“We’re Going Through Tough Times Right Now”: How Students of Color Navigate the Field of Child Life

It is important to examine the education process of child life, as research supports that education can play a significant role in increasing workforce diversity in healthcare fields (Glazer et al., 2018). In turn, increased workforce diversity may reduce racial and ethnic health disparities (Phillips & Malone, 2014). However, it is also known that healthcare providers and students with marginalized identities may experience various barriers that harm their wellbeing (Filut et al., 2020; Iheduru-Anderson & Wahi, 2021). These findings come from a larger study on the experiences of child life students and specialists with marginalized identities (Gourley et al., 2022). Marginalized identity may refer to any racial, ethnic, sexual orientation, or class identity that historically has experienced social and political inequality in the United States (Seng et al., 2012). The purpose of this study is to consider the experiences of child life students with marginalized racial and ethnic identities, hereafter referred to as child life students of color.

Literature Review

Child Life and Healthcare Professional Inequities

Approximately 60% of the certified child life specialists (CCLS) in the United States identify as White, 15% are Hispanic or Latino/a, 11.1% are Black or African American, and 6.4% are Asian (Zippia, 2022). Less is known about the demographic statistics of child life students. The diversification of the healthcare workforce may reduce health disparities (LaVeist & Pierre, 2014; Morrison & Grbic, 2015), but professionals with marginalized identities report experiencing microaggressions and discrimination in the workplace (Filut et al., 2020; Gourley et al., 2022; Iheduru-Anderson & Wahi, 2021). This, in turn, diminishes professionals’ mental health and wellbeing. Given the research on healthcare professionals (including CCLS) and students, it is essential to consider the experiences of child life students of color.

Educational Outreach from Other Healthcare Professions

To date, there is no published research on the experiences of child life students of color. This necessitated a review of other healthcare professions and academic programs. In response to insufficient diversity in the nursing workforce to match the increasing diversity of the U.S. population and the significant health disparities resulting from this, Phillips and Malone (2014) outlined ways to increase nursing workforce diversity in order to eliminate health disparities. Their recommendations include creating fellowships and other training opportunities to support health equity, requiring opportunities for underrepresented nurse leadership and involvement, and expanding service learning in nursing schools that focus on health equity (Phillips & Malone, 2014).

Intentionally diversifying academic medical institutions “benefits the intellectual development, service orientation, critical thinking, and cultural competence of all involved” (Nivet & Berlin, 2014, p. 16). Having a more diverse learning environment promotes a more diverse healthcare workforce, and also has the potential to engender spaces of cultural humility (Brown et al., 2021). Glazer and colleagues (2018) highlight the role that colleges and universities can play in increasing workforce diversity in healthcare fields. Their program evaluation found that increasing the student diversity at the Academic Health Center within the University of Cincinnati subsequently increased the workforce diversity of the Greater Cincinnati Health System (Glazer et al., 2018).

Application to Child Life

Certified Child Life Specialists (CCLS) are expected by the rest of the healthcare team to be experts on the child and family (Lookabaugh & Ballard, 2018). Achieving this expertise requires knowledge and understanding of all families, including their cultural nuances (Lookabaugh & Ballard, 2018). In their qualitative study assessing the scope of the child life profession, Lookabaugh and Ballard (2018) found that many CCLS feel they need to better understand the impact of cultural diversity on families. Cultural competence in healthcare is the set of perspectives held by clinicians that allows them to care for patients of various cultural backgrounds and to plan for and provide care that is appropriate to that culture and to the individual (Betancourt et al., 2002). Despite their perceived expertise in cultural competence, CCLS do not have all the skills needed to support families of marginalized groups (Lookabaugh & Ballard, 2018).

As documented in studies on other healthcare professions, one way to increase cultural competence is to diversify the workforce (LaVeist & Pierre, 2014). The Association of Child Life Professionals (ACLP) has made some efforts to increase workforce diversity, such as the diversity scholarship for internship candidates that started in 2017 (ACLP, 2022a) and upcoming edits to the internship common application in an effort to make the internship selection process less biased and more accessible (ACLP, 2022b). These are important steps because a significant barrier to the profession is the amount of unpaid training required to become a CCLS. The impact these additions will make to the diversity of the field is yet unknown.

More information is needed about the recruitment of underrepresented groups at the university level. The ACLP’s Internship Equity & Access Pledge states that internship programs ought to: “Utilize inclusive marketing materials and develop recruitment strategies to increase candidate interest from historically excluded groups” and “when possible, create opportunities that increase accessibility for underrepresented groups and minimize the financial impact during the internship experience (e.g., scholarship fund”); Association of Child Life Professionals, 2023, para. 4). Although a master’s degree is not currently required for certification, the scope of a CCLS’s responsibilities is wide and those with master’s degrees tend to feel more prepared in their roles (Lookabaugh & Ballard, 2018). The increasing need for a master’s degree adds an additional financial barrier. Along with financial concerns, practicing CCLS from underrepresented groups have reported subtle discrimination and feelings of isolation and disconnection from their colleagues (Suzuki, 2015). The present study aims to explore the role of the child life education process in the current lack of workforce diversity, through the lens of current child life students and recent child life graduates.

Research Questions

1. How do child life students of color conceptualize the role that the child life educational process plays in the diversity of the child life workforce?

2. What challenges, barriers, and protective factors do child life students of color face during their education process?

3. According to participants, how can child life education programs better recruit and support students of color?

Method

Recruitment and Eligibility

In the larger study on the experiences of child life students with marginalized identities, eligibility criteria included being 18+ and a child life student or having been certified as a child life specialist in the last ten years (Gourley et al., 2022). Participants needed to hold any racial, ethnic, gender, or sexual orientation identity they considered to be underrepresented in the child life field. After the authors received IRB approval from Towson University, participants were recruited via purposive and snowball sampling, through child life online forums, and through direct contact with child life academic program directors at universities across the United States.

Data Collection

After signing consent forms, 18 participants took part in one-on-one telephone interviews that lasted approximately 60 minutes. Interviewers trained in qualitative analysis asked questions from a semi-structured interview guide, beginning with grand tour questions and then using prompts and probing questions as needed. Questions were asked about the participants’ barriers to progress and protective factors in succeeding in the field of child life, maintaining boundaries, and enlisting support.

Data Analysis

Through qualitative thematic analysis (Braun & Clarke, 2006), the authors identified prevalent themes among the varying experiences of child life students of color navigating the child life profession. Scrutiny techniques (Ryan & Bernard, 2003) were used to find themes and subthemes. After the authors independently read the interview transcripts, they met to discuss their largely congruent themes. A second meeting was held to refine the list of themes and subthemes.

Trustworthiness

Together, the authors discussed how their identities shaped their response to the data. The first and third authors established rapport with participants prior to their interviews, thereby achieving credibility. Interpretive member checking enabled participants and researchers to co-construct the meaning of descriptions during the interviews. All authors practiced reflexivity by noting their experiences and thoughts during data collection and analysis (Morrow, 2005).

Results

Twelve individuals of color participated in the present study. Four participants identified as Black or African American, one identified as multiracial, one identified as Native American, four identified as Latino or Hispanic, and two identified as Asian American. Two participants identified as male and ten identified as female. Ages ranged from 23 to 36 years old. The authors identified five themes concerning how people of color navigate the field of child life: 1) barriers to progress, 2) protective factors, 3) fitting one’s marginalized identity into child life, 4) connecting with patients and families, and 5) the social landscape of child life.

Barriers to Progress

Participants described a variety of barriers that impacted their experiences as child life students. Some barriers discussed were categorized as systemic, including financial, internship, and certification-related barriers, as well as the feeling of navigating the field “on your own.” Other barriers were categorized as relating to one-on-one or small group relationships, such as feeling isolated from peers and feeling unsupported by faculty and supervisors.

Systemic Barriers

Financial. The financial burden of sustaining oneself throughout the education and certification process was widely discussed among participants. Nine out of twelve (75%) participants of color reported experiencing financial barriers they needed to overcome in order to move forward in the profession. Many contrasted their own financial experience with the experiences of their peers. One participant reflected:

From having heard everyone else share their stories of how they came into it, it was a lot of people who didn’t have to work throughout high school and college and had a lot of time to volunteer at hospitals … I… and others who need to fulfill all the volunteer requirements while being a full-time student and working possibly two or three jobs to afford that education, did not allow for us to have an equal opportunity to get the volunteer hours or experience in.

Other participants felt they were at a disadvantage for obtaining an internship because they, as one person commented, “didn’t have the financial ability to move anywhere” and were limited to applying locally.

Obtaining Internships. In addition to the financial burden of the internship process, many participants noted that their internship application experience contributed to significant social and emotional strain. Ten out of twelve (83.3%) participants of color pointed to the internship application process as a significant barrier. One participant reflected on the internship application process, its competitiveness, and the instinct to compare oneself to peers:

I went through maybe three rounds of internship interviews, and I didn’t get anything until the very… final round. And so it was really difficult for me to kind of sit back and see that my counterparts…were receiving all of these internships and getting all these offers…in the back of my mind, knowing that I had way more experience than them…It was really kind of this process of me questioning whether this is a field that I would like to be entering into, and why is this happening to me?

Another participant, who did not obtain an internship on the first attempt, shared their experience trying to process this with trusted faculty from their university:

I was really worried about not graduating and I debriefed a lot through conversation, I asked a lot of questions. One professor [told me] I was being talked about behind my back with other faculty, that I was complaining too much that I didn’t get an internship.

One Latinx participant who had not yet completed an internship at the time of the interview shared a variety of barriers that interfered with obtaining and completing an internship, including being a single parent, personal health issues, and the changing requirements for internship eligibility. She shared how she felt at this point in the process in the following quote:

It is discouraging because it seems like…it’s taking me forever to do something that another person might be able to accomplish right away after graduating…I was in school full-time, I was working full-time and I was volunteering. How did I do all of that? I don’t know, but I did, … and it still was not enough.

Certification. Two out of twelve participants (16.7%) expressed frustration about certain academic and professional experiences that did not count towards their certification, despite the professional value they found in them. A Native American participant discussed unique work experiences they, and some of their colleagues, had that they did not always feel were valued on the same level as volunteer work:

Even though we felt like we were kindergarten teachers or we’ve worked with diverse settings on different reservations and that’s provided us with a unique experience, but it wasn’t counted as volunteer hours, right? So I think somehow, some acceptance of lived work experience I think should be counted towards … volunteer work.

Similarly, a Latinx participant discussed a play course they took through their university:

You go to a local nonprofit Mexican art center that works with youth giving free art classes … and so I really felt that that was the most important course that I had ever taken and that taught me so much about play so in my mind, there was no doubt that that would meet the requirements because it had to do with meeting the needs of children that are impacted with stress and traumatic events and utilizing a play modality… that was culturally competent or relevant, you know? But it was denied.

This participant also shared that in their volunteer work at several hospitals in their area, they have never encountered a child life specialist who is a native Spanish speaker, despite the large Spanish speaking population these hospitals serve. They went on to say that being bilingual has felt “undervalued” when applying to child life positions.

Navigating the field “on your own.” Four participants (33.3%) expressed feeling alone in navigating the field for varying reasons. One person attributed this to the fact that, for financial reasons, they made the decision to get their degree online, even though that meant they would not get the same institutional support one might get in an established child life cohort.

They described having to advocate for themself when they were not getting the support they needed from their academic advisor who was not familiar with the child life profession. They explained: “So, for my undergrad, you know, I was very adamant with my college advisor like, this is what I want to do, I don’t want to spend my time doing an [irrelevant] internship or practicum that aren’t going to help me.”

Another participant attributed the feeling of being on their own to being a first-generation college graduate from an immigrant family. They said:

My parents didn’t even complete high school. So, I’m the first person in my family … to have completed their bachelor’s in another country … and so even though we celebrate it … it’s still a representation of, of overcoming obstacles because …you navigate it all on your own, not only your identity, but your goals, you have to navigate all of that.

Relationship Barriers

Feeling isolated from peers. Each participant of color described different experiences with diversity growing up and how it compared to the diversity of their child life peers. Some participants came from very diverse communities, or communities predominantly of color, and were struck by the lack of diversity in child life. Others had an upbringing that mirrored their experience in the child life field, being one of the only people of color. Despite these varying backgrounds, the feeling of isolation from one’s cohort was a common experience (seven out of twelve; 58.3%) among participants of color and was noted as a barrier to success. Several participants expressed how it felt to be the only, or one of the only, people of color in their cohorts or on their child life team. In the following quote one Latinx participant attributed this isolation to socio-economic differences:

From the very beginning, it kind of felt like I was outcasted a little bit. And so that was a struggle in and of itself … and in addition to that I still had a lot of financial responsibilities, and so as I was, you know, studying throughout this entire master’s degree … I had four jobs … And so I think when it came down to, to kind of gathering together, I just could never really find time to be with the people in my cohort. And … they kind of took it as ‘Oh, she just doesn’t want to… hang out with us.’ But in reality, they didn’t know that I had four jobs.

Another participant more pointedly attributed this isolation to their racial identity. In the following quote they reflected on being the only Black student in their graduate cohort:

I didn’t have the – I don’t want to say “ability to” because they were there and I could have reached out to them but I didn’t feel comfortable. We were all competing for the same spot for an internship, and I had already felt a little like an outcast because I was the only Black child life student in that cohort, and they had really great relationships amongst one another. So that, that particular process, I didn’t really lean into them. I just did it on my own.

The following quote from the same Black participant illustrates the impact of this isolation and how it acts as a barrier to progress within the profession:

Not having that peer support, that was certainly a barrier for me, because I was such a social person. I went from undergrad feeling like I had a grip on my social circle, and then you go to grad school, and that when you think of the cohort that you’re directly with, and you don’t really relate to any of them, besides being in the same, you know, educational track. It was a barrier when it came down to just feeling supported and feeling like I belong somewhere and feeling like I could reflect on things that maybe somebody else was facing, simply because of the color of your skin.

One participant even experienced being blamed for not fitting in well with their graduate cohort. In the following quote, they share a conversation with their professor:

It didn’t seem like I was getting along with the other … students. So instead of… acknowledging or asking me about what was going on in my life - she actually didn’t know I was working four jobs, she didn’t know I was feeling this way. She could visibly see that I was, you know, ethnically different. But instead of having a sit down conversation … it was very much a blaming conversation.

Not feeling supported by faculty. Eight out of twelve participants (66.7%) of color articulated not feeling fully supported by their university’s faculty. For some participants, this was partly due to not seeing their racial or ethnic identity reflected in university and hospital leadership. A Black participant explained this lack of support during graduate school in the following quote:

I tell people this to this day, like, I would never go back to school solely because of that experience. And it was more so how tough it was, and just feeling like I had the right people in place and mentor me and… really see my situation a little differently… like to know that you’re the only Black student in this particular program. That is something to acknowledge… It was… something that I don’t think my academic coordinator really, you know, teased out in our conversations. And I didn’t bring it up because I just didn’t want to make a big deal about it…Your confidence as someone that you already feel like you stand out and when you don’t feel like you are … achieving certain things in a certain way compared to your peers that are in your cohort, it was hard.

This participant later elaborated on the support they wished they received from faculty at their university:

I’m an out of state student who’s the only Black student in this cohort. Check on me a little differently. Have a different conversation with me. Be willing to jog some of those things with me or navigate some of those challenges with me because they are unique to my identity.

Several other participants articulated a similar sentiment that getting support with identity related issues was not easy to ask for from professors, advisors, and mentors. The following quote contrasts these experiences and demonstrates how much it meant to one Asian American participant to have a professor that shared her racial identity:

She reached out to me and supported me …when I felt very overwhelmed. For example, I asked for a day off, like I told the department I wasn’t going to be available during the weekend of Chinese New Year. And I think in previous situations I’ve always been worried people will call me out for that and think that it’s not a real holiday or think it’s kind of weird you’re celebrating it but I felt the department was so supportive of it … and my professor… invited me over … to celebrate that it was the new year.

Furthermore, participants reported not only a lack of support from university faculty but overt discouragement from continuing to pursue the profession. One participant described how it felt when an academic advisor encouraged them to change their major:

How am I supposed to thrive in an environment where I’m already the different, odd person out, but I’m also in an environment where the people that are supposed to be helping me thrive and helping me learn, don’t believe in me being here?

Another participant described feeling unsupported by an academic advisor throughout their graduate education. When this participant ran into their advisor at a conference later in their career the advisor said, “Well, I see you stuck with child life,” passively indicating she did not expect the participant to succeed.

Protective Factors

Each participant described overcoming some or all of the barriers discussed above in order to get to their current academic or professional position. They discussed protective factors that supported them in overcoming the aforementioned barriers, including financial support, emotional support, and determination.

Financial Support

Eight participants discussed financial support as a protective factor. Financial support sometimes came from family. As one participant shared, “I was very fortunate that my family was able to support me through my education.” Other participants noted financial aid and teaching assistantships gave them access to child life education programs that they might not otherwise have been able to complete. One participant shared that their choice in graduate programs “came down to a unique offer where my job is paying for my schooling.”

A participant who had a teaching assistantship said, “My other TA and I were lucky because…we could use the money that was normally used to pay for books and things to pay for…the traveling we had to do [for internship].”

Emotional Support

Eleven out of twelve participants (91.7%) highlighted the emotional support from family, friends, and classmates that helped them get through the education and certification process of child life. In the following quote one participant described what it meant to them to have their family’s support, especially after a very challenging internship experience:

I think family is just one of those resources that I was blessed with to really get over the hump of something I think that cripples the ability of people when they go through the … educational process and internship process, that some people break. They have those breaking points, and they might not feel supported, but my family is amazing. And when I came home they just really poured into me and built me back up.

A common form of emotional support described by several participants was the experience of having at least one classmate or colleague who could relate to their marginalized identity. One participant who felt very outcasted from their graduate school cohort explained how validating it was that the only other person of color in their cohort felt similarly outcasted: “That was really empowering too, to know that it’s actually not just me and my … defensive beliefs, it is actually happening to someone else.” Similarly, when another participant was asked if they felt supported by their child life cohort they responded, “by my peers it’s a little bit debatable … I feel like the other child life student who was Black [and I] … supported each other a lot, because we were the only two students of color in our cohort.” The same participant described what it meant to them to encounter another student who shared their marginalized identity during their internship:

She was just like this refreshing person. I was like, I’ve never seen an Asian child life student before. Yeah so that was really helpful. I think just having someone who looked a little bit more like me compared to the other people.

Some participants that did not have anyone who could relate to their identity described the importance of having one person who believed in them and invested in their success within the field. One Latinx participant described a volunteer preceptor who did this for them:

She gave me a letter of recommendation, and she insisted on… it. … I think she understood that it was intimidating for me to ask her for something. So she insisted on giving me that letter of recommendation and she insisted that I apply for the internship. And… although that was a goal, I did need someone to say “yes, you’re the right fit for this, this is your path, and you shouldn’t give up.”

Determination

Four participants (33.3%) attributed their progress in part to their intrinsic motivation and determination to “just get it done” and “be 100% successful” despite the obstacles they faced. One Black participant described this drive in the following quote: “I’ve always been a hard worker. So, for me if it’s something that I set my mind to, and I’m going to work seven days a week to come up with that money to do what I said I was going to do.” Similarly, a Latinx participant explained that the challenging experiences they have faced throughout their career have acted as fuel to keep pushing forward. They said:

I wasn’t going to let … those multiple experiences affect my desire to be in this field. If not, it was gonna make- push me even more, because I think it’s just too important to have representation in all types of interdisciplinary team members. And it really, again, it’s for the benefit of our patients and families.

Fitting One’s Racial or Ethnic Identity into Child Life

Five participants of color (41.7%) spoke of their struggle to fit within what they perceive to be the typical child life specialist. As participants realized that the field of child life “looked a certain way,” they expressed fear that their identity would not be accepted. One participant shared that their time as a child life student was “the only time since my childhood years that I actually felt that I really stuck out and did not belong.”

Several participants expressed the need to change their behavior or presentation to be better received in the child life field. A male participant reflected on the intersectionality of his gender identity and racial identity and how that affected his behavior when working with a vulnerable patient population. He said, “I needed to be a bit more passive, a bit more soft spoken than I’m typically used to being.”

A Black participant shared how she had to strategize how she would present herself during interviews:

I think that specifically being African American and Black hair. That wasn’t something that came up in class but myself and another student had conversations about what our appearance may look like during the interview process and how we were going to go about it.

One participant spoke about feeling out of place as the only Black student in their cohort. In the following quote they explained how this impacted their confidence in entering the workforce:

I would be so self-conscious about everything that I said, everything that I did. Even doing projects together at times I would take a back seat, even though I’m such a leader, I’m so vocal, I would do that to myself, just because I didn’t want to seem like … I didn’t know what I was talking about or I didn’t understand the content … It took me a while after grad school to really feel like that competent and confident going out to pursue that certification.

A Native American participant shared their experience with their own identity development and how it has shaped how they approach their child life practice:

I first had to assimilate [my two racial backgrounds] and have harmony with them. And then you know once I reached my later teens and then through my higher education … now that I know and have harmony within myself I need to learn more about others.

Connecting with Patients and Families

Despite this struggle to fit one’s identity into the child life field, some participants found strength in their identity and what it brought to their work. Eight participants of color (66.7%) described how their racial or ethnic identity provided an avenue for connecting with patients and families who shared their marginalized identity. One Black student noticed that during their fieldwork, all other providers were White and therefore patients tended to “gravitate towards” them. They explained this by stating, “It’s nothing against another person … it’s just reassuring to have someone that they can identify with.” Another Black participant articulated this concept in the following quote:

Just feeling like you can see something in children, and they see something in you, you know what I mean? Like you’re able to relate on something without saying something first. Like… “oh that person is Black or Brown and I am too.” That is a foot in the door.

A Latinx participant described connecting with Spanish-speaking patients both linguistically and culturally. They give an example of this in the following quote:

[I built] quick rapport with that patient because we spoke the same language … I kind of asked all the right questions because I could see myself in her and … the mother of the patient opened up to me about how she was feeling super stressed because she was missing work and how she was not able to relax for her child who was in the emergency room, because she was worried about missing one day off … and what a risk it was for her to take the time off … I was so thankful I could speak her language and be able to help her get that off her chest so that she could be present and engaged with her child.

The same participant explained why being able to make those cultural connections is so important to the field of child life:

This is a relationship-based job where you have to build rapport with families to be able to serve the patients that you’re working with and you have to do that quickly. And if the family is already experiencing difficulties establishing relationships with their healthcare providers because they don’t speak the language and they need interpreters, then they’re gonna have a much more difficult time requesting or asking for what they need or communicating effectively.

Establishing Boundaries

In addition to the positive experiences participants shared about connecting with patients and families due to a shared identity, eight participants of color (66.7%) reported challenges with navigating boundary issues related to their marginalized identities. Some participants described patients and families who shared their marginalized identity feeling overly comfortable with them and at times crossing boundaries. An example of this is shared in the following quote:

The first hospital that I volunteered at, it was a patient’s father, who was trying to thank me so much for just helping his daughter. And he started to make me feel uncomfortable because he was asking like, “Oh I want to give you a gift” or something or “let’s meet up out somewhere else so I can give you this”… but I definitely feel that it was because, he felt so comfortable to be able to speak to me in the same language.

When navigating issues like these, participants described receiving varying levels of support from supervisors. In the scenario described above, the participant’s supervisor addressed the situation by directly speaking with this family and holding the boundary for the participant, who was a volunteer at the time.

Another participant described their practicum supervisor as someone who helped them in navigating identity issues as they arose:

She was very open and vulnerable about her own experiences … She was going through a lot in terms of understanding her own identity and how it affects other people. She [was in an interracial relationship] … And I think because of that she was so open about it that I felt like I could talk to her about my own identity, and we could talk about being Asian. And especially when I had a situation with a patient, I reached out to her first because I don’t know what I should do. And she was really great with supporting me through it and being honest: “I don’t really know what to say, and I don’t really know how to support you but like, I’m always here if you want to talk about it and I acknowledge that we have to be better about it.”

Other participants described less positive experiences. One Black participant recalled attempting to bring up an identity-related issue in one of their graduate courses and getting a response of discomfort from the professor. The participant concluded, “That’s how you know it’s something that has not really been brought up before.”

Cultural understanding of boundaries. In discussing boundaries, two participants (16.7%) reflected on their own cultural understanding of boundaries and the ways they are taught in the child life profession. One Latinx participant shared their experience doing child life field work in a Spanish-speaking country and how it shaped their understanding of boundaries in a cultural context:

One of the lessons that I learned there was … when we say “boundaries,” kind of like, speaks to a certain level of distance you’re supposed to have with patients and families. But when I was in [country], it was the exact opposite … it’s more of like an intimate setting, which I think improves the therapeutic experience for the families of the patient and also their comfort zone … I feel like whenever I do come into contact with a Latinx family or somebody that identifies as something similar to me, I do hold that boundary but I’m also really humble in understanding where they’re coming from, their expectations of great services, and understanding that if they hug me that’s okay because … they want to be comforted.

Another participant reflected on how they had been coming to understand professional boundaries through their field work:

When I got into this job, I decided that I would know if I crossed a boundary by deciding if I was … prepared to do for anybody else you know, like… if anybody else needed that level of attention… it wouldn’t really matter what their background was, I would give it to them. But because they are marginalized they do need extra [attention] and I think that’s okay. So, the boundary is different … because … they’re disenfranchised, they’re often overlooked … so I might have to compensate.

Social Landscape of the Child Life Field

All twelve participants of color noted the homogeneity of the field, with the dominant demographic being White females. Eleven out of twelve participants of color (91.7%) identified the disparity between the diversity among the patients and families and the workforce serving them. Ten participants of color (83.3%) described their child life academic programs as being predominantly White, while two considered their programs “uniquely diverse.” One of the participants that came from a diverse cohort of child life peers reflected on their experience going to internship and realizing how homogenous the field is:

It ended up being a bit of a surprise as I moved further along … I would say the internship application process, in learning about the various sites and those that had … images of their team I would say gave me kind of an inkling of what the landscape looked like. Probably not until I was accepted to my internship site did it really … and my peers were accepted to their internship sites and they would share what their teams looked like.

Some participants expressed feeling like other child life specialists do not quite understand the extent of this issue. One participant of color described an observation of others’ incongruous proclamations about diversity:

They were talking at the end of the conference about how we’re making such great strides in this field. “It was becoming so diverse!” and “we have a boy!” and “we’re looking so much different with our ethnic identities.” I was looking around, I said, “There’s only like less than five people in this room who can identify as a different ethnicity that isn’t White.”

How to Diversify

All twelve participants of color stated that more diversity in the child life workforce would positively impact the profession. When asked what they felt could be done to increase diversity, participants presented a variety of ideas to mitigate barriers and support people with marginalized identities entering the field. One participant discussed application processes that they felt added to their financial barriers that could be changed:^[1]

Why couldn’t we email everything? … Email’s free you know what I mean? … and even with the common application people think “oh that’s easier,” but if you compare it with college applications, college applications have a waiver for students who can’t afford to pay. There’s no child life waiver so you just have to come up with the money or not apply.

Some participants pointed to university recruitment as an avenue to diversify the profession. As one participant said:

I think when it comes to … bringing more diversity within the child life field, it definitely starts from the very beginning and so, if I’m just talking about like the college itself, and their selection process of who they’re accepting for this program … Because, you know, they are continuously advocating for one specific group of people or community, then the exact same results are going to be happening.

Others suggested hospital child life leadership can play a large role in better supporting students and young specialists of color. One participant described how the advocacy of a supervisor made them feel supported as a child life student:

From the moment I walked in here as an intern I just felt such a level of respect from my management and leadership. And I physically saw and hear the advocacy that she spent, you know during staff meetings from all the way to having webinars with the ACLP about whiteness and the effects it has in the child life field … and so because of all her advocacy and because of all of her wisdom and because of all of her bravery … I feel like that was the beginning for me to kind of really understand that this is the staff I would like to be a part of. And it was also trickled down or very much respected with the staff, you know her points of view and values of the staff.

Pushback from Colleagues and Peers

Four participants of color (33.3%) expressed getting pushback from colleagues or peers when bringing up issues of diversity, equity, and inclusion. This sometimes led to participants feeling discouraged about the lack of progress in this domain. One participant mused:

With my peers, I feel like because they’re so used to child life looking a certain way, they’re not necessarily open to it changing even though there are some things that definitely need to change. Um, but I think that’s just lack of knowledge, not necessarily them purposely not being supportive.

A Latinx participant expressed that some members of their cohort gave the sense that they were annoyed or in disagreement when identity issues were brought up. They said there would be “huge eye rolling, like dismiss every comment.” Another participant expressed disappointment when discussing race issues with their colleagues following the George Floyd murder in May of 2020:

We’re going through tough times right now, um, just with forms of police brutality or people acknowledging what Black people are going through. And I’m actually kind of feeling a little down with the people that I thought were my friends because when they’re saying insensitive things I brought that to their attention, not in a way to be antagonizing, but just in an open discussion and they haven’t been receptive to the point like, now they won’t even talk to me.

Cultural Competence

The term “cultural competence” was discussed at length throughout interviews and four out of twelve participants (33.3%) felt this term did not adequately encompass what goes into providing services that support the diverse patients and families served by child life specialists. When one participant was asked about cultural competence they explained:

That is another word that I feel has kind of taken over the child life perspective and what our expectations are. So cultural competence means I am proficient enough to know what your culture is and your ethnicity, to feel confident enough to give you services. But instead I like to … shed light on cultural humility, where I’m consciously, always working on learning more and growing and reflecting on the things and experiences that I have with staff and patients and families. And so I do not feel culturally competent whatsoever, I am mostly feeling I have a cultural humility perspective … to actively learn from the people that I come into contact every single day. And that is what helps me become a better child life specialist and provide the highest quality of care that I possibly can.

Another participant also reflected on the term “cultural competence” in the following quote:

I think competence is something we should be striving for in all aspects of the care we provide. Culturally though, once we start breaking down what culture means … that it’s so intricate and there’s so much to learn from a cultural standpoint. So I don’t know if we ever master that in our lifetime. It’s something we can strive for.

Discussion

This is the first study to explore the experiences of child life students of color and to consider the social, psychological, and economic barriers they may face navigating the professional field. It is also important to contextualize these findings: data collection took place from 2019 to 2020, during a significant period of national and professional reflection on racial injustice. Since 2020, the ACLP has modified its DEI plan multiple times, and as previously stated, is currently being revised.

In this study, participants described race- and ethnicity-centered experiences versus race- and ethnicity-embedded experiences. In race- and ethnicity-centered experiences participants’ race or ethnicity was a central factor in an encounter. For example, maintaining boundaries with patients and patients’ families who shared their racial or ethnic identity. Race- and ethnicity-embedded experiences included those in which race, ethnicity, and other marginalized identities co-existed. For example, financial barriers to pursuing child life are not limited to students of color. However, in the United States, people of color, including students, disproportionately experience economic instability (Bowdler & Harris, 2022; Chetty et al., 2020; Gaskin et al., 2005). These findings suggest that people of color, particularly Black Americans, may be less likely to have intergenerational financial support to make the child life education and certification process less burdensome.

Beyond child life, other healthcare disciplines have reported similar barriers to recruiting, supporting, and graduating students of color. These disciplines include art therapy, medicine, nursing, pharmacology, and physical therapy (Campbell et al., 2020; Dickson & Zafereo, 2021; Johnson et al., 2021; Matthews et al., 2022; Olsen, 2019; Rocha et al., 2022). The theme of protective factors (specifically, instructor mentorship) is transferable to other healthcare disciplines. In light of the COVID-19 pandemic and nursing shortage crisis, Matthews et al. (2022) studied the strategies of nursing programs to support and retain students of color; they concluded that additional peer and supervisor mentorship programs are needed.

Related is the difference between extrinsic and intrinsic protective factors: these factors do not operate in a vacuum and the individual participants played a role in achieving success from these factors. For example, many participants identified the protective factor of having one person in their child life cohort or child life department who they could relate to about their marginalized identity. Whether or not an individual will be placed with someone who shares their marginalized identity is out of the control of the individual. However, it is important to acknowledge the individual’s role in building relationships and deriving support from them.

Limitations

Selection bias may be present in this study: child life students who utilized child life-focused websites and social media platforms were more likely to learn about this study than students who do not utilize, or have access to, such resources. Moreover, it is possible that the individuals who participated felt safer telling their stories than those who did not. The authors note this as a possible limitation (also related to selection bias) since some participants described concern that their supervisors would learn that they had participated in a study in which they described negative experiences in the field of child life.

Implications

This study yields several research and practice implications. This study focused on the experiences of child life students with racial and ethnic marginalized identities. Future research ought to consider students with other marginalized identities, including those who are transgender, genderqueer, and non-binary. It would also be helpful to replicate this study in the future to learn how shifting ACLP policies affect support for child life students of color.

Participants in this study addressed the need to rethink how topics including cultural competence and professional boundaries are taught in child life academic programs. The notion of revising curriculum to include diverse developmental and theoretical perspectives has been previously proposed (Koller & Wheelwright, 2020). Academic program directors and internship supervisors should consider how professional boundaries are discussed and how personal identity plays into understanding and establishing healthy boundaries. On a larger scale, efforts should be made to revise widely used texts and teaching materials to include a more nuanced approach to cultural competence and professional boundaries.

Participants also discussed the need for substantial support. Academic program directors, professors, and student supervisors may benefit from training on how to give space to students to process their identity and reflect on how it impacts their work/fits into the profession. Education programs of other professions have made efforts to create a learning environment more conducive to retention and success of students of color. For example, Matthews et al. (2022) discussed the diversity goals of a college’s nursing program and along with developing a more diverse faculty, recommended linking students to academic advisors and peer mentors to provide built-in support.

All participants identified the need for increasing the diversity of the profession and some suggested early recruitment of diverse students and more widespread education about the child life profession. Mclean et al. (2018) assessed the effectiveness of exposing high school students of color to healthcare research and professions via summer internship programs; this may be a route for the ACLP to consider. Many suggestions made by participants are validated in the recent changes made to the internship application process. With the development of the new Internship Readiness Common Application, the ACLP has made efforts to reduce bias and increase accessibility (Association of Child Life Professionals, 2023).

This is the first study to explore the experiences of child life students of color. Their insights provide much-needed perspective on the barriers and pathways to becoming a CCLS. Future research should explore the lived experiences of child life students with other marginalized backgrounds. Such research may help to identify mechanisms for support and ultimately diversify the field, thereby sustaining students, specialists, and the patients and families they serve.