Child Life Systems: A Secondary Data Analysis

Child Life Systems: A Secondary Data Analysis

In recent years, researchers have explored the many stressors, concerns, and lived experiences of child life professionals (Ginter et al., 2024a; Ginter, Cahlander, et al., 2024; Hoelscher & Ravert, 2021; Tenhulzen et al., 2023). Certified Child Life Specialists (CCLS) and supervisors alike have reported numerous difficulties in navigating workplace stress and burnout (Ginter, Cahlander, et al., 2024; Ginter, Kegan, et al., 2024; Holley et al., 2024). The authors of this study set out to explore the experiences of CCLS and supervisors via two separate qualitative studies. While conducting the thematic analyses, the authors noted that CCLS and supervisors often spoke similarly about their frustration with hospital systems (e.g., lack of transparency and communication). It was determined that a secondary data analysis, synthesizing the two qualitative data sets, would be useful for further exploration of the lived experiences of CCLS and supervisors. Healthcare researchers are increasingly employing qualitative synthesis approaches (Sattar et al., 2021). The following manuscript describes a secondary analysis of child life systems from the lens of CCLS and supervisors.

Literature Review

Determinants of Workplace Burnout

The causes of workplace stress are complex. Imposter syndrome, itself a multifaceted concept, significantly predicts burnout among CCLS (Ehinger & Bales, 2023; Tenhulzen et al., 2023). Initially, people may find satisfaction and purpose in their work, but as pressures mount, they become consumed by an unrelenting sense of responsibility (Ekstedt & Fagerberg, 2004). In one seminal study, disorganization and ambiguous leadership within individuals’ workplaces often exacerbated these feelings, and they struggled to balance the emotional demands of work and personal life. Many began to derive their identity from their work, and as they lost control, feelings of failure and self-doubt grew (Ekstedt & Fagerberg, 2004).

Nurses and other healthcare providers, when asked to describe what led to their professional burnout, have reported the following: struggling to achieve unattainable goals, perceiving that their patients were not receiving adequate care, and attempting to balance incompatible demands (Ericson-Lidman & Strandberg, 2007; Gustafsson et al., 2010). De La Fuente-Solana et al. (2020) reported that burnout occurs when stress from one’s occupations causes negative effects on an individual and their environment, characterized by high emotional exhaustion, high depersonalization, and low personal accomplishment. They determined that having support from supervisors is crucial to nurses’ job satisfaction, reducing absenteeism, and staff turnover. The roles and functions of the job should be clearly defined, and an adequate work environment should be promoted by reducing overload and providing social support at work. Nurses that are more satisfied with their work will be more equipped to cope with stressors (De la Fuente-Solana et al., 2020).

Self-Care

Martínez et al. (2021) clarified the definition of self-care in a concept analysis as the ability to care for oneself through awareness, self-control, and self-reliance to achieve, maintain, or promote optimal health and well-being. Martin et al. (2020) identified a difference between personal and professional self-care. Personal self-care encompasses practices for health and personal well-being while professional self-care is the process of purposefully engaging with practices that promote an effective professional self (Martin et al., 2020). Martin et al. (2020) determined that self-care could reduce workplace risks such as burnout, compassion fatigue, secondary traumatic stress (STS), and vicarious traumatization. However, the use of only personal self-care risks it becoming superficial, meaning it may temporarily reduce stress but would not improve health or professional well-being. Barriers to self-care were identified as personal/family, not enough time/too many demands, and work-related issues and money (Martin et al., 2020).

Miller (2020) examined the effects of a self-care education course on social workers currently in the field. They conducted a statewide assessment of over 1,000 social workers and found that only a moderate number of professionals engaged in self-care, and social workers new to the field were less likely to practice self-care. After completing the course, there were significant increases in knowledge, skills, value in self-care, and significant increases in self-care practices. The study emphasized that these practices can be applied while students are obtaining their degree, not only after entering the field (Miller, 2020).

Pandemic Repercussions

Many studies have examined the impact of the COVID-19 pandemic on healthcare workers. Pandemic-related stress is correlated with burnout among CCLS (Ehinger & Bales, 2023). Denning et al. (2021) reported that COVID-19 challenges (e.g., adapting to a new method of working, increased demands in services, a feeling of powerlessness to manage patient conditions, and the fear of being infected or infecting someone) may have led to an increase in providers’ professional burnout (Denning et al., 2021).

McCoyd et al. (2023) surveyed 1,472 social service providers surrounding issues related to how COVID-19 disrupted their workplace. Themes surrounding the transition to remote services include a lack of intra-agency guidance, communication and support, a breakdown of community and governmental services and responses, administrative and funding challenges, and social justice implications of organizational breakdown. Implications of the study include that there was a breakdown in communication that put social service providers in a position where they had to learn to adjust to new situations and create solutions to new problems (McCoyd et al., 2023).

Theoretical Framework

Family systems theory (FST) posits that family members are linked to each other via boundaries that determine who is in and out of the family as well as various subsystems within the family (Bowen, 2012). Feedback loops refer to the ways that individuals communicate to each other, how the recipient of a message absorbs that message, and what behavioral modifications they make based on that message. In FST, it is commonly accepted that individuals are not to be blamed for systemic dysfunction. Rather, the locus of pathology is the system itself.

While FST has previously been applied to child life in the context of families who receive child life services (Ginter, Kegan, et al., 2024), an extant search of the literature yielded no articles on the application of FST to the child life profession. Arguably, FST’s exploration of boundaries, feedback loops, loci of pathology, and subsystems is relevant to social groups beyond families. Jakimowicz et al. (2021) analyzed how FST might be a useful framework for supporting critical care nurses, concluding that the theory’s emphasis on not blaming individuals for systemic dysfunction may be especially relevant to supporting providers. In this study, FST informed our thematic analysis, as we noted the commonalities between specialists and supervisors, as well as the systemic dysfunction of hospital systems.

Methods

Primary Data Sets

Data for the secondary data analysis come from two separate studies: the first, on the perspectives of early career child life professionals (Ginter et al., 2024). That study comprised 19 telephone interviews with currently and formerly practicing CCLS about their experiences navigating workplace stress and burnout. The second study was an online mixed-methods study. The open-ended questions garnered responses from 12 CCLS supervisors. For both studies, participants were recruited via child life-oriented listservs and social media. The second study has not previously been published.

Reflexivity and Data Quality

For qualitative research, reflexivity is an essential component of the process. There is potential for bias in how findings are interpreted and synthesized, especially when the second author of this study was also the PI for the original studies. Credibility was sought by working with peer debriefers, who reviewed the manuscript after the secondary data analysis was complete. Another mechanism for achieving credibility is by including rich, detail-laden descriptions of participants’ experiences (Morrow, 2005). The authors included such descriptions in analysis and manuscript preparation. To mitigate confirmation bias, the authors sought feedback from a peer debriefer (trained in qualitative methods, yet outside the field of child life) to review their audit trail. The peer confirmed that the methodology and resulting themes were logically linked.

Secondary Data Analysis

Ginter et al. (2024) addressed the experiences of child life professionals in the workplace, specifically regarding burnout. The authors were working on a study on child life supervisors’ burnout experiences and recognized these two studies may have commonalities between them. The researchers decided it would be beneficial to compare and contrast the two studies through a secondary data analysis. The primary research question for this study was: How do CCLS and child life supervisors conceptualize their own roles and each other’s roles in mitigating burnout? The researchers began by reviewing the two studies’ respective datasets. They independently read the transcripts and noted meaningful concepts. The researchers created their own codebook of common themes found in both studies. They used Ryan and Bernard’s (2003) scrutiny techniques to identify themes across both studies. The most used scrutiny techniques in this study were repetitions, similarities and differences, and theory-related material (family systems theory) (Ryan & Bernard, 2003).

The researchers compared their codebooks to look for commonalities and differences. They put their themes side by side to compare them. When they saw a similar theme, they created a reconciled theme to encompass both ideas. For example, one researcher created the theme “COVID context” while the other created the theme “COVID.” This was reconciled into the theme “COVID exposed fault lines of existing system failures.” When differences were identified, the researchers discussed their thoughts on the differences until a consensus was made on whether the theme should stand on its own, be encompassed by another theme, or included as a subtheme. For example, one researcher had the theme “causes of burnout” while another researcher created the themes “short staffed, covering other units, overworked, and underpaid.” This created the theme “Locus of pathology is systemic” with the subtheme of “feeling disregarded.” The researchers continued this pattern until all themes were reconciled.

The researchers reconciled the themes between their codebooks and determined six themes and two subthemes. The reconciled themes are: COVID exposed fault lines of existing system failures; locus of pathology is systematic with a subtheme of feeling disregarded; the specialist-supervisor subsystem is uniquely challenged; permeable boundaries lead to confusion and dysfunction; supportive systems outside the hospital are a protective factor with a subtheme of the healthcare team; and feedback loops and communication about burnout signs, effects, and protective factors (self-care). The researchers determined there were similar themes within both studies and found these themes to be relevant in both studies.

Results

Two qualitative data sets were used for this secondary data analysis: a study on 19 child life professionals (collected in 2022) and a study on 12 child life supervisors (collected in 2023). In the first study, all 19 participants identified as white women. On average, they had begun their first CCLS position 2.75 years prior to their interview. In the second study, the supervisors had spent on average 7.3 years in a supervisory position. Table 1 presents the six themes identified through the secondary data analysis, along with their descriptions, frequency counts, and exemplar quotes.

COVID Exposed Existing System Failures

This theme describes how the pandemic exacerbated issues child life specialists were already facing. However, with the addition of the added stress of the COVID-19 pandemic, these challenges were further exposed within the healthcare system. One specialist noted the systemic changes of the hospital environment:

As COVID progressed and that second wave came in like 2020 and we had the nursing shortage, that was definitely a stressor on the hospital in general and because they started paying so much to staff, to start picking up more extra shifts and they were giving such high bonuses to travel nurses that left no money really for a lot of other things. A lot of programs that benefited patients and families that the child life team was involved in were cut. A lot of our, in fact, all of our child life PRN or Per Diem staff were, their positions were cut indefinitely. And so, we had less staff, child life staff available, and so that left the rest of us to cover more.

Another specialist voiced how the pandemic affected finances within the hospital:

I think the way that COVID impacted it was putting additional stressors on the institution so that made money tight, so that impacted my areas of burnout, when the institution doesn’t have money to pay me, I feel burnt-out. But also when my institution doesn’t have money to provide the best possible care for patients, that also bothers me. And COVID definitely hit the institution financially.

One supervisor explained how their role during the pandemic affected their overall wellbeing:

During the pandemic, while supporting my team to navigate all the challenges that arose during such an unusual situation, I listened and supported them as they experienced tremendous distress and failed to recognize that I was burning out. It was one of my team members who recognized it and spoke with me about her concerns. If she had not done so, I feel certain that I would have continued to spiral until I left my position and the field. I reached out for support and am in a much better place now.

Locus of Pathology is Systemic

This theme describes how child life specialists felt they needed more support from their supervisors, while supervisors felt they were unable to push certain issues with upper leadership because of rules in place or other issues that were occurring at the time. Supervisors felt their hands were tied, while specialists felt they were unheard, leading to the subtheme of feeling disregarded. One specialist said:

I’m very burnt out of the hospital as a business thing. Everything the hospital does is very geared toward how we can make or save money and that doesn’t always mean the best outcomes for our pediatric patients. A lot of times we do what is fastest, not necessarily what’s best for the patient so I get really burnt out too with constantly having to advocate for patients and families when I feel like I just have a whole set of values and morals that [the administration] doesn’t understand because they don’t have our education.

Another specialist commented on their perception of upper management regarding child life:

Conversations have been had with upper management like our direct supervisor and then our department director and like the VP that’s over us then. From what I understood from those conversations that there was empathy but there was no real solution to solve the problem, with that there is no change in salary yet the needs that the people were looking for when they were leaving, they weren’t met and so that’s why they left.

One supervisor discussed the difficulties of working with leadership as well as the child life team:

Being a CL supervisor is incredibly lonely based on the pressures from upper leadership and our CL staff thinking we are making decisions not in the best interest of them, but often times it is just doing what upper leadership have told us to do (with very little choice from us).

Feeling Disregarded

The subtheme of feeling disregarded refers to how both specialists and supervisors felt unheard and dismissed in their roles within the healthcare environment. Two specialists noted about upper management, “… just more acknowledgment from upper management outside of my direct manager that they see how hard we’re working, and that, you know, they acknowledge what we deserve.”

A second specialist commented about their perception of how clinicians viewed child life versus administrators: “In general, child life specialists are highly respected at our institution from clinical providers, but not necessarily administrative providers who don’t like, the administrative side of [hospital] don’t value our work like the doctors and the students and everyone does.”

One supervisor commented on their view of specialists as a whole, “I feel that majority of CCLSs that are not being well supported feel increased amounts of burnout because they are not provided a global perspective or validation of their feelings.”

Specialist-Supervisor Subsystem is Uniquely Challenged

This theme describes how both specialists and supervisors felt they were navigating their professional relationship with each other and setting boundaries.

When asked to describe boundary setting with her supervisor, one specialist explained: “So it’s a little different because she was my supervisor as an intern as well so we went from her being my intern supervisor to being her colleague to her being my supervisor again,” This statement underscores that in a relatively small field, a specialist and supervisor may come in contact with one another repeatedly and in different roles. The specialist went on to say, “… I’m very opened with talking about my mental health and how that relates to my work, so we do talk about stuff like that.” This specialist viewed the more permeable boundary as a positive: “I think we have a very good relationship in that regard.”

Sometimes, participants noted that the supervisors had difficulty moving from a CCLS position to a supervisory role. One specialist reflected, “I think just some [have] trouble integrating to a higher role and what those boundaries look like.” Another specialist described challenges with their supervisor:

She will now admit it to people that we talk to but she herself will say that like she was in like extreme burnout when I started and because I have a natural kind of personality to want to lead things, I am very organized and all of those things we naturally just like butted heads a lot when I started the first two months but like she has now kind of is starting to come out of that burnout, is taking better care of herself, and so now our relationship is improving.

One supervisor commented on how they have observed burnout throughout their whole child life team: “It’s cyclical and it seems to spread throughout a team quickly so you are dealing with people in mass experiencing it, likely due to systems and life challenges. It’s differently challenging when it’s one person vs many at once.”

Permeable Boundaries Leads to Confusion and Dysfunction

This theme describes how not setting clear boundaries initially can lead to building confusion within a child life team, therefore causing dysfunction over time. One specialist noted their perception of what affects burnout:

I’ve seen a trend at hospital specifically, where a lot of the burnout comes from doing things, that’s not necessarily in our job description but might not be \direct patient support interventions assessments the things that we all get excited about doing that we were trained to do.

A second specialist discussed how she felt boundaries were broken: My supervisor went through a really tragic experience with her [family member]…. I think a lot of us always try to give her the benefit of the doubt because of her personal experience, which to a certain point we’re like okay, this is also our work environment, we can’t let that interfere with our lives either so it was like a kind of a hard balance to deal with that.

Although supervisors also spoke about the need for maintaining boundaries, their comments frequently focused on setting boundaries between work and home. The following quote exemplifies this: “I encourage boundaries early, creating boundaries and knowing your limit is the most important step in preventing early burnout.” Similarly, another supervisor reflected: “I mean, having good boundaries for sure and finding your people.” Only one supervisor acknowledged the need to set boundaries between themselves and others: “Setting boundaries with staff” was offered as a suggestion to other supervisors for protecting against burnout.

Supportive Systems Outside the Hospital are a Protective Factor

This theme describes how the supportive relationships outside of work and across the entire healthcare team created impactful experiences and were essential to continuing care. One specialist commented on how outside support was beneficial to their wellbeing:

One of my best friends is in grad school for occupational therapy, and so she sees a lot of the similar things with the kids that she works with in her clinicals and things, and I’ve always been able to talk to her and like troubleshoot when I’m frustrated about anything because she is kind of going into a similar field and so I’ve always been able to like call her up and be like this.

One supervisor mentioned the importance of having someone outside the field of child life to talk to about their experiences, “Practice self care even when you think you don’t need it. Have someone within the profession and outside the profession to talk to; to process with.”

Healthcare System

This subtheme describes the different ways in which the healthcare team supported specialists within the healthcare environment. Three specialists commented on those who supported them on the healthcare team, “They highly regarded my opinion. I was asked by staff on a daily basis for input and support. And my biggest goal was to coach staff on how to help kids with coping.” A second specialist noted a doctor that saw the value of child life, “I literally have one doctor who won’t do anything without me.” A third specialist discussed how they felt like a highly regarded member of the team, “So I think the ER, the PICU even radiology I feel like they’re more in favor of child life than they really look at us as a really important member of the care team.” One specialist explained how they viewed their position in relation to their own team, “I felt like I could advocate for my place in the room when it came to the health care team as whole. What I didn’t expect was having to advocate for myself within the child life team.”

A supervisor discussed the conversations they have with new specialists when they are entering the field:

I talk about the importance of self-reflection and discussing the challenges of the role. We often keep it inside often because we have been made to believe we are weak if we ask for help. I remind them that if there is something they can’t leave at work or leave behind to support other families, it is something that needs to be discussed.

Feedback Loops and Communication

Participants described the perception that only small, ineffectual changes are being made. One specialist commented on the subjectivity of self-care, “Because I think right now the answer people are giving is self-care and that’s just not helpful for most people.”

One specialist noted how discussions of burnout and boundaries would benefit child life, and wished that a supervisor might say the following to someone experiencing burnout:

I understand if we need more team, like, like what do you call those? Team building things. Whatever we can to do, to support, their mental health, I think those are important things that need to be coming from supervisors.

One supervisor commented on the importance of setting boundaries:

You have to take your lunch break. Full 30 minutes or whatever time is allotted. Away from your desk / area of work. Leave and arrive on time. Try to stay later as minimal as possible. Find a project or role that inspires you to do responsibilities outside the day to day patient facing interventions. Take your PTO / holidays and don’t feel guilty about it.

A supervisor discussed how trying to request support from upper management to improve working conditions contributed to their burnout:

I’ve experienced work-related burnout from August 2021. During this time, we had a spike in patient admissions and remained consistent throughout 2022. During this time, there felt like a lack of support from administration requesting for additional child life staffing. Other child life units had different schedules than our ED unit. We had requested changes in our weekend rotation and provided input for additional staff hires, which were denied and ignored. Lastly, our department was due for a salary review, which were postponed until December 2022 as other [non-CL] staff members were receiving bonuses or increase salary raises system-wide.

Discussion

The authors identified six themes in their secondary data analysis of child life specialists and supervisors: COVID exposed existing system failures; locus of pathology is systemic (subtheme: feeling disregarded); fraught specialist-supervisor subsystems; permeable boundaries lead to confusion and dysfunction; supportive systems (subtheme: the healthcare system); and multitudinous feedback loops and communication.

Previous research determined that the COVID-19 pandemic had a profound impact on all healthcare workers, including new challenges such as increased demand, feeling powerless, moving to remote services, administrative challenges, and organizational breakdown (Denning et al., 2021; McCoyd et al., 2023). This previous research determined these factors to be positively related to burnout (McCoyd et al., 2023)

These experiences were reflected in both CCLS and supervisors in this study. They emphasized the challenges that came with changing hospital rules and restrictions, increased stress, the nursing shortage, cutting patient and family-centered care programs, lack of available finances, and lack of overall morale. Multiple child life staff members perceived these challenges to be related to their own or coworker’s burnout. CCLS would seek support from their supervisors, but supervisors felt they could not push upper leadership, leaving both supervisors and specialists feeling disregarded. These larger systemic issues were not a priority during the pandemic as hospitals were focused on the immediate needs that resulted from the pandemic. Specialists felt hospitals were running as a strict business, gearing their energy towards saving and making money, and putting less emphasis on what is best for the patients and their families. Specialists felt other members of the healthcare team did not value their knowledge, including administrators that could not directly see the effects of their interventions. Child life staff was left to cover additional units, spreading their bandwidth even thinner. Even if conversations with upper management were happening, there were no real solutions to these problems. Peer-reviewed scholarship has addressed the singular experiences of specialists and supervisors (Ginter et al., 2024; Hoelscher & Ravert, 2021; Holley et al., 2024). Using a secondary data analysis helped us employ a systemic and synthesized analysis of specialists and supervisors’ experiences. Family systems theory was an effective framework for organizing the data across specialists and supervisors, underscoring that both families and workplaces comprise multiple individuals who are in constant (if not always effective) communication with one another about their needs and concerns.

Limitations

There were multiple limitations in this study. One, the participants of both studies were primarily white women. While the samples are representative of the field at large, it is also known that CCLS with historically marginalized identities may experience hospital settings and child life work differently (Gourley et al., 2022). Future research should use purposive sampling to learn more about supervisors with other identities. Second, aside from time spent in the field, other demographics were not collected. This was due to participants’ concerns about their privacy being protected. Given that child life is a relatively small field, we elected not to collect additional, potentially identifying information.

Implications for Practice

In this study, specialists reported feelings of burnout, particularly due to taking on additional responsibilities outside their scope during the pandemic to help mitigate gaps in patient care. This contributed to significant feelings of stress and a sense of role confusion. These feelings were further exacerbated by a perceived lack of support from supervisors and upper leadership. Child life supervisors reported perceiving themselves to be in the middle, feeling separated from the rest of their team because it seemed as if they were not making decisions in their best interest paired with the additional pressures from upper management. This disconnect fostered a sense of isolation among supervisors and contributed to a breakdown in communication and trust within child life teams. Both specialists and supervisors reported recurring dysfunction, where unclear expectations and lack of support seemed unresolved and cyclical. This cycle emerged as a pattern of a broader systemic issue. Participants described upper management to have a lack of established role boundaries, decreasing overall morale and leaving both specialists and supervisors feeling disregarded. This lack of structural change contributed to the impression that the system was not responsive to the needs of child life roles. As a result, some professionals left the field, further reducing staff capacity and increasing the workload for those who remained in the field. Child life programs need to prioritize clear role descriptions, establish definitive boundaries, and create ways for upper leadership to receive feedback and address all concerns. Without these systemic changes, the cycle of burnout is likely to continue, affecting specialists, supervisors, and ultimately, the patients they serve.

Conclusion

The findings within this study point to systemic issues, including unclear boundaries within roles, lack of recognition, insufficient communication across organizational levels, and inadequate support from hospital leadership. These negatively affect both morale within teams and retention of employees. Success in overcoming these challenges hinges on hospital administrations’ commitment to continuous social support, rewarding team accomplishments, and building a sustainable workforce.