}, p. 37), it is important to break down each competency into capacities and abilities, with capacity being the “skill grouping” or “constitutive element of competence”. The skill would be "a simple wisdom that integrates declarative knowledge", that is, knowledge. Therefore, we can consider that the acquisition of work skills is a complex process (fig. 2) that requires innovative and effective teaching and learning strategies, such as group, experiential and cooperative methodology.

Source: Self elaboration

FIGURE 2: Competition development process  

The development of professional skills of hospital teachers occurs through the combination of continuing education processes, professional experience and reflective practice, in the same way as in other professional areas. Hospital pedagogy as a profession, from a perspective of educational quality, requires the definition and continuous review of the profile of specific competences based on the functions it develops, research and basic, specialized and integrated training. For this, the corresponding evaluation and self-evaluation processes must be coupled to the responsible organizations, applying strategies such as the competence balance proposed by Rodríguez Moreno (2006), which is very useful for self-identification. In this way, each professional becomes aware and can apply improvements in relation to their professional project.

For the development of the functions described in the previous section, it is necessary to specify the works that each of them involves. The delimitation of the competencies linked to each task, according to Rodríguez Moreno (2006, p.71), requires understanding how the professional "activates his baggage of competences" with regard to how he solves the problems, the means used and the strategies that he uses to achieve the goals. The author understands by professional competence "the general capacity that a person has, although linked to a specific work task and that requires the interpretation of the context, knowledge of the rules and the implementation of effective solutions". At hospital pedagogy, we reiterate the particularity of the teaching performance in a complex environment such as the hospital, in which the professional must combine the norms that affect the teaching and learning process in the different areas of performance, with those that govern the hospital, including hygiene and hygiene security of all health institutions. On the other hand, the questions that hospital teachers have to answer are diverse and more complex than in normal education. The objectives go beyond curricular education, necessarily diversified, to achieve improvements in well-being and quality of life, and also in the level of satisfaction with the service received. From the different perspectives that present themselves on professional competence, we deduce that the one that best fits the field in question is understood as participation in a community of professional practice, since it considers the experience acquired as a constructive methodology, the basis of a “ Heuristic, investigative mentality, the core of a competent mentality” (^{RODRÍGUEZ MORENO, 2006}, p.75). In hospital pedagogy, much of the knowledge has been generated from professional experience, since the construction of knowledge through research is a relatively recent process and subsequent to the origin of the first pedagogical actions in hospitals (^{MOLINA, 2020}). It is necessary to integrate this heuristic mentality into professional practice, that is, oriented to investigate and discover creative and simplifying ways of understanding and analyzing situations that help to make decisions and solve problems. Other components of this approach are the development of collective professionalism, cooperation and self-regulation. The work of the hospital teacher sometimes is individual and belongs to the daily work, but, as a whole, it has contributed to the construction of the hospital teacher's professional identity, favored by forums for dissemination, debate and technologies, along with national and international networks that act proactively so that hospital education reaches all people with no exception.

Professional competence must be seen from its three-dimensionality, as suggested by LeBoterf: subjective dimension (biography and social skills); work dimension (professional situation); and dimension of training (qualification). Competition would be the area of intersection between them (^{RODRÍGUEZ MORENO, 2006}).

The skills of the hospital teacher must integrate those of the normal school teacher with the specific requirements of hospital education. The methodology of the Tuning Project (Tuning educational structures in Europe) (TUNING MANAGEMENT COMMITTEE, 2006) raises two types of professional skills: generic and specific.

Generic (transversal) competences are classified as instrumental (cognitive, methodological, technological and linguistic), interpersonal (individual skills and social skills) and systemic (understanding, sensitivity and knowledge). The specifics would be corresponding to each area. In turn, the Agency National Evaluation Quality Assurance (ANECA) proposed another model for classifying generic competences (^{RODRÍGUEZ MORENO, 2006}, p. 181): knowing (possessing knowledge), knowing how to do (mastering the methods), knowing how to learn (being able to graduate), knowing how to be (showing attitudes and ways of acting) and making known (enabling the development of learning through personal intercommunication)³.

For the professional hospital pedagogy, based on the transversal (generic) competences of the University of Barcelona (UNIVERSITAT DE BARCELONA, 2008), we propose the following:

• Ethical commitment. Behavior consistent with personal values ​​and the code of ethics. Acceptance of the profession's ethical standards. Commit to professional identity and ethics. Recognition and respect for diversity.

• Learning ability, autonomy and responsibility. Ability to analyze and synthesize, to apply theory to practice. Willingness to get involved in work efficiently and autonomously.

• Team work. To relate and collaborate in carrying out works with an interdisciplinary and multicultural team and from a complex perspective. Contribute to a common project.

• Communicative ability. Learn to express ideas clearly, as well as listen and understand many ideas of other people in different situations. Learn how to find and integrate information.

• Problem solving and decision making. Identify, analyze and define the significant elements that constitute a problem to solve it effectively with criteria.

• Adaptability. Adaptation to changing many different situations, acting with versatility and flexibility and taking into account people's emotional and health status.

• Sustainability. Find out how to assess the socio-environmental impact of field actions. Ability to look for integrated and systemic views.

• Creative and entrepreneurial ability. Ability to formulate, design and manage projects. Ability to seek and integrate new knowledge and attitudes.

Regarding specific competencies, based on the ANECA model (^{RODRÍGUEZ MORENO, 2006}), we show the most significant ones (table 1).

TABLE 1: Specific competences of the hospital teacher 

Knowing (knowledge)	To know the theoretical and epistemological bases of hospital pedagogy.
	Recognize the psychoeducational care of people with diseases from a transdisciplinary, inclusive and holistic perspective.
	Understand the theories and models of psychoeducational care throughout life.
	Integrate theoretical and methodological knowledge acquired, applied in different areas of study of hospital pedagogy.
	Knowledge of research methods and strategies applied to hospital pedagogy.
Learn how to do it (skills / abilities)	Coexistence management
	Organizational and economic management
	Analyze the psychoeducational needs of people with health problems and their families.
	Develop intervention proposals, based on scientific evidence and good practices according to the stage of life and the context.
	Identify and apply effective teaching strategies according to the stage of life and family educational monitoring.
	Identify and apply creative and inclusive teaching strategies in view of the different realities of the population with health problems.
	Know how to select and apply digital tools suitable for educational and communication activities.
	Conceive and apply evaluation processes in intervention and research programs and projects in the field of hospital pedagogy.
	Analysis and assessment of reality using different methodologies.
	Analysis of work-related risk and protection factors
	Apply strategies for self-care of health
Knowing how to be and be (attitudes)	Responsibility
	Empathy
	Engagement
	Flexibility
	Self confidence
	Self control

Source. Self elaboration

As an example, we developed the responsibility competence below, following the model of Rodríguez Moreno, Serreri and Cimmuto (2006) and Rodríguez Moreno (2014). These authors attribute to the concept of responsibility at work the meaning of involvement as a demonstration of personal and professional competence. This requirement is important in the field of hospital education, as it is about improving the well-being of the person with the disease and requires a helping relationship and the establishment of affective bonds.

TABLE 2 Development of responsibility competence in hospital education 

1. Advertise or increase the competition.
The hospital education professional will demonstrate in practice his responsibility in the educational process of children and adolescents with illness.
2. Define the curricular or work context in which it should be implemented
Teacher in classroom and / or hospital school
3. Explain the meaning or significance of the competition
Responsibility is a fundamental competence inherent in the educational and assistance profession itself. It represents the involvement and commitment to trust, well-being and quality of life of children and adolescents in situations of vulnerability to their families. It assumes that education is a right.
4. Write down the elements or components of the competition: capabilities	5. Record the skills that converge on the skill
Know the physical and mental burden of being a teacher in a hospital.	Find out how to fulfill the commitments made with the institution. Learn how to identify risk factors for excessive workload and its consequences Know how to identify the overload or excess of self-assigned responsibilities. Learn how to reconcile workload with family responsibilities.
Know the curricular regulations that regulate teaching work and those that regulate the health context with regard to hygiene and safety.	Find out how to comply with educational and health standards. Know how to serve diversity. Learn how to maintain personal hygiene and teaching materials. Learn how to apply hospital safety standards.
Get involved in teaching work with children, adolescents hospitalized and their families.	Act without prejudice. Identify criteria of efficiency (evidence and good practices) and educational quality. Worry about learning outcomes and emotional state. Meet the expectations and interests of the people you serve. Comply with ethical principles.
Get involved in collaborative work with the rest of the professionals.	Establish respectful interprofessional relationships. Express interest in the work of other professionals Report transparently. Accept contributions from others.

Source: self elaboration.

The training of the hospital teacher: Learn to teach and educate

The hospital teacher needs training based on transdisciplinarity, where the knowledge of the educational sciences is linked to the health sciences, social sciences and humanities. In view of the context of vulnerability due to health reasons, we agree with ^{Ortiz (1999}), who claims that training must have a human and academic character at the same time. It must include humanistic content that encourages critical and reflective thinking and promotes an empathetic and affective approach to reality mediated by ethical values. As stated by Sánchez Andrade and Pérez Padrón (2017), this approach goes beyond disciplinary content, with the objective to favor integral development as a person.

It is worth highlighting the importance of addressing the training of hospital teachers through teaching and learning processes from a learning by work perspective, where theoretical-practical, experiential and practical training is integrated together with the intervention contexts themselves. Direct interaction with professionals and the target audience favors the development of professional skills more effectively. One of the most important elements of this process is the development of reflective capacity, which will affect both the learning process and professional practice (^{RODRÍGUEZ MORENO, 2006}).

According to Ruiz Revert and García Raga (2019), the hospital teacher, the regular school teacher and all education professional is vulnerable to having a child or adolescent with illness in their educational group. Meantime, for the hospital context, they must receive specific training due to the uniqueness of the environment (health versus education). Based on many kinds of research, ^{Arreola (2019}) refers to multiple differentiating elements between the hospital and the ordinary school that the teaching professional must attend and, therefore, must be taken into account in the training of these professionals: the socioemotional climate that occurs in students ; pain, suffering and fear are present in the hospital; disease diversity, in addition to different levels of education; difficulties in having strategies adapted to each educational stage, the situation of each moment and its flexible character; need for knowledge about health aspects other than educational ones.

Three training modalities are proposed in hospital pedagogy:

- Initial university training: The training that prepares and accredits for practice as an education professional in any of its modalities (teacher of early childhood education, basic and secondary education, social education, pedagogy and psychopedagogy) must introduce this field of intervention. These professions are inserted in hospital pedagogy, whether in regular educational, socio-educational or hospital services, since every child or adolescent, in any of the educational spaces where they are, has the right to an inclusive education. On the other hand, this initial training will contribute to reduce the social ignorance of this discipline, since, according to Ruiz Revert and García Raga (2019), this is also a reality with little knowledge of education professionals.

The study of these authors in Spanish territory reports that, in undergraduate courses in the Spanish context, no public university offers disciplines related to hospital pedagogy. In relation to private universities, only the University of Navarra teaches a discipline with the title of hospital pedagogy in the grades of Early Childhood and Primary Education (0-6 and 6 to 12 years respectively). Some universities have offered content or subjects with this theme in specialties or mentions: special education (University of Vigo). In the Pedagogy course, according to the study by Ruiz Revert and García Raga (2019), the University of Burgos (mandatory), the University of Santiago de Comportela (optional) and the University of Navarra (optional) offer similar disciplines. In the social education course, mention is made only of the University of Valencia, which offers a Health Education course.

The Faculty of Education of the University of Barcelona (UB)⁴ offers courses in degrees that relate education and health or that include content related to this theme: in Early Childhood Education the mandatory discipline is offered: “Childhood, health and education”. About Attention to Diversity in Early Childhood and Elementary Education, hospital pedagogy is considered one of the areas of diversity. In the degrees in Pedagogy and Social Education, the subject “Education, Training and Health” is shared, which contains a block for hospital pedagogy. We must also to mention the importance of training based on external curricular practices in hospital classrooms, in foundations and associations and other health organizations, as well as the Degree Projects that refer to this field of activity.

- Specialized university training: Since the academic year 2015-2016, UB has offered the Master's Degree in Hospital Pedagogy throughout life, as the highest academic level in terms of specialization, which started its sixth edition in the academic year 2020-2021 and has students from Spain and from Latin America, since it is taught in mixed mode (b-learning), through virtual presence. Other specialties taught are the Specialization / Postgraduate Diplomas in Hospital Pedagogy, as well as the specialization in other courses.

The university's doctoral teaching programs allow for doctoral theses to be carried out in lines of research related to hospital pedagogy. It represents an opportunity to investigate and, therefore, contribute to the construction of knowledge in this disciplinary field.

- Continuing education: If we understand education from a permanent and lifelong perspective (lifelong Learning), professional development implies updating and deepening knowledge, as well as reflection on the practice itself. For this, the university, the contracting agencies and the public administration must assume co-responsibility in the continuous training of professionals to guarantee good practices, principally with regard to assisting people in situations of vulnerability.

A fundamental element in training is the development of collaborative and participatory research, the results of which will contribute to the construction of the knowledge necessary for training and evidence-based professional practice.

Conclusions

Hospital education is the most widespread practice aimed at school-aged pediatric patients who, for health problems, can not attend a regular educational center. Its operating framework, hospital pedagogy, makes sense for the international recognition of the right to education and health, understanding it from a biopsychosocial perspective. Thus, prestigious international education bodies like UNESCO demand quality education for all, that is, based on the principles of equity and inclusion.

These principles are not always applied in a real way, and are reduced to their theoretical and normative expression. Equity has been one of the main objectives of educational, health and social policies for many years, although progress is being made very slowly to achieve it.

Hospital pedagogy represents an opportunity to move in this direction. Observing its evolution, new hopes and perspectives are opening up in the improvement of quality and in the sense of an ever broader coverage of the school-age population of children and adolescents. In the perspective of lifelong learning, its performance framework is already visibly expanding in many experiences and projects developed in this context.

It is especially relevant to place hospital pedagogy in a broad perspective that incorporates these approaches and characterizes it as a discipline, since, through research, it has a body of knowledge based on evidence and good practices and experiences. This dimension will give it meaning and knowledge, for social recognition as a necessary profession that contributes to quality education.

On the other hand, there is a need for the different contexts of action of hospital pedagogy to integrate an inclusive educational system of quality in conjunction with the regular school, alongside the co-responsibility of the community and public administration.

A fundamental axis for this quality education aimed at people with health problems and their families is the professional. It goes without saying that the individual must be competent to perform his duties effectively and ethically. As a discipline, hospital pedagogy must also move towards professionalization, defining the specificity of the profession and promoting professional development, through quality training based on the general skills of any educational act and the specific ones that correspond to the many functions it performs.

The public administration, the contracting entities and the professionals themselves must assume the shared responsibility of ensuring initial, specialized and continuous training, through teaching and learning methodologies that promote the reflective capacity on their own practice based on a work approach that integrates theoretical elements such as practical, experiential and practical training in the intervention contexts themselves.

Progress has started, but there is still a long way to go. In this journey, putting into practice the appropriate strategies, we can achieve small goals that will bring us closer and closer to a quality, equitable and inclusive education for all people with health problems and their families, bringing, in turn, improvement of well-being and quality of life.