Child life services have become a standard in most pediatric hospital settings (Romita et al., 2021). Since child life is a profession composed primarily of women, embedded within the male-dominated medical world, preparing women to establish successful careers in a public service is an important element to promoting growth in this profession. Additionally, fostering leadership and mentorship in child life will help the profession scale with its growth and increase diversity. Despite recent growth in the profession (ACLP communication, 2020), there remains a lack of certified child life specialists (CCLS) able to fill open positions (Heering, 2022). There are a number of reasons for this gap, including delays in training due to COVID-19 (Sisk & Wittenberg, 2021), as well as limited practicum and internship opportunities (Sisk et al., 2023; Wittenberg Camp et al., 2023). Acquiring a child life internship is becoming increasingly difficult (Boles et al., 2024; Sisk et al., 2023; Wittenberg Camp et al., 2023) as more research suggests growing competitiveness in the profession (Tenhulzen et al., 2023). This may also be partially due to a lack of confidence among CCLS when it comes to their abilities to lead and supervise students. Providing CCLS with tools for confidently leading students may help address the current job crisis, supporting the profession’s growth and ensuring children and families receive child life services. Too, accessible tools that increase practicing CCLS’ confidence in their leadership and advocacy abilities may also aid in retention of those already in the profession.
The child life community wants tools for leadership and advocacy. As far back as 1982, researchers noted a lack of training as an obstacle to mentoring pre-service child life specialists (Brown, 1982). More recently, Holley and colleagues (2024) interviewed 13 first-time internship supervisors to explore their thoughts, feelings, and experiences associated with being a first-time supervisor. The participants expressed feelings of nervousness and being ill-prepared in their role, suggesting that a leadership training program would help prepare first-time clinical rotation supervisors. Certified child life specialists are professionals trained to understand the importance of providing pediatric patients with opportunities for education and preparation, in order to increase mastery while decreasing stress, anxiety, and uncertainty (Matthiesen et al., 2024); therefore, these same tenets of tailored education, assessment, and preparedness can tangentially be applied to emerging leaders within child life. With study participants such as Holley and colleague’s (2024) expressing feelings of inadequacy and ill-preparedness due to a lack of leadership training, it is not surprising that an apprehension to train future students has been observed in recent years.
The theory of transformational leadership is well-documented in healthcare literature and can lead to improved staff retention and increased patient satisfaction scores when effectively implemented (Fletcher et al., 2019). This theory encourages a mutually respectful and interactive relationship between leaders and staff, allowing for a team approach in achieving a collective vision (Robbins & Davidhizar, 2020). This type of relationship and training builds confidence, trust, and empowerment among all involved, leading to a healthy environment that transforms individuals’ abilities to voice questions or concerns (Fletcher et al., 2019). Understanding how leadership training, practices, and values such as these trickle down to all levels within a healthcare system, including to students and patients, begins with recognizing that not all leaders have the skills necessary to perform the tasks in which they are assigned (Robbins & Davidhizar, 2020). In an effort to combat this reality and equip participants with the knowledge necessary to thrive as a child life leader, this theoretical approach of transactional leadership underpinned the particular skills this study endeavored to cultivate. Among others, these leadership skills included learning how to clinically lead and supervise others, how to conduct research and engage with scholarly literature, how to transfer child life training to fit a variety of nontraditional settings, and how to improve advocacy skills through an anti-racism lens.
Leadership has continued to be defined in a variety of ways over time (Benmira & Agboola, 2021; Dussault et al., 2013). While definitions vary, most include some aspect of influencing or mobilizing others to reach common goals with some making a distinction between leadership and management and others incorporating definitions that highlight the complementary nature of leadership and management roles (Benmira & Agboola, 2021). In their literature review on the evolution of leadership theories, Benmira and Agboola offer this distinction between the two roles by stating that “leaders are generally viewed as visionaries and strategists whereas managers monitor and control performance, maintaining order and stability in an organization” (p. 3). Professional development tailored to leadership in child life settings can help CCLS in more ways than one. It may help them feel more confident in their skills supporting the professional development of the students they supervise, as well as in “influencing or mobilizing others” (Benmira & Agboola, 2021, p. 3) in regard to the needs of the patients and the families they serve, as well as the profession at large.
Another issue facing the profession is its homogenous nature with 99% of Association of Child Life Professionals (ACLP) members in 2018 identifying as women, and 91% identifying as White (ACLP, 2018). This predominance of the majority culture in the workplace can further contribute to a lack of confidence in speaking out and speaking up for the needs of others (Gourley et al., 2023). Additionally, the profession’s lack of diversity may contribute to microaggressions, the perception of being othered, tokenism, and workplace discrimination experienced by child life students and specialists with historically marginalized identities (Gourley et al., 2022). As a response to the profession’s published commitment to Diversity, Equity, and Inclusion (DEI;ACLP, 2020), the ACLP called for more professional opportunities and monetary support for Black, Indigenous, and People of Color (BIPOC) thought leaders.
Despite publishing calls for this support, some of the ACLP’s current leadership training opportunities still come at a cost to participants, which may limit access. In an attempt to respond to the ACLP’s call, child life faculty at our university designed a free, virtual peer leadership program titled, “Pioneering Leaders in Child Life” (PLCL). The university’s demographics situate the team with a unique position to provide leadership training for child life specialists, with a specific goal to help women advance their leadership skills and experience in pediatric medical settings to prepare them to take on successful roles in advocating for the need for child life, both inside and outside of traditional medical settings. The aim of this program was to provide CCLS with targeted trainings and peer interaction to develop and strengthen their leadership and advocacy skills. The program included a series of workshops featuring child life leaders and peer meetings designed to foster inclusion, networking, leadership, and advocacy. In 2022, the authors received a state-funded grant to launch the first cohort of participants with a targeted recruitment population being those new to the field or new to leadership positions within the field. The first year of the program served 15 CCLS working in the field who participated free of charge. Applicants eligible for participation were women who held a CCLS credential and were employed in the field of child life. Applicants were required to commit to attending four leadership sessions and a minimum of two peer cohort meetings between sessions. Participants received program readings to examine between sessions and reflect upon with their peers in peer cohort meetings. Upon completion of each boot camp, participants received ACLP approved professional development units (PDUs) to be used to satisfy part of their continuing education requirements for certification and complimentary registration to a national or regional conference of their choosing.
The overarching aim of this program was to prepare women working in medical settings to be leaders and advocates for the profession and the children and families whom they serve. Since the medical field remains primarily male-dominated, it is vital that women working in medical settings have access to tools to build their confidence to lead and advocate for the populations whom they serve. This program allowed us to continue to foster leadership after certification has been earned and support a wider population, which will help develop more women leaders in male-dominated medical settings. The program was evaluated for its ability to improve participants’ perceived leadership and advocacy skills with outcomes guiding future programming and research. This paper describes those outcomes of the first year of this program.
The specific research questions include:
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Does participation in PLCL increase perceptions of confidence in leadership abilities?
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Does participation in PLCL increase perceptions of confidence in advocacy abilities?
It was hypothesized that post-test scores would reveal more positive perceptions of participants’ leadership and advocacy abilities.
Method
Participants
To participate in the program, participants had to identify as women, had to currently hold a CCLS credential, and had to be working clinically as a child life specialist in the profession. Researchers emailed a listserv of 192 child life leaders to recruit for this program. Included in the email was a request to forward the email to those who might benefit from the program. Those interested in participating in the program submitted an application detailing their professional goals specific to leadership and advocacy. Applications were blinded and research team members used a rubric to score applications.
Procedure
This mixed methods outcome evaluation was conducted using a pre-test/post-test design to evaluate efficacy of program participation, with open-ended questions offered to allow participants an opportunity to elaborate on their answers. Upon IRB approval, recruitment commenced and pre-test data on perceptions of leadership and advocacy skills were gathered from participants. At the conclusion of the program, post-test data were collected, and comparisons were made between pre- and post-test scores. Collected data also included what participants found most beneficial about the program and what areas could be improved.
Program Development
In an effort to address the leadership training gaps identified by the literature, the researchers developed a plan for a leadership training program targeted at CCLS who were new to the field or new to a leadership role in their program. Funding through the Jane Nelson Institute for Women’s Leadership (JNIWL) was used to support this project. The JNIWL is a state-funded institute that provides opportunities for women to progress their leadership skills via networking, mentorship, and educational programming. These cultivated experiences aim to prepare women to lead successful careers in a variety of fields through subsequent implementation of the newly refined skill sets (About Us: Jane Nelson Institute for Women’s Leadership, 2023).
Program Implementation
The first year of PLCL consisted of 1) four leadership bootcamps lasting three hours each, 2) three peer meetings lasting one hour each, 3) a program orientation lasting one hour, and 4) a program wrap-up lasting one hour (see Table 1). The bootcamps were designed meet the specific needs of emerging CCLS leaders in the profession. Upon offer of acceptance via email, along with a request that they commit to attend all of the scheduled meetings, participants were mailed a welcome package consisting of two books on leadership, a notebook, pens, and stickers as a welcome to the program. The syllabus and boot camp dates were provided via email once they agreed to participate.
The first meeting provided an orientation to the program, introductions of the research team and participants, assignment of small groups, and an opportunity for questions. After participants were oriented to the program and had received all of their items, the boot camps began the following month. Bootcamps were led by established leaders in child life who were paid for their time with grant funds. These leaders were known to the researchers through professional interactions and selected based on their specific expertise in topics related to leadership and advocacy in child life and/or content expertise on their assigned topic. Upon completion of each boot camp, participants received ACLP-approved PDUs for their participation. They also received complimentary registration to the regional or national professional conference of their choice, which was provided at various times depending on when registrations were due. Between each bootcamp, participants met in closed, small groups to discuss the previous bootcamp and how the content related to their professional growth. These small groups were participant-led using a Zoom link provided by the research team.
The Program
The cohort participated in four leadership bootcamps on topics including supervision, research, service, and anti-racism (see Table 1). Bootcamps were held via Zoom and scheduled on Saturday mornings. Participants were all provided with topic specific resources prior to each bootcamp (supplied by the speaker) and each received two books on leadership to assist them in their journey: The Making of a Manager: What to Do When Everyone Looks to You by J. Zhou (2019) and Thrive: The Third Metric to Redefining Success and Creating a Life of Well-being, Wisdom, and Wonder by A. Huffington (2014).
In addition to bootcamps, participants met in small groups of five to facilitate peer discussion on the content covered in the bootcamps and the leadership books provided by the authors. Meetings were participant-led and occurred through Zoom. Table 1 provides a timeline of program activities.
Measures
Quantitative data were collected to examine the efficacy of the program. To assess the program’s ability to improve participants’ perceptions of their leadership and advocacy skills, members completed 26 Likert-scale items of the Leadership Self-Report Scale (Dussault et al., 2013) and 15 Likert-scale items of an advocacy self-report measure designed by authors before and after participation. Due to the lack of an advocacy self-report measure in the literature, the researchers developed their own based on a review of the extant literature. Once developed, face validity was determined by sharing the measure with experts in the profession before deployment. We asked experts in the profession to provide us feedback on whether the items in the survey captured the nuances of advocacy in the child life role and integrated this feedback into the survey. In addition to these pre and post measures, participants completed nine Likert-scale items of a bootcamp evaluation survey after each bootcamp.
In addition to the quantitative data, open-ended questions (Table 2) were included in the pre and post surveys and the bootcamp evaluation in order to gain more insight from participants about certain items. Outcome evaluations such as this often use qualitative methods to add context and detail while quantitative data play the major role in measuring outcomes (Patton, 2014).
Data Collection
Surveys were administered using Qualtrics (Qualtrics, Provo, UT). Prior to participation in program meetings, participants filled out baseline measures. After each bootcamp, participants filled out the evaluation survey of the bootcamp attended. At the end of the program, participants completed their final post-test survey.
Data Analysis
In an effort to answer the research questions posed, pre- and post-test data were examined. Descriptive statistics were computed for the sample. Paired t-tests were used to compare pre-and post-test data to evaluate program efficacy. Additionally, the bootcamp evaluation data were assessed to examine participant satisfaction with each topic and presentation. Finally, answers to open-ended questions from the post-survey examined whether participants felt their goals had been met. Here is an example of a participant’s goals: “My main goals are being more confident in my abilities and knowledge, learning how to professionally speak up, providing constructive feedback in an effective way to peers and professionals in management positions, learning how to effectively delegate tasks.” These answers were thematically analyzed to identify key patterns, themes, and insights related to participants’ self-reported improvements in leadership and advocacy skills.
Results
This program provided targeted professional development trainings to 15 CCLS with the aim of improving participants’ perceived leadership and advocacy skills. Over 100 applications were submitted, and 15 CCLS from across the country were selected to participate in the program. Participants with fewer years of experience in the profession, who were newly appointed to a leadership role they had not held before, and who elaborated on leadership goals in relation to program participation scored highest on the rubric. The top 15 applicants were selected and offered acceptance to the program based on funding.
Among the 15 CCLS who participated, nine identified as White, two as Latina/Hispanic, four as Asian/Pacific Islander, and the mean age of participants was 36 years old (26-54). Members of this cohort had been working in child life for an average of seven years (1-17) at the time the program began. Thirteen CCLS worked at freestanding children’s hospitals, and two worked on pediatric units in a standard hospital. Six held a bachelor’s degree, and nine held a master’s degree.
Results suggest that participation in the program improved participants’ perceptions of their leadership and advocacy skills. Compared to baseline pre-test scores (M = 74.73; SD = 5.84), scores on the leadership measure were higher after participating in the program (M = 81.10; SD = 5.28), t(-4.6) = 14, p < .001. Similarly, compared to the baseline score (M = 43.93; SD = 4.82), the advocacy measure scores were higher after participating in the program (M = 49.26; SD = 6.44), t(-3.98) = 14, p < .01.
Qualitatively, 14 out of 15 (93%) participants shared that they met their own goals for participating in the program. For example, when one participant was asked if they met their goals, they said, “Yes and so much more. I was able to connect with a network of individuals who brought so much more insight and knowledge to my current role and future work.” However, one participant shared, “I did not feel that I had the opportunity to meet peers at my level of leadership or develop further as a leader.”
The theme of increased confidence after participation emerged from the data. Specifically, 8 of the 15 (53%) participants felt more confident in their leadership skills after participation. One participant shared:
I was able to better recognize the needs of others and grow in my communication skills to best find out what my coworkers and staff needed. I grew in my advocacy skills to my team members as well as for my patients and families. I also became better in recognizing my own needs and filling my own cup in order to best support my team and coworkers.
Another mentioned, “I am a more confident leader. It was helpful to learn how to turn my desire to be a leader into actionable skills in doing so.”
In addition to these results, participants reported several positive outcomes while they participated in the program. For example, multiple members of the first cohort acquired promotions during their time in the program. Participants shared that it was beneficial to meet and network with others from different regions and professional settings. One participant shared:
I think the honor of being selected for this class and being part of a diverse group from across the country gave me a confidence boost, so I now see myself as a leader. I have gained perspective and the motivation to continue to seek out leadership roles.
Participants also benefited from attending the 2023 Annual Child Life Conference hosted by ACLP, with many reporting that they would have not attended without the grant’s funding. Last, one participant noted how prior to the program she was experiencing burnout in her role, and PLCL helped her regain her passion and motivation for the profession.
Participants found the cohort design to be the most helpful aspect of the program. One participant mentioned, “The most helpful aspect of the program was having so much different representation-from years of experience to what region of the country we work in. It was helpful to learn from so many people with different experiences and perspectives.” Another wrote:
I really enjoyed the small groups and community aspect of the program. I really enjoyed networking with others and being able to meet many people in person at conference.[…] I feel that I have formed relationships that will last outside of this program. I was also able to obtain a leadership position during this program due to having more confidence in my abilities to lead.
When looking at the bootcamp evaluation data, participants found the bootcamp on clinical leadership and supervision to be most helpful for improving their confidence in their leadership abilities and the anti-racism bootcamp most helpful for improving their confidence in their advocacy skills. Participants were asked on a scale from one to four if the bootcamps were helpful for their general professional growth. The anti-racism bootcamp was most helpful (M = 4, SD = 0), followed by the research and scholarship bootcamp (M = 3.78; SD = 0.44), then the bootcamp on association service and community practice (M = 3.75; SD = 0.43), and last, the clinical leadership and supervision bootcamp (M = 3.53; SD = 0.66).
Participants noted that some of the materials selected were less helpful for their professional development such as the books provided at the beginning of the program. Likewise, participants shared that scheduling the small group meetings was difficult due to the varying schedules of participants. Participants brainstormed solutions to scheduling concerns, and some recommended reconsidering Saturday morning. Participants also provided recommendations for additional topics to consider for future bootcamps such as navigating job transitions and leading difficult conversations.
Discussion
Participants in the first cohort of PLCL experienced improved confidence in their leadership and advocacy skills after participating. Scores on both the leadership and advocacy measures were higher after participating in the program and 14 out of 15 (93%) participants shared that they met their own goals. Participants found the bootcamp on clinical leadership and supervision most helpful for improving their confidence in their leadership and the anti-racism bootcamp most helpful for improving their confidence in their advocacy.
The current job crisis in child life has been previously documented (Heering, 2022), and more leaders are needed to support the growth of the profession. Providing targeted training specific to developing leadership and advocacy in child life can support CCLS’ specific career goals and ensure that the profession can continue to grow. Results from this program evaluation suggest that programs like PLCL could improve CCLS’ perceived leadership and advocacy skills. As mentioned by Holley and colleagues (2024), clinical CCLS who are training students are eager to acquire leadership training and support for their role as a supervisor. Programs like PLCL can provide child life student supervisors with tools for building their confidence working with students, which in turn can support the student-to-professional pipeline.
It is clear from our recruitment efforts that this type of program is highly desired as we received over 100 applications for the first cohort, suggesting there is interest in more leadership and advocacy support in the profession. After engaging in PLCL, participants felt positively about this program and shared that they met their goals for participating. Results suggest that participation in the program improved CCLS’ perceptions of their leadership and advocacy skills. In addition, the program resulted in networking opportunities and social support despite being hosted online.
Participants had valuable feedback for improving the program. Results from participant evaluations indicated that the most helpful session was the one focused on anti-racism with the least helpful session focused on supervision. This was surprising because this finding contradicts literature suggesting CCLS need more training in supervision (Holley et al., 2024) and highlights the importance of programs that focus on broader aspects of leadership and advocacy. While the supervision bootcamp was still well received, it was the session rated as least helpful by participants in this cohort. Future research should continue to explore the specific training needs of CCLS in the profession and what topics are most desired.
When asked what other topics they would like to see addressed, participants indicated topics related to transitioning between roles and leading difficult conversations. Per these suggestions, a bootcamp on how to have difficult conversations in the child life setting to subsequent cohorts was added. Additionally, changes to the schedule and resources provided to participants to further tailor the program to participant feedback were made. Programs that are developed to emulate the PLCL in other states or using other sources of funding may want to consider including five bootcamp sessions in order to allow participants to benefit from training on both avoiding racial bias and having difficult conversations, due to the popularity of the former and the request for more training on the latter.
While the sample of participants for this program evaluation is small, it still provides promising results to help inform leadership efforts in child life. With knowledge about how this program was conceptualized, funded, and implemented, other similar programs can be implemented by other entities in other locations and with other funding streams. These findings also provide information about the topics that were most valued by the participants and which ones may have felt redundant, which can also inform other programs with similar goals. Additionally, the impact and importance of gaining an increased understanding about how leadership and advocacy trainings such as this can benefit CCLS in the profession cannot be overemphasized. As mentioned in the results, one participant shared that she had been experiencing burnout, and the program helped her feel more motivated after completion. Burnout has been well documented in child life literature and contributes to turnover in the profession, impacting the job crisis (Ginter et al., 2024; Hoelscher & Ravert, 2021; Lagos et al., 2022; Tenhulzen et al., 2023). Future programs seeking to emulate PLCL should continue to evaluate their outcomes and explore additional variables such as burnout and motivation.
In addition to the small sample size, other limitations of this outcome evaluation exist and results may need to be interpreted with caution. The lack of an adequate measure of self-perceptions of advocacy abilities required the research team to develop their own. Without psychometrics on this measure, we are unable to provide evidence for its reliability or validity. As an initial step, we were able to gather face validity by integrating feedback from experts in child life into the creation of the survey and future projects can expand on this by determining this measures’ content validity. Additionally, there is the possibility of research bias in the study design and interpretation of results, since each author is a stakeholder in the child life training community and hopes to see the job crisis addressed to support the many child life students needing training placements.
Conclusion
Despite these limitations, the results of this study may inform future research and training programs for CCLS. We are hopeful that programs like PLCL can support the growth of both the profession of child life and those CCLS who work within it. Access to free leadership and advocacy trainings in the child life community ensures that CCLS are able to cultivate their professional growth regardless of their institution’s financial support. As we move into the 2nd and 3rd cohorts for PLCL, we will continue to evaluate the program’s ability to meet its goals of improving participants’ perceived confidence in their leadership and advocacy skills.