Attitudes of Child Life Specialists Towards Telehealth

Telehealth is the use of virtual platforms to facilitate interactions between patients and medical providers, and its use has increased in recent years and especially during the COVID-19 pandemic. Studying attitudes of medical providers towards telehealth is an important first step to effectively providing services virtually. Previous researchers have explored the attitudes of physicians towards telehealth, but none have surveyed Certified Child Life Specialists (CCLSs). CCLSs provide coping strategies and support for children in medical settings (e

Medical facilities are pushing for new improvements to the healthcare system to integrate and leverage technology. Telehealth is a broad term used to describe online and virtual pathways that create new forms of communication regarding diagnoses, treatments, and check-ins (Sheikhtaheri et al., 2015). This electronic program provides potential benefits for the patient, including convenient access to a physician's assistance, limited travel to a physician's office, and faster communication for essential needs. In addition, the medical worker may also gain value from telehealth as it provides an ease in their workload, travel, and in-person exposure. However, telehealth also poses some barriers, including concerns regarding patient privacy online and the need for medical professionals and patients to have the necessary skills to effectively use eHealth devices (Zayapragassarazan & Kumar, 2016). In addition to this, healthcare workers must consider financial aspects regarding insurance coverage and payments, technological concerns of access, quality, and effectiveness, and barriers in communicating with people from different cultures (McClellan et al., 2020). Healthcare workers' skills and experience with technology (Olok et al., 2015;Zayapragassarazan & Kumar, 2016) and attitudes of healthcare worker towards telehealth (McClellan et al., 2020;Sezgin et al., 2018) also heavily influence the effectiveness of telehealth.
Most of the research on barriers and attitudes towards telehealth has been conducted with physicians (Acharya & Rai, 2016;Kong et al., 2020;Ly et al., 2017Ly et al., , 2019Sheikhtaheri et al., 2016;Wernhart et al., 2019). However, there is a need to explore these aspects with CCLSs in the hospital setting, when working with children and families to provide a less stressful environment during treatments and procedures (Fisackerly et al., 2016;Lookabaugh & Ballard, 2018). Studying the rise in telehealth in relation to child life is especially important as the COVID-19 pandemic has brought about significant changes to technology use in healthcare systems as telehealth continues to be used as a tool to counter contagion and risks associated with the pandemic. (Blumenthal et al., 2020). The current study was designed to understand how CCLSs reacted to the current pandemic and how telehealth played a part in the communication between child life specialists and their pediatric patients. To our knowledge, this is the first study of telehealth in child life.

Method Participants
Participation in this study was completely voluntary and anonymous. This study was approved by an Institutional Review Board, and permission was received from the Association of Child Life Professionals (ACLP) to collect data via their online forum. A Qualtrics® survey link was posted on the ACLP forum to be viewed by those subscribed to the forum posts. 68 Certified Child Life Specialists (CCLSs) responded via the ACLP forum in August and September of 2020. Of the 68 respondents, five did not complete the survey, but data from the remaining 63 was assessed. Professor a Bacon, K., & Mallavarapu, S. (2022). Attitudes of Child Life Specialists Towards Telehealth. The Journal of Child Life: Psychosocial Theory and Practice, 3(1). https://doi.org/10.55591/001c.33266

Questionnaire
The survey was composed of questions regarding how CCLSs currently use telehealth, how they altered their work during the pandemic, whether telehealth played a role, and their attitude towards the use of telehealth (see Appendix A). The entire survey took approximately 10 minutes to complete.

Data Analysis
Data were analyzed using IBM® SPSS® Statistics. Descriptive statistics were run for all variables. Independentsamples t-tests were conducted to compare responses between participants who had provided telehealth services (either now or in the past) and those who had never provided telehealth services. The qualitative data were analyzed using thematic analysis, a method used to find patterns and themes across qualitative data (Braun & Clarke, 2006;Nowell et al., 2017). Thematic analysis was used to categorize participants' responses to the open-ended questions on keywords that came to mind when thinking about telehealth in child life, as well as challenges/barriers and benefits participants saw in implementing telehealth services. A second rater independently coded the responses for inter-rater reliability (IRR) purposes. An agreement between the first and second coder meant that all responses were identically categorized. Inter-rater reliability above 70% is generally acceptable for exploratory studies (Lombard et al., 2002). The mean IRR across the 4 open-ended questions was 90.6%.

Demographics
Of the 63 participants, most were female (98.4%) and White (96.9%), and 3.1% of participants were of Hispanic/ Latin origin. The average age of all participants was 37 years old. Sixty-two participants worked in the United States, and one worked in Canada. Table 1 describes the demographics of the participants. Most participants had a master's degree), 11 or more years of work experience in child life, and resided in the South. Most participants also worked in a freestanding children's hospital. As indicated in Table  1, most participants reported that no telehealth training was provided by their employer. However, a majority reported favorable/slightly favorable attitude towards telehealth. Levels of exposure to telehealth varied among participants from no exposure at all to having provided and/or received telehealth (Table 2). Reported access to the necessary telehealth technology at work also varied among participants with a majority reporting access to some of the necessary technology (Table 3). Participants were also asked for their opinion on the impact of telehealth services on various aspects of healthcare (e.g., communication among providers, service speed, tracking patient status, staff workload, information confidentiality, patient privacy, financial costs to patients, and legal challenges) (Table 4).
Fifty-four out of sixty-three participants answered a question about whether they had ever provided child life services through telehealth. Of the participants who an-swered this question, 44.4% reported providing telehealth. Of the participants who reported not having provided these services, 20% reported expecting to provide telehealth services in the next 12 months while 20% reported not planning to provide telehealth services in the next 12 months. 60% were unsure about their future use of telehealth services.

Results from those who Provided Telehealth Services
Of the participants who reported having provided telehealth services, 62.5% reported never providing these services prior to the COVID-19 pandemic, 33.3% reported providing these services a few times a year, and 4.2% reported providing these services monthly. Between the months of March and August 2020, 54.2% reported providing these services a few times, 16.7% reported providing these services weekly, 16.7% reported providing these services daily, and 12.5% reported providing these services monthly. During data collection in August and September of 2020, 66.7% of participants reported currently providing services through telehealth while the remaining 33.3% reported not currently providing telehealth services. Ways in which participants provided telehealth services varied, with most reporting utilizing a combination of individual and group video conferences and telephone calls (Table 5). Participants were also asked to rate the extent to which they were satisfied with their patients' progress because of the telehealth services they provided (Table 6). This was measured on a 5-point Likert scale ranging from 1 (not satisfied at all) to 5 (extremely satisfied). The mean satisfaction rating was 2.79 (SD = 0.98). On the same scale, participants were also asked to rate the extent to which they perceived their patients as satisfied with the telehealth services provided ( Table 6). The mean perceived satisfaction rating was 3.17 (SD = 0.96). Finally, participants were asked to rate the extent to which they experienced technical difficulties while providing telehealth services (Table 7) as well as the extent to which they experienced delays and time constraints when providing telehealth services (Table 8).  Only been a recipient of telehealth services 17.9 Only been a provider of telehealth services 14.3 Both a provider and a recipient of telehealth services 12.5 No exposure at all 12.5 Seen other people use telehealth services, been a provider and recipient 8.9 Seen other people use telehealth services, been a recipient of services 8.9 Seen other people use telehealth services, been a provider of services 5.4

Independent-samples T-test
Independent-samples t-tests were conducted to compare responses between participants who had provided telehealth services (either now or in the past) and those who had never provided telehealth services (Table 9). The group that provided telehealth services prior to the COVID-19 pandemic rated themselves as significantly more comfortable with telehealth technology (t(52) = 2.44, p = 0.02), and significantly more knowledgeable about telehealth, (t(52) = 3.06, p = 0.004). They also agreed more strongly that using telehealth services would facilitate job duties (t(52) = 2.08, p = 0.043) as well as communication among providers (t(52) = 2.01, p = 0.05) and were significantly less inclined to agree that telehealth services would threaten staff positions (t(52) = -2.04, p = 0.047). There were no significant differences on the remaining measures. A majority of our participants believed that telehealth services in child life were important; however, there was no significant difference in the perception of how important these services were when comparing participants who had provided telehealth services in the past (M = 3.58, SD = 0.93) and those who had not (M = 3.10, SD = 1.03), t(52) = 1.79, p = 0.08.

Qualitative Data
The survey also included open-ended questions to gain narrative data. The first question asked, "What keywords come to mind when you think about telehealth in child life?" Based on our thematic analysis, 4 themes emerged that we categorized as Positive, Negative, Technology, and Other (Table 10). Words and phrases with a positive connotation appeared 40 times in the open-ended responses to the first question. Words and phrases with a negative connotation appeared 23 times. Those related to technology appeared 18 times. In the second question, participants were asked, "What challenges/barriers do you see in implementing telehealth services within your organization?" See Table 11 for the frequency with which each challenge/barrier appeared in the responses. The third open-ended question asked, "What benefits do you see in implementing telehealth services within your organization?" Themes from participants answers were that they most frequently saw telehealth as advantageous in the time of COVID-19 and other cases for isolation; however, participants also found it beneficial in the ability to reach more people, reducing the amount of travel time, ability to form connections, increase in the availability, and an increase in flexibility. The last open-ended question asked if participants had any other thoughts on telehealth to share, however, no new themes emerged from the responses to this question.

Discussion
The main goal of the study was to understand the attitudes of CCLSs towards the use of telehealth services. We also wanted to assess the level of exposure to telehealth services in general and found that 12.5% of our participants reported no exposure at all. Most of our participants had some form of exposure, whether it was by being a recipient, provider. and/or seeing other people use these services. In addition, we wanted to assess the technological capabilities needed for participants to provide telehealth services at work. 46.4% reported having access to some but not all the necessary technology, and 42.9% reported having access to all the necessary technology. Although the level of exposure to telehealth and reported technological capabilities to provide these services at work were high, 62.5% of the participants reported that no telehealth training had been provided by their employer, and an additional 14.3% were unsure of whether any such training was provided. While it is encouraging to see that most participants reported having access to telehealth technology at work, these findings indicate that if telehealth services become more common in the child life field, more training needs to be provided to CCLSs. This is especially true given that most of our participants believed that telehealth services in child life were important, and there was no significant difference in the perception of how important these services were when comparing participants who had provided telehealth services in the past and those who had not.
In addition, it is interesting to note that most participants strongly agreed or agreed that telehealth services in child life would facilitate job duties and communication among providers, help patients stay better informed, increase service speed, provide more comprehensive healthcare services, and improve tracking of patient status. Most participants disagreed or strongly disagreed that telehealth services in child life would threaten staff positions, information confidentiality, and patient privacy or increase costs for patients. While these findings indicate a positive attitude towards telehealth in child life, most participants agreed or strongly agreed that telehealth services would increase staff workload, create new responsibilities for staff, make it difficult for some people who are not familiar with technology, and exclude certain groups of people with limited technology access. These are valid concerns that need to be addressed if child life professionals continue to provide telehealth services.
Overall, 33.9% of the participants reported a neutral attitude towards telehealth, 41.1% reported a favorable or slightly favorable attitude, and 25% reported a negative or slightly negative attitude. There was no significant difference in this overall attitude between CCLSs who had provided telehealth services in the past and those who had not. Although it is encouraging to see that most participants reported a favorable or slightly favorable attitude, a third of participants reported a neutral attitude. This neutral attitude could be a result of the novelty of telehealth to healthcare workers, the limited knowledge of the impact of telehealth, and the concerns that participants expressed in the open-ended responses. CCLSs who provided telehealth services in the past reported being more comfortable with telehealth technology and had more knowledge about telehealth services when compared to CCLSs who had not provided these services, which is similar to past research findings indicating a positive relationship between healthcare workers' experience with telehealth and knowledge of telehealth (McClellan et al., 2020). CCLSs who provided telehealth services were also more likely to believe that using telehealth services would facilitate job duties and communication among providers when compared to CCLSs who had not provided these services. Unlike CCLSs who had not

Attitudes of Child Life Specialists Towards Telehealth
The Journal of Child Life: Psychosocial Theory and Practice   CCLSs. Notably, every participant reported that they provided these services between March and August 2020, and 66.7% of these participants reported that they were currently providing telehealth services when this survey was conducted. This shows the usefulness of telehealth during times of need like a pandemic as many of the CCLSs adapted to the changing conditions within the healthcare system using telehealth services. Another positive finding was that most participants reported being satisfied with their patients' progress as a result of the telehealth services provided, and none of the participants reported their perception of patient satisfaction as "not satisfied at all." Most participants reported using a combination of individual video calls, group video calls, and telephone calls to deliver telehealth services. Examples of platforms used for individual and group video calls were Zoom, Skype, Doxy, Microsoft Teams, and Facetime. Very few (4.2%) participants reported connectivity/speed issues that prevented the completion of sessions. None reported that there were enough hardware/software issues to prevent the completion of sessions. Given that most participants reported not having received any telehealth training from their employers, it is encouraging to see that technology issues did not prevent the completion of sessions for most participants. This could be attributed to the participants' familiarity with platforms used for virtual communication, many of which are mainstream. In addition, whereas some participants reported that patients never or rarely showed up late to sessions (62.5%), had difficulties accessing the link (54.2%), or experienced technical difficulties (62.5%), the remaining participants reported these issues occurred a few times (and in a few cases, several times) and caused delays. Although

Attitudes of Child Life Specialists Towards Telehealth
The Journal of Child Life: Psychosocial Theory and Practice it is a positive sign that technology issues did not prevent the completion of sessions for most participants, it would be beneficial to find ways to decrease the frequency of the delays caused by lateness, link accessibility, and technical difficulties. Finally, whereas some (54.2%) participants never or rarely experienced time constraints (in terms of time spent with patients), others (45.9%) reported feeling like there was not enough time with patients during sessions. It would be beneficial to identify situations that require more time and plan accordingly to provide the best possible experience for CCLSs and their patients.
When asked for keywords that came to mind when participants thought about telehealth, most participants used positive words and phrases. This finding is consistent with other studies that show more positive attitudes of healthcare workers towards telehealth than negative (Ly et al., 2017). Although most of the open-ended responses to this question were positive, there were some negative opinions. The negative attitudes are like the findings from a study on veterinary doctors' views on telehealth (Watson et al., 2019). These researchers found negative concerns and attitudes towards telehealth, specifically because of a potential for financial dilemmas (how much of telehealth would consist of free vs. paid consultations), over-working healthcare workers, and more. Other researchers have found negative attitudes towards telehealth in healthcare workers primarily related to concerns about patient privacy and record confidentiality (Wernhart et al., 2019). The biggest challenge of telehealth reported in the current study was limited access and resources. Zayapragassarazan and Kumar (2016) found similar results in the obstacles of telehealth being a lack of telehealth skills, management, and technology. As suggested by McClellan et al. (2020), research needs to be conducted on whether increased training and access to technology will improve attitudes towards telehealth. The greatest benefit reported in the current study was the ability to reach patients during times of isolation such as the COVID-19 pandemic, indicating that telehealth could be beneficial for CCLSs to assist children in isolation who may normally not be able to receive these services.

Limitations
This study had several limitations. The small sample size and exploratory nature of this study limits generalizability. Future researchers should recruit from a more diverse sample and target participants who do not identify as White, female, and from the South. It would also be beneficial to study CCLSs outside the U.S. and Canada to gain a crosscultural perspective. Most of our participants worked in a hospital setting, and in future research it will be necessary to target CCLSs working in academia non-profit centers, and rehabilitation centers. Despite its limitations, this study produced foundational knowledge that will aid other researchers in understanding the attitudes of CCLSs towards telehealth.

Conclusion
The need for telehealth has increased over the years and especially during the COVID-19 pandemic. To utilize telehealth efficiently and successfully, it is essential that CCLSs and other healthcare workers have more training and experience working with these services. In the times of a pandemic, telehealth can allow CCLSs to continue to facilitate safety and comfort in the hospital setting. There is a need for additional research to be conducted on the barriers of telehealth and the resources needed to overcome them. With more research, telehealth can be an asset in the healthcare community in providing services during times of need. By understanding the attitudes of CCLSs towards telehealth, the profession can better understand how to integrate telehealth services into their work.