A Content Analysis of Professional Literature in Child Life Focus : 1999-2019

Certified Child Life Specialists, as both consumers and producers of research related to the care of children and families in duress, have relied upon Child Life Focus as a source of evidence-based practice since its inception in 1999. However, this resource has not yet been comprehensively examined with respect to trends in authorship, content, format, or alignment with the foundational principles of the child life profession. The purpose of this content analysis was to identify the characteristics of Child Life Focus articles published be-tween 1999 and 2019 to inform future individual, departmental, and organizational efforts to establish the child life profession as an emerging field. Using a deductive coding scheme, two researchers independently coded 82 articles that met inclusion criteria; all discrepancies were resolved through additional review and consensus meetings. Results demonstrate opportunities for collaboration to generate diverse article content, increase congruence with the Child Life Certification Exam Content Outline, and support developing Certified Child Life Specialist clinician/researchers. Although growth is apparent over the two decades included in this study, more work can be done to increase child life scholarship in academic, clinical, and administrative domains. The types of evidence used to inform professional practice across health and education fields is varied.

The types of evidence used to inform professional practice across health and education fields is varied. Although evidence-based practice in established professions privileges scientific research, recognition of practitioners as both consumers of and contributors to research and scholarship can be located across articles published in both academic and professional journals (original research; review articles; clinical case studies; clinical trials; perspective, opinion, and commentary; book reviews). In the still-emerging child life specialist profession, reliance on several forms of practitioner contributions is essential in order to establish interest and momentum for writing and research. As reported by Boles and colleagues (in press), there has been a consistent increase in peer-reviewed publications by and about child life practice since 1998. However, notable trends indicate an absence of authors holding the Certified Child Life Specialist (CCLS) credential as well as limited content concentrated on the spe-cific assessments and interventions of Certified Child Life Specialists within medical and psychosocial care teams.
Although perhaps not present in indexed, peer-reviewed publications, a body of child life practitioner scholarship with a focus on identifying, describing, and presenting evidence of the work of the Certified Child Life Specialist does exist and can be found in textbooks, chapter contributions in related texts, published conference proceedings, and professional publications such as the Association of Child Life Professionals' (ACLP) ACLP Bulletin and Child Life Focus. Although each of these publications signify a notable contribution, the collection of work published in the peer-reviewed Child Life Focus is the indicator of interest for this content analysis research study. According to Little and colleagues (2011), "Content analyses are deemed important in a profession because of the necessity for evidence-based practice and as a barometer on the current status of the profession" (p. 570). Yet little has been done to systematically analyze the characteristics and contents of Child Life Focus as the primary professional publication of the child life profession. Therefore, this paper describes the contributions found in Child Life Focus since its inception, drawing attention to the importance of the child life practitioner-author in forming the foundations of child life literature required to ground the professional identity and work of child life practitioners.

Literature Review
A body of professional literature in any field accumulates over time as a discipline develops, defines roles and functions, prescribes processes for preparation, establishes regulations, creates systems for evaluation and accountability, and receives recognition as a distinct phenomenon. As just one of the potentially defining elements, a valid body of knowledge and expertise provides documentation of the progress and expansion towards becoming a recognized profession (Saks, 2012). Due in part to the relatively recent rise of child life, literature about the chronology of child life professional literature is just beginning. Therefore, the need to look to a related profession for a model of progressing scholarship is necessary; to this end, literature chronicling the development of scholarship in the field of school psychology is presented, followed by an overview of child life professional literature to date. School psychology, as a developing profession and discipline of study, provides an informative and applicable model for interpreting the research contributions of Certified Child Life Specialists. Similar to child life, school psychologists adapt established psychological and developmental theories for application in school settings, typically working in conjunction with multilevel and multidisciplinary teams to assess and provide interventions for children and their families.

Development of Professional Literature in School Psychology
Professional literature in school psychology dates to the later half of the twentieth century (Floyd et al., 2011). Accounts of this development (Fagan & Wise, 2007, cited in Floyd et al., 2011Runge & French, 1999, cited in Floyd et al., 2011 indicate progress starting from a presence of school psychology literature in books, psychological and educational pub-lications, and eventually journals devoted to school psychology, starting with the Journal of School Psychology in 1963 (Floyd et al., 2011). Floyd and colleagues' (2011) analysis identified rapid growth in employment demand, practitioner preparation needs, and expansion of services as factors enabling the expansive growth of empirical publication outlets for school psychology scholarship. In addition, their application of content analysis methods to publications in the field of school psychology has allowed examination of trends and publication patterns, productivity and impact, author affiliation, and content compatibility with professional standards.
Aligned with the purposes of this article, Floyd et al. (2011) reported results of a review and classification of all articles in nine school psychology journals in a single volume year (2007). Articles coded were categorized as quantitative, qualitative, or narrative; also included were test reviews, book reviews, commentaries, and editorials. The authors reported high variance in the number of issues published each year by journal, noting that many published themed issues, and most articles were research articles, few of which were qualitative. Precedent for the inclusion of content such as news or updates related to the profession was not observed; however, one journal in the study included narrative review articles exclusively (i.e., did not report the results of qualitative or quantitative studies, but cited published research). Quantitative research using varied research designs and drawing causal inferences was noted as an indicator of progress in the field. However, the coverage of a single year, as seen in this study, does not capture any changes in editorial and publication approaches across time.
A study by Caroll and colleagues (2009) of four major school psychology journals published between 2000 and 2008 was extended by Aspiranti et al. (2018); they conducted a content analysis of the same four school psychology journals as Carroll et al. but covered the years 2009 through 2015. The findings of Aspiranti et al. (2018) were consistent with those of the Caroll and colleagues (2009) study: Aspiranti et al. identified limited contributions to the evidence base by clinical practitioners compared to university affiliated authors; the proportion of university affiliated authors increased over time compared to clinical practitioner authors; further, clinical practitioners were suggested as more likely to collaborate in their research endeavors and thus participate as secondary authors. This gap between the research produced in a controlled academic environment and clinical practitioners working in the field was viewed as a barrier to implementation of interventions. According to the authors, " [T]o bridge the gap between university and practitioner authors, it becomes increasingly important for practitioners to not only be responsible consumers of research but contributors as well" (Aspiranti et al., 2018;p. 172).
The content from the model of training and practice for school psychology of the National Association of School Psychologists was used to create a content analysis scheme by Little et al. (2011). In recognition of the practitioner as a consumer of professional literature of school psychology publications, a study of the alignment of the content of one journal, School Psychology International, over a 22-year period (from 1990 to 2011) was undertaken. Eleven categories for research articles, plus a category of "other" (descriptive, not practice oriented), were recorded. Consistent with Carroll et al. (2009) and Aspiranti et al. (2018), most authors in the 671 articles reviewed by Little et al. (2011) were university affiliated. The most frequent article type observed was "other" (33.1%), which notably was the default category for coding content that did not fit within the research-oriented categories. The second most frequently coded category was legal, ethical, and professional issues (21.3%) followed by prevention and responsive services (16.4%). Regardless of the lack of correspondence observed between article content and the categories identified by the National Association of School Psychologists, this content analysis of an international journal nonetheless helped to improve understanding of trends in school psychology practice and research. However, the expectation that publications would comprehensively reflect all areas of the school psychology field was not met; Little et al. (2011) asserted that the link between research and practice is important to the provision of evidence-based practice in school psychological services.

Development of Professional Literature in Child Life
Child life is often described as a young and growing profession. Recognised as a formal entity in 1982, the separation from the Association for the Care of Children's Health allowed the child life working group to unite practitioners and begin the work to establish a new profession (Turner, 2016). Communication with members, a key factor in building a group identity, progressed from the Child Life Council Newsletter into Child Life Council Bulletin and in 1999 included a peer-reviewed insert, entitled Child Life Focus. The advancement to include peer review opened the door for then Child Life Council members to step into roles as authors, researchers, and editors (Turner, 2019). These developments required enormous efforts by an initially small group of visionaries and volunteers who gave their time and expertise to elevate the place of Certified Child Life Specialists in health care.
Over its twenty-year existence, the Child Life Focus collection has served as a catalogue of the progress made toward achieving the necessary indicator of a profession: an established body of professional literature. However, this established body of research has not yet been systematically analyzed. Therefore, the purpose of this study was to highlight, document, and describe Child Life Focus content with attention to the lead author characteristics, article content characteristics, and Certified Child Life Specialist first-author contributions to the child life professional literature. This analysis reveals opportunities for continued efforts to acknowledge the value of practitioner-author contributions to the professional literature and evidence-based practice and innovation within the child life profession.

Method
The purpose of this content analysis was to characterize articles published in Child Life Focus between 1999 and 2019 to highlight opportunities for continued growth, development, and support of the emerging child life field. Content analysis, as a methodology, was chosen for this study due to its longstanding use across academic disciplines and flexibility to accommodate the specific goals, interests, and theoretical orientations of various research endeavors (Hsieh & Shannon, 2005). Although content analysis can be used to code, categorize, and develop themes from qualitative data, the term is also inclusive of strategies used to order and classify nominal data-such as the authorship and content characteristics of articles published in Child Life Focus between 1999 and 2019.

Sample
This study included all articles published in Child Life Focus between 1999 and 2019. The Anthology of Child Life Focus (Child Life Council, 2009) served as an archive of articles published between 1999 and 2009, and later articles were obtained from the ACLP Bulletin/Child Life Focus archives housed within the ACLP website (www.childlife.org) as an exclusive member benefit. Each year, with the exception of 1999, in which only two issues were published, a total of four issues of Child Life Focus were published, each typically with one feature article. However, upon initial review it was determined that some issues contained one feature article followed by related or complimentary articles. A decision was made to include only the feature articles for the content analysis, as these were most consistent with the submission guidelines posted by Child Life Focus. This resulted in a total sample of 82 articles for inclusion in this analysis.

Coding Procedures
Both authors independently accessed the Anthology of Child Life Focus and archived ACLP Bulletin/ Child Life Focus publications. The authors developed a deductive coding scheme and generated a shared codebook (see Table 1). Using the codebook, each author independently reviewed and coded all articles included in the sample. Once individual analyses were completed, both authors entered their codes and any associated notes (including details for each article to support decisions around coding) into a shared spreadsheet. All discrepancies were again independently reviewed by both authors; differences that remained after this round of review were discussed, resulting in a clarification of the coding definitions, elimination of unnecessary code categories, and collapse of related code. Following this process, 100% inter-rater agreement was achieved.
Each included Child Life Focus article was coded along two dimensions. First, author characteristics (highest level of education completed, Certified Child Life Specialist certification status, and affiliation) were recorded as observed in the article byline. Second, the characteristics of the article were observed and coded as described below.

Type of Article
The following definitions were applied: "research" articles, either qualitative or quantitative studies, presented typically following a literature review, methods, results, discussion, and conclusion format; "descriptive" articles presented an account of a concept, practice, program, or initiative; "evidence-based practice" and "article reprint" status was identified as such in the article header; and "literature review" included articles presented as systematic reviews or critical reviews.

Child Life Domain
The coding for child life domain was constructed using the Child Life Professional Certification Exam Content Outline (Child Life Certifying Commission, 2019), which presents an integrated and comprehensive overview of professional practice competencies. Domain I, "Professional Responsibility"; Domain II, "Assessment"; and Domain III, "Intervention" were coded in accordance with the competencies described in this exam outline document. Further sub-coding of each child life domain was completed to further delineate characteristics of the article content.
Professional Responsibility. In cases where "professional responsibility" was the domain identified, the article was further assigned an additional code based • practice within the scope of professional knowledge and clinical expertise (scope) • engage continuously in self-reflective and evaluative professional child life practice (engagement) • collaborate and communicate effectively as a member of the care team (collaboration) Assessment. In cases where "assessment" was the domain identified, the article was further assigned one of five domain sub-category codes and includes: • identify and apply relevant health care data to develop a comprehensive assessment and care plan (relevant data) • identify and apply developmental frameworks to develop a comprehensive assessment and plan of care (developmental frameworks) • identify and apply knowledge of family systems to develop a comprehensive assessment (family systems) • identify and apply cultural and contextual factors to develop a comprehensive assessment (culture) • demonstrate assessment strategies and processes (strategies) Intervention. In cases where "intervention" was the domain identified, the article was further assigned an additional domain sub-category code based on the type of intervention present in the article (as described in the Child Life Professional Certification Exam Content Outline; Child Life Certifying Commission, 2019).

• play • education
• coping support related to grief and loss (coping) • adaptation of child life skills to support diverse populations (adaptation) • emotional support (including environmental safety, emotional safety), and communication and relationships (support) • Communication and relationships (communication)

Data Analysis Procedures
Codes were analyzed using Statistical Package for the Social Sciences (SPSS), analytic software used across disciplines and professions to interpret numerical data. Codes were assigned numeric entities, which were entered for descriptive analysis using IBM SPSS Statistics Premium Campus Edition V26, thereby allowing quick and accurate calculations of proportions and frequencies.

Results
A total of 82 Child Life Focus articles were included for analysis. Descriptive statistics and crosstabs provided a general overview of characteristics of the first author, article content characteristics, and child life practitioner-author contributions.

First Author Characteristics
Certified Child Life Specialists made up 61% (50) of the first authors. Two health play specialists were noted, eight were coded as "other," and 22 article bylines did not include credentials. Therefore, 32 (39%) of first authors were designated as non-Certified Child Life Specialists. Most first authors were identified as holding a degree at the master's level and included Master of Arts, Master of Science, and Master of Education (42; 51.2%). An additional 17 (20.7%) held a Doctor of Philosophy. Additional educational credentials represented include bachelor's degree (5; 6.1%), registered nurse (3; 3.7%), medical doctor (1; 1.2%), miscellaneous degrees (7; 8.5%), and seven (8.5%) did not include education level in the byline.
Author affiliation was also determined from byline content: 45 (54.9%) of first authors were Certified Child Life Specialist practitioners, five (6.1%) were academic/researchers, and 31 (37.8%) were coded non-Certified Child Life Specialist affiliation; one Certified Child Life Specialist did not include information on affiliation. Three Certified Child Life Specialist practitioners and two Certified Child Life Specialist academic/researchers held a doctorate level degree. Thirty-one of the Certified Child Life Specialist practitioners held a masters level degree (68.8%).

Child Life Focus Article Characteristics
Characteristics of the Child Life Focus articles were categorized in two ways. First, the type of article was coded with the following results: 49 of the articles were of a descriptive format (59.8%), 17 were research (20.7%), nine were reprints (11%), four described evidence-based practice (4.9%), and three were literature reviews (3.7%). Second, articles were coded by child life content domain; intervention was identified in 47 (57.3%), professional responsibility in 30 (36.6%), and Assessment in 5 (6.1%) of Child Life Focus articles. Type of article was further explored by child life content domain (see Table 2).

Certified Child Life Specialist First Author Contributions
The majority of first authors were Certified Child Life Specialists, held a master's level education, and were working as practitioners in health care or community settings. The majority of the 50 articles authored by Certified Child Life Specialists were descriptive (38; 76%), and only five (10%) research articles, four (8%) article reprints, and three (6%) literature reviews were observed (see Table 3).
Twenty-seven (54%) articles were coded as intervention, 20 (40%) as professional responsibility, and three (6%) as assessment. Figure 1 illustrates the frequency of domain sub-categories coded for each domain. Education (11), engagement (10), and adaptation (9) were most frequently observed across the 50 articles with the first author identified as a Certified Child Life Specialist.

Non-Certified Child Life Specialist First Author Contributions
First-author contributions without a CCLS credential identified in the article byline accounted for 31 (37.8%) of the articles reviewed in this study (see Table 3). Figure 2 illustrates the frequency of sub-categories coded for each child life content domain. The majority (64.5%; 20) of the articles were coded intervention with play and education being the most frequent (6 each) intervention sub-categories observed, followed by adaptation (5).

Discussion
The purpose of this content analysis was to identify the characteristics of Child Life Focus articles published between 1999 and 2019 to inform future individual, departmental, and organizational efforts to establish the child life profession as an emerging field. This body of child life scholarship with a focus on identifying, describing, and presenting evidence of the work of the Certified Child Life Specialist is recognized as a foundation of professional literature and signals the ongoing engagement so necessary for the further development of knowledge and expertise unique to the profession.

Figure 2 Non-Certified Child Life Specialist/Other First Author Contributions by Domain and Domain Sub-Category
The majority of first authors were Certified Child Life Specialists trained at the master's degree level. In contrast to the findings from school psychology research, the majority of first authors observed in this study were clinical practitioners; few authors were affiliated with universities or trained at the doctoral level. This is not surprising given the relative youth of the child life field, since its formal inception was in 1982, and the lack of academic training opportunities for Certified Child Life Specialists beyond the master's level.
One benefit of this content analysis of Child Life Focus authors is clearer recognition of the contributions of Certified Child Life Specialist practitioners to the growing foundation of child life literature. As the field has grown, so too has its scholarly foundations; at the end of 2018, ACLP reported 6603 Certified Child Life Specialists, an increase of 22% over the past 5 years (ACLP, 2019). The potential for ongoing engagement of practitioner-authors in the production of professional literature is promising and calls for innovative and collaborative approaches to building a valid research foundation on the professional responsibilities, assessments, and interventions of the Certified Child Life Specialist.
Notably, child life practice and program descriptions were most evident across the articles included in this sample, as compared to other types of articles. These descriptive pieces covered a range of topics, the majority of which focused on child life interventions (as opposed to assessment techniques or topics in professionalism). Although anticipation of a greater proportion of research articles was high, the results of this analysis indicate a dearth of research specifically produced by Certified Child Life Specialists; in fact, the research articles and evidence-based practice statements included in this analysis were typically authored by non-Certified Child Life Specialists. However, there was a caveat in that secondary author education and credentials were not investigated in the present study, suggesting that perhaps the contributions of Certified Child Life Specialists may have been underrepresented in this study. At the same time, the collaborative philosophies of child life practice were clearly demonstrated in this prevalence of non-Certified Child Life Specialist authors in the profession's foundational literature.
As reliance on Child Life Focus as the primary source for practitioners has grown with ACLP's now more than 5500 members (ACLP, 2019), so too does the need for a stronger and more accessible evidence base. The limited quantity of original research content found in this review indicates the need for greater attention to promoting opportunities for publication of research within the field. As mentioned earlier, (Boles et al., in press), there has been a consistent increase in peer-reviewed publications by and about child life practice since 1998. Many child life specialists engaged in research are directing their work to official peer-reviewed outlets because of both the publishing benefits and the opportunity to reach a larger and more diverse audience. Further, child life specialists, particularly graduate students or practitioners, may participate in research studies that are not advanced to publication due to lack of appropriate and relevant publication outlets. Whether through continued academic and clinical training, organization-level supports, or opportunities for multi-site or multidisciplinary collaboration, more needs to be done to ensure the growth and sustainability of child life research and scholarship. Perhaps strategic partnerships between academic and clinical programs or enhanced research-related training requirements may be interim steps towards a more solid disciplinary footing for the child life profession.
The lack of practitioner research activity in child life has also been a topic for discourse in the school psychology literature (Lampropoulos et al., 2002). A variety of reasons exist for the lack of involvement: limits on time, funding, training, motivation, and the realities of the naturalistic work settings. Additionally, in child life, Boles and colleagues (in press) suggest barriers such as the lack of research requirements for Certified Child Life Specialists, emersion within a medically dominated context, and a general sense of limited confidence in research capabilities are also at play. Yet, "some research can complement and strengthen practice, heightening the satisfaction that practitioners feel in their work while improving the quality of their services" (Lampropoulos et al., 2002(Lampropoulos et al., , p. 1251. In order to support practitioner engagement with research activity, topics must be interesting, methodologies must be suitable, and the research process must be feasible. Practitioners offer first-hand observations of relevant and important phenomena leading to the growth of relevant research questions that reflect those important phenomena. A focus on patient research using case study methodologies is discussed by Lampropoulos and colleagues as a systematic approach to practitioner research addressing day-to-day interests: "Theoretically based case studies involve many of the same activities and skills as clinical practice … the holistic focus typical of interpretative studies may help overcome the complaint that research is narrow and boring" (Lampropoulos et al., 2002(Lampropoulos et al., , p. 1255. Another notable finding of this study was the distribution of content across the three domains of the child life practice-professional responsibility, assessment, and intervention. The Child Life Certifying Commission (2019) reports that the certification exam for child life is divided thus: professional responsibility is 20% of the exam, and assessment and intervention are weighted at 40% each. However, this analysis revealed that most articles published in Child Life Focus are intervention-focused (57.3%), followed by professional responsibility (36.6%), and then most infrequently, assessment (6.1%). Like findings in school psychology from Little and colleagues (2011), it is evident that Child Life Focus content does not comprehensively and equivocally address all domains of current child life practice.
Like any study, this analysis was not without limitations. Primarily, limitations revolved around the availability of author byline content, as formatting standards within Child Life Focus are noted to have changed significantly in the twenty-year sample included in this study. At times, author credentials and affiliations were unavailable, especially in the earliest years of the publication. In addition, the finite sample size available for this study limited the complexity of analyses that could be conducted, so it is possible that these results may have offered more insight than it is currently statistically appropriate to calculate.
Despite the areas for growth and improvement that the results of this analysis indicate, this study attests to the advancement and growth of child life professional literature over the past twenty years. Furthermore, this developmental trajectory is continuing with the establishment of The Journal of Child Life: Psychosocial Theory and Practice in 2020. The first peer-reviewed outlet dedicated exclusively to principles and concepts relevant to child life practice, the journal breaks ground on the sustainable base of research and scholarship that the child life profession needs for growth in decades to come. Given this historical and timely development, continued research should seek to establish a baseline of child life achievement in the professional literature to date, perhaps by analyzing the content of annual conference programs, conducting interviews or focus groups with past and present child life author/practitioners, and someday reviewing the evolution of the newly established Journal of Child Life.

Conclusions
We anticipate that future study of child life publications will move beyond the present emphasis on child life practitioner literature as the profession matures. As the number of child life academic programs and tenure-track academic positions grows, an expectation of an increase in research publications supporting the evidence base for child life training and practice is reasonable. Acceptance of the amount of time needed for a profession to mature is facilitated through exploration of professions such as school psychology. However, setting our sights on the establishment of a foundation of independent and collaborative research is imperative if we are to improve the status of child life as a field of study.