Inpatient Care Team Views on Child Life Services: A Scoping Review Free

Only a limited body of published data exist regarding the role and integration of CLS into the inpatient team. Therefore, a scoping review of the existing literature was conducted on the basis of the guidelines of the Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews.^19–21  The patient/population, intervention, comparison, and outcomes framework was used to identify the primary research question, with CCLS as the population, other health care team members’ perspectives as the inquiry, and hospital setting as the context. The aims for performing a scoping review on CCLS in team settings were to:

1. identify and assess common themes;

2. provide an overview of available information within the primary literature; and

3. identify trends to inform future study and guide efforts in improving the understanding and utilization of CLS.

A literature search from the inception of each database to the date of study initiation (November 10, 2021) was conducted. Following guidance of a medical research librarian, literature searches using a combination of keyword and database-specific controlled vocabulary terms was performed for 5 databases: MEDLINE, Embase, CINAHL, PsycInfo, and Web of Science. Search quality was ensured by adhering to the guidelines provided by Peer Review of Electronic Search Strategies.²²  After these databases were reviewed, Google Scholar was surveyed for gray literature in fields not encapsulated in the 5 databases above. Lastly, the cited references from any article obtained for any additional research were manually reviewed.

A mix of controlled vocabulary and text words was used to identify relevant literature associated with the concepts of CCLS, health care perspectives, and hospital settings within the patient/population, intervention, comparison, and outcomes framework. These concepts were combined using Boolean operators. Details of the full search strategy for the 5 databases are outlined in Supplemental Table 2. The initial database searches yielded 132 articles (MEDLINE, 10; Embase, 11; CINAHL, 16; PsycInfo, 6; Web of Science, 89). Results were exported from all queries into Zotero and duplicates were removed on that platform.²³  An additional 9 articles met inclusion criteria and were considered after manual citation searching and gray literature searching in Google Scholar. After deduplication, 123 unique articles remained. Using Rayyan software,²⁴  title and abstracts were screened using inclusion and exclusion criteria. Studies were included if they contained themes of CLS as a subject of interest, original data on hospital staff attitudes in the inpatient setting, and discussion on interdisciplinary collaboration and/or interactions within the medical team. Therefore, studies were excluded if:

1. CLS were not a subject of interest

2. there was no original data on hospital staff attitudes in the inpatient setting; and

3. discussion on interdisciplinary collaboration and/or interactions within the medical team were missing.

In addition, studies that were not published in English or studies where the full text could not be retrieved were excluded. After initial screening, 75 full-text articles were reviewed for relevance following strictly to criteria established a priori. At final assessment, 9 articles met the inclusion criteria and were thematically analyzed by 2 independent reviewers (Fig 1, Supplemental Table 3).^25–33 

Two independent researchers extracted data from each included article, such as article title, date of publication, journal, authors, subject demographics, study setting, primary outcome measures, analytic methods, main outcomes, strengths, and limitations. Disagreements or questions regarding data were discussed in weekly meetings and consensus was established. Major findings organized by common themes among the selected articles were described and summarized. The data charting tool can be found in Supplemental Table 4.

Nine primary research articles were included in the final review. Studies ranged in publication dates from 2001 to 2021, with the majority (78%) published in various pediatric specialty journals after 2017 (Fig 2, Supplemental Table 5). Most articles were published in different journals, with only 2 commonly found in Children’s Health Care.^25,26  Of the 9 included articles, 7 (78%) were questionnaires or survey studies, 1 (11%) involved focus groups, and 1 (11%) involved in-person interviews (Fig 3A, Supplemental Table 6). In the 9 articles, multiple health care professional groups were represented, in addition to frontline clinical providers, including social work, medical assistants, respiratory therapists, and administration. Each group had the potential of appearing 9 times, with the viewpoints of CCLS, nurses, and physicians studied more frequently than the other groups (Fig 3B, Supplemental Table 7) (Supplemental Table 7). Study method, main outcomes, and authors’ conclusions are summarized in Table 1. Participant information, strengths, limitations, and other pertinent information for each article are summarized in Supplemental Table 4.

Four unique, but not mutually exclusive, themes were identified among the articles of interest (Fig 4, Supplemental Table 8). Six articles (66%) state that responsibilities of CCLS extend beyond those commonly recognized, and another 6 (66%) include the positive impact CCLS have on patients and families. Seven articles (78%) describe the challenges of interprofessional collaboration between CCLS and other team members. Nine articles (100%) discuss the value in educating others on the role of CLS.

The aim of this scoping review was to summarize published literature on how CLS are understood and used in the hospital setting to date. The review was conducted to help provide a framework for future study by:

1. identifying and assessing common themes; and

2. providing an overview of information currently available on this topic to help guide future efforts in improving the understanding and utilization of CLS.

Six studies conclude that CLS responsibilities are broad.^{25–28,30,33}  Cole et al²⁵  first noted that there is a discrepancy in health care professionals’ knowledge of CLS responsibilities. For example, psychological preparation was a more well-known responsibility among the clinical team than patient and family support. Although a recent study by Wittenberg and Barnhart³³  demonstrated this no longer to be the case, they noted a handful of other behind-the-scenes duties, such as medical record documentation, that were largely underrecognized. Although therapeutic play is commonly associated with CLS,⁶  a study by Stenman et al³⁰  concluded that play is a broad term with a wide range of applications for patients and families in different settings. Nurses surveyed by Drayton et al²⁷  believed that CLS had better distraction techniques for pediatric patients and eased the burden for nurses who were simultaneously also assisting physicians during procedures. Smith et al²⁶  specifically researched the expanded roles of CCLS with families who had children in the NICU. They reported the top 3 responsibilities in this department to be sibling care, palliative care and bereavement support, and family education. Furthermore, the CCLS participants in a study by Lookabaugh and Ballard²⁸  similarly state that their responsibilities have also expanded to settings beyond pediatric inpatient units to areas such as imaging, neonatal intensive care, dental clinics, early intervention, parent education, and more.

Six articles of interest had data that points to the positive impact of CLS in the clinical setting.^{25–27,29,30,33}  Cole et al²⁵  noted that nurses, physicians, social workers, and administration members rated CLS the highest on average in improving psychosocial well-being compared with 15 other professions, most likely related to their well-accepted role in psychological preparation. In their study on the role of play in trauma-informed care, Stenman et al³⁰  demonstrate that play is an important CLS tool that helps with patient experiences, teaches patients to gain control of their environment, and improves communication between patient and provider. This aligns with findings by Wittenberg and Barnhart,³³  where CLS provides patients with emotional support and developmentally appropriate education. Nurses from a pediatric unit in New South Wales participating in a focus group agreed that CCLS improve procedural experience, are well received by the patients, and are essential members of the team by providing education on various aspect of child development.²⁷  CCLS also play a role in providing nonpharmacological pain management, including environmental stimuli regulation and kangaroo care in the NICU.²⁶ 

The positive impact of incorporating CLS into new settings within the hospital may also have monetary value. Mistry et al²⁹  surveyed pediatric urologists within the Society of Pediatric Urology who report that CCLS help to reduce traumatic experiences and the need for anesthesia, which may offset the costs associated with implementing CLS.³⁴ 

Even though CCLS play a crucial role in the health care team, there are barriers when it comes to team integration. Cole et al²⁵  first reported that CLS were rated among other professions in the health care setting as having little power even though they were previously rated as having the greatest impact on psychosocial well-being. When surveying CCLS in the NICU, <50% of participants felt fully integrated and visible in the team, especially in the presence of physicians.²⁶  These findings were similarly echoed by other CCLS who responded to the survey by Lookabaugh and Ballard.²⁸  They believed that many members did not see CLS as an integral part of the team. Interestingly, although Wittenberg and Barnhart³³  reported that CCLS and other health care professionals were mostly aligned in their perception of the CCLS role in patient education, play, and normalization of the hospital experience, they found that regular communication between CCLS and the medical team was not perceived to be important by some health care providers. Lastly, Hoelscher and Ravert³²  report that a perceived “lack of respect or understanding of their role” from other medical professionals and hospital staff was the second of 6 most-common perceived causes of CCLS burnout.

All 9 publications of interest mention the value in educating others about child life responsibilities. Although CCLS have clearly defined work roles, their responsibilities continue to expand.²⁸  As a result, despite increased awareness of their responsibilities over the years, misconceptions still exist within the care team.³³  Through education that better articulates child life competencies, others may better understand the depth and diversity of the CLS role.^25–27,32  This can provide better insight into the utility of CCLS,²⁹  increase team support,³²  decrease burnout,³²  and improve staff perceptions and attitudes toward CCLS.²⁷  With increased interprofessional collaboration, CLS can more effectively care for patients and families.^25,30,31 

Most databases did not have a controlled vocabulary term or subheading for CLS. Embase is the only 1 of the 5 databases to have “child life specialist” as an index term. Thus, a combination of other terms and key words were used to fully encapsulate the CLS concept in the majority of databases. This included “child welfare,” “child guidance,” and “pediatric advocate.” Given an increase in publications on CLS, it will be important to designate a heading or term specifically for CLS for these types of reviews. It was found that interprofessional concepts and clinic-setting concepts had adequate terms and subheadings.

The most popular method of gauging perceptions and understanding within the medical team was with a questionnaire or survey distributed through mail or e-mail.^{25,26,28,29,31–33}  Among the groups that were studied, CCLS, nurses, and physicians/providers were the most frequent groups studied. Social work was the next most frequent and was studied in a third of the papers included. Feedback and information from other, unspecified groups only occurred in 2 studies.

A common limitation was that the study was being conducted in a single hospital^25,27,33  or had a small sample size.^28,29,31,33  A few of the studies attempted to address sampling bias in reaching a larger audience by utilizing professional listserves of their respective national societies.^28,29,32  One study included data from 2 hospitals in 2 different locations in the United States.³⁰  However, the studies that do reach a broader audience also experience low response rates, as is common to survey design.^28,29,32,33  Although these studies all individually have their own limitations, taken together, they highlight some consistent themes and considerations for future work.

This scoping review has several limitations that should be considered when interpreting these results. First, although the search was extensive, it is not certain that all literature on this subject was identified, in part because of the lack of controlled vocabulary to represent the concept of CLS. To address this, 5 comprehensive databases were searched, and manual searching was conducted through publication references with the guidance of a medical librarian. Our results are also limited to publications written in the English language. Lastly, this is not a systematic review, so critical appraisal of the results of these papers was not included in the methodology. Inherent to a scoping review, the goal was to survey and summarize available literature. Despite these limitations, a better understanding of CLS, how they are perceived by others, their integration into the interdisciplinary medical team, and directions for future research on overcoming the barriers to optimal utilization of CLS was gained.

This scoping review found 9 articles addressing how CCLS are perceived by members of the medical team in the hospital setting. Although there is a paucity of data available on this topic, thematic analysis revealed that CCLS responsibilities are broad, they have a significant positive impact on patients and their families, and underscored the value in educating others on the roles of CCLS. However, most interestingly, there are challenges to interprofessional collaboration and complete integration of CCLS into the health care team. We hypothesize that this is largely because of a gap in our understanding of the child life profession as a whole. One way we can begin to address this is by incorporating more opportunities that increase exposure and education during the formative years of training across all clinical programs. This may also provide a path to increasing CLS utilization and reducing total hospital and patient costs of treatment. However, further studies are needed to carefully examine the overall cost reduction associated with CLS implementation in various departments.

CLS is a growing profession in the medical field, with expanding responsibilities and scope of practice that add significant value to our hospitals, patients, and families. In an effort to further drive patient and family-centered care, additional research is required to fully understand and overcome the challenges to optimizing their utilization and full incorporation into the interdisciplinary medical team.