Child Life Internship Readiness: Perspectives of Child Life Academics

Child Life Internship Readiness: Perspectives of Child Life Academics

Certified Child Life Specialists provide psychosocial services to children, youth, and families aimed at preventing the harmful impact of pediatric hospitalization or other life disruptions (Romito et al., 2021). Often employed in hospitals, child life specialists provide developmentally informed interventions, such as therapeutic play, expressive modalities, and psychological preparation, to facilitate coping and normalization. To become a Certified Child Life Specialist (CCLS), a student must meet the Child Life Certification Commission (CLCC) Certification Eligibility Requirements including completion of ten university level courses, a 600-hour internship supervised by a CCLS, and a bachelor’s degree to establish eligibility to sit for the Child Life Professional Certification Exam (ACLP, 2022c). Multiple mentors support the professional development of an emerging child life specialist, including the faculty of child life courses and the coordinators and supervisors of child life practicums and internships.

Recently, the ACLP reported the number of CCLS has grown from 4,064 in 2009 to more than 6,456 in 2022 (ACLP, 2022c). Child life academic programs continue to have cohorts of child life students entering programs each academic year, but there is an anecdotally evident decrease in students obtaining internship placements. Understandably, this gap in the training cycle does not support the growth of the child life profession and has left many students with disruptions in their professional development and financial stability (Sisk & Wittenberg, 2021). This gap has contributed to the current job crisis whereby many open child life specialist positions are left unfilled (Heering, 2022).

Historically, child life has been seen as a competitive profession and students often spend multiple semesters waiting to receive an internship position. Reportedly, child life internship coordinators often receive 50 to 100 applications from prospective internship students each application round, but despite the large number of students enrolled in child life academic programs, some hospitals do not fill their open internship positions (Sisk et al., 2023). When obtaining an internship position is so difficult, these un-filled positions are especially concerning. This gap suggests a disparity between students’ academic preparation and the expectations of child life internship programs.

When discussing child life, four components are often generalized into one: (a) the emerging academic discipline, (b) the emerging field of inquiry (research), (c) the profession, and (d) the professional organization (ACLP; Sisk & Cantrell, 2021). In 2020, the ACLP launched the internship readiness project with the aim of improving the internship process experience and supporting more shared communication between the four components of child life. One of the tasks of the internship readiness project was to construct a consistent set of knowledge, skills, and abilities (KSAs), or critical competencies necessary for an “internship ready candidate” (ACLP, 2022b). The ACLP recommended that internship sites use this document starting with the Fall 2023 internship selection round. It is not clear, however, what KSAs the academic community deem necessary when preparing students. The present study builds on the existing evidence related to child life student training readiness (Sisk et al., 2023). The purpose of this mixed-methods descriptive study was to understand what child life academics prioritize when preparing students for internship readiness. The following research questions guided this study:

1. What do child life academics prioritize when preparing students for internship?

2. What makes a child life student qualified for a child life internship?

3. What makes a child life student unqualified for a child life internship?

4. How many rounds of internship applications do child life academics recall students have applied for from 2015 to 2020?

       a. Has the number of application rounds students have applied for changed over time?

5. Why do students apply to more than one internship round?

6. What academic alternatives are provided for students who do not secure a child life internship?

Method

This paper is part of a larger study examining child life internship training readiness from two stakeholder’s perspectives: (a) child life clinical internship coordinators and supervisors (Sisk et al., 2023), and (b) child life academics. This paper will focus on internship training readiness from the child life academics’ perspectives. The operational definition of a child life academic for this study was a CCLS employed by an academic institution to teach child life coursework in any capacity (i.e., full-time, part-time, and adjunct).

A concurrent triangulation mixed-methods design (Creswell et al., 2003) was used to gather both quantitative and qualitative data on child life academics’ perceptions of what KSAs they see as indicating child life internship readiness with an online survey and optional submission of abbreviated course syllabi. In this mixed-methods design, researchers select the primary and secondary methodologies while collecting qualitative and quantitative data simultaneously. In this study, qualitative design was the primary approach (Braun & Clarke, 2012) with quantitative design being the secondary approach with the mixed-methods design combination providing in-depth answers to the research questions (Creswell et al., 2003). This study was approved by the institutional review board of the third author.

Participants

Participants (n = 18) consisted of current child life academics who held the CCLS credential, were employed by an academic institution to teach, and who had been teaching child life coursework during the years of 2015 to 2020. A total of 17 academic institutions were represented in the sample. One participant represented two institutions, and two participants were affiliated with the same institution (on two occasions). The academic institutions in which participants were employed were in a variety of U.S. regions. Table 1 includes a breakdown of participant roles and program information. Approximately 72 child life academics were recruited for study participation via email and 257 child life academics were able to review the recruitment post in the ACLP Child Life Connect forum. Of the 28 child life academics who agreed to participate, ten participants were removed from analysis due to incomplete or missing data, thus yielding an approximate response rate of 5.47%.

Approximately 22% (n = 4) of the sample submitted optional abbreviated course syllabi to the researchers, representing five child life academic programs: three undergraduate and two graduate programs. One participant provided syllabi for their undergraduate and graduate child life programs. Three participants, representing undergraduate child life programs, submitted a total of 19 course syllabi, and two participants, representing graduate child life programs, submitted a total of 14 course syllabi.

Measures

Child Life Training Readiness-Academic Instructor Survey. Participants completed the Child Life Training Readiness-Academic Instructor Survey (CLTR-Academic; see Appendix A), a measure created specifically for this study by the authors. The authors, who have each completed their doctoral degrees, served a combined 25 years in child life academic preparation for students, and worked for a combined 21 years as clinical child life specialists, developed this measure by separating common intern candidate expectations into categories of KSA as reflected in ACLP’s internship readiness KSA document (ACLP, 2022b). The survey consisted of seven questions about participants’ job, academic institution, and child life program(s) where participants worked; one quantitative question about the amount of rounds their students submitted internship applications; and six open-ended qualitative questions assessing the participant’s perceptions of indicators of child life internship readiness. At the end of the survey, participants were provided with the option of emailing abbreviated versions of their child life course syllabi to the third author.

Child life course syllabi. Participants had the option to provide syllabi information for courses meeting the CLCC’s Academic Coursework Requirements, including the ten CLCC Certification Eligibility Required Courses (Table 2). Data requested from the syllabi were the course title, course description, course objectives, and course credit hours. Participants submitted the syllabi data in any format they preferred via email.

Procedures

The CLTR-Academic survey was hosted through Qualtrics, an online survey management system. Participants had to complete the electronic informed consent before participating in the CLTR-Academic survey. A follow-up recruitment email was sent to potential participants four weeks after the initial invitation. The survey was open for data collection from November 2021 to December 2021. The median amount of time it took for participants to complete the survey was 34.91 minutes.

Data Analysis

In this concurrent triangulation mixed-methods study (Creswell et al., 2003), qualitative data were analyzed via thematic analysis resulting in the discovery of themes emerging from the data (see Appendix A). Utilizing the six phases of thematic analysis, the researchers became familiar with the data, generated initial codes, searched for themes, reviewed potential themes, defined and named themes, and reported on the themes (Braun & Clarke, 2012). After codes were initially generated, the researchers met to discuss differences in coding and reach a consensus. Next, researchers searched for and discussed the themes that emerged from the data. During this discussion, researchers reflected on their potential biases regarding child life training. The researchers then estimated frequency analyses and paired samples t-tests to analyze the quantitative survey data. All data (i.e., qualitative, quantitative, and course syllabi) were triangulated to answer the research questions.

Qualitative survey question 14 was used to answer research question 1, and qualitative survey question 11 was used to answer research question 2. For research question 3, two qualitative survey questions were analyzed (questions 12 and 13). For research question 4, descriptive statistics were provided from survey question 8, and paired samples t-tests were estimated to understand whether there had been change over time in the amount of application rounds students applied for. Qualitative survey question 9 was used to answer research question 5, and qualitative survey question 10 was used to answer research question 6. Course syllabi content was analyzed in relation to the CLCC Required Academic Coursework and incorporated in the research questions to corroborate survey findings (ACLP, 2022c).

Researcher Reflexivity

As stakeholders in the child life internship process, the researchers have work experience as child life academics and clinicians, supporting students at every touchpoint in their child life education; however, because the researchers have all been in full-time child life academic positions at some point in their career, we recognize the possibility of bias toward participant experiences in academia. Reflexivity was used during the thematic analysis process and each researcher discussed the biases that emerged while coding and searching for themes. We have reflected on our biases and attempted to balance this viewpoint in all aspects of the study, including survey development, participant recruitment, data analysis, and writing of results.

Results

Results provide insight into how academic programs prepare students for child life internship and the KSAs that child life academics assess when evaluating internship readiness.

Student Preparation

To answer the first research question, one qualitative question inquired about how child life academics prepare students for internship (CLTR-Academic, question 14): Participants reported holding individual and group advising appointments, integrating internship preparation into course requirements, and hosting a specific workshop or orientation devoted to the internship application process as to how they help prepare students for internship. Most salient, participants reported spending time discussing internship preparation in advising appointments. For example, Participant 18 mentioned, “I do a lot of 1:1 meeting preparation with individual students.” Some participants also integrated internship application preparation into course requirements. For example, Participant 14 noted, “One assignment in my course has been to complete the common application, and I provide feedback on common app questions as well as making sure they understand the information to provide.” Lastly, some participants indicated they host a specific workshop or orientation devoted to preparing for internship applications. Some programs do all three: “We provide an orientation to the application process, have added the completion of the application to a course, and provide moc[k] interviews” (Participant 1).

Below is an excerpt of the course description and course objectives from a syllabus for the one child life course taught by a CCLS course requirement (ACLP, 2022c):

Introduction to theories and research about the impact of illness and injury on children and families within the healthcare environment. Provides an overview of the profession and steps required to become a Certified Child Life Specialist.

Course objectives: 1) Explain development and evolution of pediatric healthcare and the child life profession. 2) Articulate the impact of illness and injury, as well as their related stressors, on children and families. 3) Assess the developmental and psychosocial needs of hospitalized children and families. 4) Facilitate interventions to mitigate the impact of stress and trauma on children and families. 5) Describe the process to become a Certified Child Life Specialist.

The final course objective suggests that didactic instruction regarding the process for becoming certified includes the internship requirement but does not indicate that specific preparation for internship is included in the course curriculum.

Readiness Indictors

One qualitative question asked participants to identify what KSAs indicate a student is ready for internship (CLTR-Academic, question 11). An “ability to apply theory to their clinical practice” (Participant 1) was the most cited KSA indicating a student is ready for internship (72%). Next, strong communication skills was cited by half of participants as an indicator for child life internship readiness. In addition to “excellent written and verbal communication skills” (Participant 4), participating academics also looked for “confidence in communicating” (Participant 5) and an “ability to interview well” (Participant 3). Regarding specific skills, many child life academics mentioned an “ability to develop rapport with children and adults and an ability to take initiative” (Participant 11). See Table 3 for a list of KSAs discussed by participants.

Areas of Remediation

Two qualitative questions asked participants to identify what KSAs were most often lacking in students applying for internship and what they spend time remediating (CLTR-Academic, questions 12 and 13). Applying theory to clinical scenarios was most often discussed as the skill lacking in students applying for internship. Following this, communication skills were discussed by the participants as a skill lacking in students applying for internship. Participant 8 noted:

Writing skills are generally lacking for most students upon entering our academic program. This is something we work hard at throughout each course. We focus on building stronger writing skills to help aid in professional communication skills, which are practiced in child life courses via video and group assignments.

Though not a KSA, participants noted that their students lacked the hospital-based experience needed when applying for internship. For example, Participant 16 shared: “I can recommend experiences for students to gain even when hospitals aren’t accepting volunteer experiences, but we’ve found many internship sites won’t waiver from their pre-COVID requirements (which often includes volunteering in hospital).” Most participants reported spending a majority of their time remediating students’ application of theory to practice. Participant 10 noted:

I waste a lot of time remediating about old developmental theories like Piaget and Erikson that have been somewhat disproven and are culturally inappropriate and decontextualized. […] I have to remediate on these outdated theories not because they will truly benefit my students’ knowledge and skills, but because child life internship coordinators are so quick to count out students who don’t give a perfect soliloquy on Erikson’s stages on command.

In addition, participants reported spending their time remediating students’ communication skills, confidence in communicating, and interview skills.

Students Applying to More Than One Round

Participants were asked to recall the average number of application rounds their students applied for by year from 2015 to 2020 (CLTR-Academic, question 8). Table 4 displays the means and standard deviations of the average number of application rounds students applied for by year from 2015 to 2020 as recalled by participants. On average, participants recalled that students applied to 1.72 application rounds before obtaining an internship offer (or leaving the field of child life). From 2015 to 2020, there was an increase in the rounds of applications filed by child life students as recalled by participants.

Table 5 displays the frequency data and percentages estimated on the number of application rounds students applied for in 2020 and 2015 as recalled by participants.

To use the rounds of internship applications submitted (as recalled by participants) as a proxy variable for students receiving an internship offer (or leaving the student-to-professional pipeline), four new variables were created from these data: (a) 2015 first round, (b) 2015 second round, (c) 2020 first round, and (d) 2020 second round. Each of these variables were dummy coded from the original 2015 and 2020 variables, respectively. For example, for the new 2015 first round variable, participants were coded whether or not they submitted only one internship round (1) or any number of rounds other than one (0). This coding was repeated for the new 2020 first round variable. Similarly, for the new 2015 second round variable, participants were coded whether or not they submitted two internship rounds (1) or any number of rounds other than two (0). This coding was repeated for the new 2020 second round variable.

Paired samples t-tests were estimated on students applying to one round and two rounds of internship applications over time (Table 6). Table 6 shows that 15% of students stopped submitting internship applications after one round in 2020 and 69% of students stopped submitting internship applications after one round in 2015 as recalled by participants. The results of this t-test are statistically significant (p < .01), meaning there has been a significant change in the number of students getting internship offers in round 1 between the years of 2015 and 2020, with students in 2020 significantly less likely to receive an internship offer in round 1 compared to students in 2015 as recalled by participants. Also, Table 6 shows that 67% of students stopped submitting internship applications after two rounds in 2020, and 25% of students stopped submitting internship applications after two rounds in 2015 as recalled by participants. The results of this t-test are statistically significant (p < .05), meaning there has been a significant change in the number of students getting internship offers in round 2 between the years of 2015 and 2020, with students in 2020 receiving significantly more internship offers in round 2 compared to students in 2015 as recalled by participants.

Reasons Students Apply for Multiple Internship Rounds

One qualitative question asked participants to explain the circumstances and reasons child life students apply to more than one internship round (CLTR-Academic, question 9). Most salient was the theme of competitiveness, including the supply and demand, of the child life internship and that students did not receive offers for internship sites. Several participants noted a “lack of preparation for internship interviews” (Participant 14) as the reason for applying to more than one round, and a couple of participants identified limited experiences and lack of initiative as rationales.

Academic Alternatives to Internship

One qualitative question asked participants to discuss educational alternatives that academic programs provide students who do not receive an internship offer to ensure the student graduates from the degree program (CLTR-Academic, question 10). The responses were evenly split, including encouraging students to switch majors or degree programs, accepting alternative field experiences for graduation, or delaying graduation until an internship is secured. Some participants mentioned the option of students graduating and returning as a non-matriculating student for affiliation. Participant 4 outlined the options for their institution: “Degree granted, but not certification eligible; take additional coursework post-graduation to be affiliated, and re-apply for internships, apply as a non-affiliated intern; enroll in graduate school elsewhere, as our university does not offer [a graduate program].”

Discussion

Child life is a growing profession (ACLP, 2022a) that relies on a symbiotic student-to-professional pipeline to propagate the profession. In this study, we asked child life academics their perspectives on what KSAs were prioritized when preparing students for the child life internship. The results indicated that child life academics help students prepare for internship in a variety of ways, including with advising sessions (individual or group), coursework, and internship-specific workshops or orientations. These findings are not surprising and begin to document the role of child life academics in supporting students within the student-to-professional pipeline, which contributes to the child life profession’s sustainability. In addition, these findings begin to outline student experiences leading up to the internship interview (if they obtain one).

When preparing students for the child life specialist career, child life academics consider specific KSAs as indicators of internship readiness. The most identified indicator of readiness was applying theory to practice, followed by verbal and written communication skills, and developing rapport with children and adults. Applying theory to practice is an abstract concept for students to understand and implement in the classroom setting. The last item identified was the students’ ability to take initiative. While these KSAs can be taught and simulated within an academic program, it would be beneficial to students if academic programs and clinical sites collaborated and discovered innovative ways to tie classroom learning to real-time interactions with children and families in the healthcare setting.

One crucial point of discussion revealed in these findings was that child life academics recalled the number of child life students applying for more than one internship round increased from 2015 through 2020. This recall of an increase in internship application rounds by students indicates that there was (1) variability in the number of internship positions being offered, (2) an increase in the number of students pursuing child life during this six-year range, or (3) some combination of the two. Looking back, the CLCC’s Certification Requirement of the one CCLS taught course was expected for the November 2013 Certification Exam (CLCC, 2011). The inclusion of the one CCLS taught course was an effort to include child life-specific academic knowledge to the certification requirements. The remaining CLCC Certification Exam Eligibility Coursework Requirements represent the generalist academic education in human and child development, which are foundational for child life specialists, but do not provide the in-depth application of knowledge to child life practice required by internship coordinators and supervisors (Sisk et al., 2023). The addition of the one CCLS taught course opened the door for larger numbers of students interested in child life to be considered for limited clinical internship positions. The one CCLS taught course was an important initial step for ensuring students applying for certification were exposed to child life at an introductory level before the child life master’s degree requirement was set to begin in 2022 (CLC, 2013). However, while founded in a generalist human/child development and family sciences education, the present findings indicate additional education and training is needed to equip students to translate theory to practice, synthesize assessment, and implement intervention, as a child life intern and entry level child life specialist. Perhaps this additional education and training looks like child life-specific academic programs.

Child life academics support students who apply for multiple child life internship rounds. Participants identified two primary reasons for students applying to more than one round of internships: competitiveness and not receiving an internship offer. These responses indicate the supply of students to the demand for limited internship positions is misaligned. Similarly, the dietetics profession experienced an imbalance in the number of internship positions available for qualified dietetic students which was associated with the lack of registered dietitians to sufficiently fill the job market (Lordly, 2002). The dietetics profession noted the lack of internship positions created a competitive culture among students in dietetics academic programs which was in opposition to the course experience academic professionals fostered for learning (Lordly & MacLellan, 2008).

Child life students face several undesired options in the academic program when not receiving an internship offer. They may be required to change concentrations or degrees which then requires the student to spend more time and money to complete their degree. Students may be able to graduate with the option to return to enroll in the internship course for clinical affiliation agreements if/when they receive an internship position. This, too, requires more investment of time and money, because when a student is not pursuing a degree, financial aid is not available so they must pay out of pocket. Some academic programs allow students to complete alternative field experiences with children and families to graduate as planned, but this often leaves the students pursuing child life feeling as if they have failed since they did not receive a child life internship. Other academic programs allow students to take additional coursework for a semester as they reapply for internship positions, but changes with financial aid may require students to be enrolled in courses required for the program of study or financial aid will not pay for the courses. Each of these options further delay training and exacerbate the job crisis (Heering, 2022). Once again, we suggest that it would be beneficial to students if child life academic programs and clinical internship training sites collaborated and discovered innovative ways to support students throughout their pathway to the profession.

Limitations

This is the first study to look at the perceptions of child life academics related to students’ internship readiness. As with any research, there are limitations. First, in social science research, memory recall is not always accurate. The CLTR-Academic survey question 8 asked child life academics to recall the average number of application rounds to which their students applied from 2015 to 2020. If we were to have asked participants for the exact number of students applying to internships after each application round over the last six years, the data collected may have been different; however, because this topic has not been studied and no data has been published on this phenomenon, we felt it was important to include the data and findings despite the limitations. Thus, the results to research question 4 must be interpreted within the light of these limitations. Second, this study had a small sample size, which is unrepresentative of all child life academics. Therefore, study findings are not generalizable to all child life academics. Consequently, the quantitative analyses do not have the statistical power to draw a robust conclusion about trends in the number of application rounds submitted by students over time. An additional limitation of the quantitative data is that it is unclear whether the number of application rounds is a proxy variable for acceptance of internship offers or leaving the child life student-to-professional pipeline because they did not receive an internship offer.

Researcher bias is an additional limitation of this study. Though it is not possible to avoid bias in qualitative research, it is recommended that other professionals who work closely with the child life training model contribute to this line of research. Recognizing these limitations, additional research is needed to further examine child life internship readiness from the academics’ perspectives.

Future Research

For this study, child life internship stakeholders, including child life academics, internship coordinators, and supervisors, shared their perspectives of child life internship readiness. Yet, there is a need for future studies to focus on students in the student-to-professional pipeline including those applying for an internship and those who recently completed the internship. The experiences of students pursuing child life internships including their child life academic preparation, number of internship sites applied to, feedback received post-application, and the number of application rounds they applied to before receiving an internship or if they ended their pursuit of child life without an internship would provide valuable data to inform the profession.

Pedagogical research of the 1) Internship Readiness Knowledge, Skills, and Abilities, 2) Child Life Competencies, and the 3) Child Life Professional Certification Examination Content Outline including Domains and Tasks could identify where child life students learn each component’s content either in child life specific academic programs, child life practicums, or clinical child life internships. This identification could eliminate duplication of efforts among the three learning experiences allowing child life professionals in each area to fully focus on their responsibilities for either academically educating or clinically training students. Research investigating various disciplines’ approaches to student education and training would benefit the child life profession. Gathering student-to-professional pathway data from fellow allied health professions to assess student education and clinical training models other than the competitive apprenticeship model child life currently uses would inform the profession of best practices for academic education and clinical internship training. Continued child life research regarding the academic education and clinical training of students for successful entry into the profession is warranted.

Conclusion

This is the first study on child life internship readiness from the perspectives of child life academics. This paper was an extension of Sisk and colleagues (2023) that examined the perspectives of child life internship coordinators and supervisors. The results and discussion from this survey with child life academic professionals add to the conversation about the profession’s expectations for internship readiness. Study findings showcase the increasing delays and difficulties students experience obtaining a child life internship. Child life academics and internship coordinators and supervisors are vital stakeholders in the student-to-professional pipeline because both perform unique roles in supporting students pursuing a child life career. Improved awareness, communication, and collaboration between each of these groups would be a strong first step in addressing the profession’s need for improving the documented job crisis in child life.