Comfort Measures for Invasive Procedures: A Major Paradigm

Comfort Measures for Invasive Procedures: A Major Paradigm Shift in Pediatric Practice

Knowing how many children, families and healthcare providers have benefitted from“Comfort Measures,” we asked Mary Barkey to reflect on the history of the comfortpositioning techniques that she pioneered in partnership with the late Barbara

Stephens.

“We’ve been very fortunate,” she says. “If you’d told me 15 years ago that I’d be traveling around the country speaking [at conferences and grand rounds], I’d have toldyou you were crazy!”

The comfort measures/positioning model for children having stressful procedures was initially inspired by Mary’s observations in the treatment room during her first fewyears as a child life specialist at Rainbow Babies and Children’s Hospital in the early1980s. A typical approach is described in an article she coauthored, entitled“Techniques to comfort children during stressful procedures” (Stephens, Barkey and Hall, 1999):

The child was taken into the treatment room while the parents waited outside the door.Often the child was not prepared in any way for the procedure other than being told thetype of procedure to be performed—“You need an i.v.,” for example, or, “We are goingto put a tube in your nose.” The child was forced to lie supine on the table with staffmembers pinning the child down. The number of staff were increased until the childwas sufficiently immobilized to perform the procedure, at times requiring 4 to 5 adults.(p.49)

“I remember thinking, ‘Why are we traumatizing our children like this? Isn’t there a betterway to do these procedures?’” Mary recalls. So she began talking to her colleague BarbaraStephens, a nurse, and they discussed their ideas for transitioning to a team approach for procedures, which would be child- and family-centered. Thus began a period of exploration,intervention, and change at Rainbow Babies and Children’s (RB&C) that resulted in the development of the Comfort Measures model.

Mary and Barbara identified doctors who they thought might be open to something new.With the support of these doctors, they involved parents, caregivers, and children in various proce-dures. “It quickly became clear that the children really wanted to have their parents [or care-givers] with them, and to be able to sit up.” Mary says, “It now seems to be such common sense,but back then it was a real paradigm shift.” The Comfort Measures model includes preparationfor the child and family, providing a role for everyone, positioning the child (sitting up wheneverpossible), creating a calm environment, and having the child choose distraction techniques.

Although this model was now commonly used at RB&C and began to generate interest fromnearby programs, it was still not widely accepted. Convinced that they were onto somethingunique that would be helpful to the pediatric healthcare community, Mary suggested to Barbarathat they submit a proposal for the 1992 conference of the Association for the Care of Children’sHealth (ACCH).

Not only was the proposal accepted; it was well-received at the conference by a room filled tocapacity with healthcare professionals interested in hearing more about the Comfort Measures

INSIDE

2 President's Perspective

3 Child Life Beyond the Hospital Has Arrived

4 From the Executive Editor

6 Election Results

IN FOCUS:EBP Statement on Therapeutic Play

VOLUME 26 • NUMBER 3 SUMMER 2008

Mary Barkey, MA, CCLS

continued on page 5

As I finish my term as President of theChild Life Council, I’d like to thank theCLC Executive Board, volunteer leaders,

and staff for their hard work, dedication, andsupport. I have had the pleasure of workingclosely with many passionate individuals,who not only have helped further the mis-sion of the Child Life Council, but also havedemonstrated a constant desire to better thelives of the children and families we serve. It has been an exciting year of growth for theorganization: we achieved record-breakingnumbers with a membership high of morethan 3,700; developed and implemented anew strategic plan; and unveiled a new Website that enhanced our members’ onlineexperiences. We published two evidence-based practice statements, created a 25thAnniversary DVD, held our first online elections, conducted a new salary survey, and continued to develop new and existingcommittees and task forces.

I’d like to share more information abouttwo of these initiatives.

We are very excited to present the secondCLC Evidence Based Practice Statement,Therapeutic Play in Pediatric Health Care: TheEssence of Child Life Practice, which appearson Focus page 1. The third Evidence-BasedPractice Statement, on assessment, will beavailable later this year. Look for the state-ments in printer-friendly format in theResource Library section of the CLC Web

site. Many thanks to outgoing Board mem-ber Stephanie Hopkinson for her leadership on this important project.

As part of the ongoing implementation ofour new strategic plan, I recently created theBill of Rights Task Force, which is chaired byCLC Board member Cathy Humphreys.There has been much discussion and interestas to whether or not the child life professionand the families we serve would benefit froma Child Life Bill of Rights. As we all know, a great deal of information relating to therights of children is already available, onboth a national and international level. Thisnew task force will research existing resources,explore the impact a Child Life Bill of Rightswould have, and make recommendations tothe Board based on their analysis.

In addition to taking part in these excitingnewer initiatives, I have been privileged toexperience firsthand the work that is beingdone to improve two of our most well-estab-lished, successful programs: Conference andCertification. Over the past year, I have hadthe opportunity to attend several importantcommittee meetings, and I was impressed bythe amount of time, energy and ingenuitythat each participant dedicated to improvingthe programs. I think many of us, (myselfincluded prior to this year’s participation),are not aware of the work that goes intothese programs. Those of us who attendedthis year’s highly successful AnnualConference in San Diego certainly enjoyedthe product of the Conference PlanningCommittees’ efforts!

This has also been an extremely busy yearfor the Child Life Professional Certificationprogram, which has benefited from the hardwork of the Child Life CertificationCommittee (CLCC) and its subcommittees.In February, the Exam Assembly Committee,led by Sharon McLeod, met in San Diego tofinalize upcoming exams. In addition,Certified Child Life Specialists fromSouthern California participated in an examdevelopment education session and itemreview process.

The Practice Analysis Task Force then metin March to begin the process of evaluatingand revising the exam blueprint, whichdefines current child life scope of practice.This process will ensure that the certificationexam continues to accurately reflect the skillsrequired of an entry level practitioner.

2 A PUBLICATION OF THE CHILD LIFE COUNCIL

BULLETIN SUMMER 2008

PRESIDENT’S PERSPECTIVE

Year in ReviewBarbara Gursky, MA, CCLS, Bristol-Myers Squibb Children’s Hospital at Robert Wood Johnson University Hospital, New Brunswick, NJ

“Never doubt that a small group of committed people can change the world; indeed, it is the only thing

that ever has.”

— Margaret Mead, anthropologist

Child Life Council Bulletin/FOCUS11820 Parklawn Drive, Suite 240, Rockville, MD 20852-2529

(800) CLC-4515 • (301) 881-7090 • Fax (301) 881-7092www.childlife.org • Email: [email protected]

President Executive Editor Executive Director Managing EditorJanet Cross Joan Turner Susan Krug Genevieve Thomas

Published quarterly, mailed the 18th of January, March, June and September. Articles should be submittedby the 15th of January, April, July and October. Please see Submission Guidelines in the Bulletin Newslettersection of the CLC Web site for more information.

For information on how to place an ad in the Bulletin, please refer to the Marketing Opportunities section of the CLC Web site: http://www.childlife.org/Marketing Opportunities/

continued on next page

So, as I pass the gavel to Janet

Cross, I would like to personally

thank all of those individuals—

CLC staff, board members,

volunteer leaders and

members—for allowing me

to serve the Child Life Council.

The CLC Bookstore is pleased toannounce the release of an exciting newpublication: the eagerly-anticipated ChildLife Beyond the Hospital, which documentsthe ongoing expansion of the child life pro-fession into new practice arenas. Whetheryou are preparing to embark on a newcareer outside of the hospital, or merelykeeping abreast of current trends in thefield, Child Life Beyond the Hospital is aworthwhile addition to any child life spe-cialist’s library.

Each chapter in Child Life Beyond theHospital was written by a child life specialist(or child life specialists) with experienceapplying child life skills in a non-traditionalsetting. While the intention of this newresource is not to teach the reader all of thenecessary clinical skills to practice in a par-ticular setting, each chapter can be considereda detailed introduction to the setting for thosewho are interested in exploring it further. Forthe academic reader, it also provides insightinto the changing and expanding dimensionsof the child life profession, as the authors dis-cuss the ways that they have adapted theirchild life expertise to new environments.

The Child Life Council worked withmember and former CLC president Melissa

Hicks to develop the concept and plan theproduction of Child Life Beyond the Hospital.“Over the last several years, there has beenincreased interest in child life practice out-side of hospital settings,” says Melissa.“People would often consult me — and oth-ers working in nontraditional settings —with questions about how to get started.Although the topic has been addressed in the

Bulletin and in discussions on the CLCForum, I thought it merited a full-lengthpublication.”

WHAT’S INSIDEChild Life Beyond the Hospital provides

readers with an introduction and conceptualframework for the topic of alternative set-tings. Each of the 19 chapters describes aspecific setting, presenting a rationale or the-oretical foundation for the application ofchild life in that setting, and a discussion ofthe potential roles and responsibilities thatchild life specialists might have there. Theauthors reflect on specific considerations forpractice, as well as the challenges and rewardspresented to those who choose to work in aparticular environment. Some chapters alsoinclude sample forms, contracts, brochures,and other materials.

To order, please visit the CLC Bookstoreat http://www.childlife.org/Book Store/

Format: Paperback

Editor: Melissa Hicks, MS, CCLS, LPC, RPT

Publisher: Child Life Council, Inc.

Language: English

List Price: $48.00 U.S. (CLC Members)$55.00 U.S. (Non-Members)

Child Life Beyond the Hospital Has Arrived!

A PUBLICATION OF THE CHILD LIFE COUNCIL 3


Child Life CouncilEXECUTIVE BOARD 2008-2009President Janet Cross, MEd, CCLS

Past President Barbara Gursky, MA, CCLS

President-Elect Ellen Good, MSEd, CCLS

Secretary Chris Brown, MS, CCLS

Treasurer Sheri Mosely, MS, CCLS

Members-at-Large Barbara Blair, CCLSEllen Hollon, MS, CCLSPatricia “Trish” Haneman Cox, MSEd, CCLSNicole Graham Rosburg, MS, CCLS

CACLL Liaison Cathy Humphreys, BASc, CCLS, CLSt

CCLS Senior Chair Jill Koss, MS, CCLS

Executive Director Susan Krug, CMP, CAE

To contact a Board member,please visit the CLC Member Directory at

http://www.childlife.org/Membership/MemberDirectory.cfm.

During this meeting, task force membersworked with a testing expert to review theperformance domains (assessment, inter-vention, professional responsibility), iden-tify tasks within each domain, and identifythe knowledge and skills required for eachtask. In addition to this internal validationprocess, a survey will be sent to 1,500practicing child life specialists, solicitingtheir input. The new exam content out-line will be based on these findings.

I applaud all of those who over the yearshelped bring the certification program tosuch a high, professional standard. TheCLC staff, in particular, Ame Enright,CLC Certification Coordinator, has done atremendous job assisting with activitiesthis year.

So, as I pass the gavel to Janet Cross, Iwould like to personally thank all of thoseindividuals—CLC staff, board members,volunteer leaders and members—for allow-ing me to serve the Child Life Council. Ithas been a true pleasure getting to knowand collaborate with so many of you, and Iam proud of what we have accomplishedas a team. With the development of a newstrategic plan, we have implemented adynamic process that will allow us to beresponsive to a constantly evolving—andoften uncertain—healthcare environment.I believe that we have laid the groundworkfor enormous growth potential over thenext five years, and I look forward todoing my part to help us reach an evenhigher level of excellence!

YEAR IN REVIEWcontinued from previous page

When I came on board the editorialpanel of the CLC Bulletin/Focus in thefall of 2006, I was prepared for a great

adventure and learning opportunity. Therole of Associate Editor was really an appren-ticeship; in the beginning, I was allowed towatch and learn from the Executive Editor,and then was introduced slowly to the chal-lenging work of producing the Bulletin on aquarterly basis. Before I knew it, nearly ayear had passed. The 25th AnniversaryEdition was going to press, and we wereplanning for my transition into the role ofExecutive Editor.

The 25th Anniversary issue represents theculmination of child life collaboration, shar-ing and achievements. We owe a debt ofgratitude to outgoing Executive EditorKathleen Murphey for her visionary leader-ship and dedication in creating a commemo-rative issue to celebrate the development ofthe profession over the past quarter century.This important resource is a valuable addi-tion to the child life literature base, and willcontinue to serve us all very well as we sharethe progression of our profession with fami-lies, students, administrators, and policymakers. It may also serve to inspire all of us,not only to continue to grow and achieve asa profession, but also to document the futureof our good work as it unfolds.

As with all leadership positions in profes-sional fields, the need to step up and replen-ish the space left by others is imperative.Humble as we are, we do not all see ourselvesas future leaders or contributors to the field.Thus, the role of current leaders is to inspireand encourage others to step out of theircomfort zones, speak up, and take on chal-lenging opportunities. In my role asExecutive Editor over the next two years, Iaim to work in this spirit. The editorialpanel will present a range of opportunitiesfor more child life specialists to have a voicein the publication.

Along with a change in the Bulletin/Focuscolor scheme to mark the editorial transition,here are some of the plans for the near future:

Writing Mentors: In a positive effort tosupport and promote the aspiring writers inour profession, the program at CLC’s 26thAnnual Conference on Professional Issuesincluded a writers’ workshop for aspiringauthors. It is our hope that the relationshipsand skill development initiated at the work-

shop will manifest into a series of informa-tive new articles ready for submission to theBulletin and Focus in the near future.Interested members who were unable to attendthe workshop are encouraged to contact theManaging Editor at [email protected] forfurther information.

New Bulletin Column: The Child LifeAlphabet will be a regular feature of theBulletin starting in the Fall 2008 issue.Designed to encourage new writers to submita brief composition (500 words), this col-umn will elaborate on concepts or termsrelated to professional practice. To start usoff in the fall will be “A is for an Attitude ofScience.” We will be seeking contributions forupcoming issues, for example, B is for Basicplay materials: books, balls, blocks, babiesand bubbles. Anyone with a great idea forC, D, E and so on is asked to contact theManaging Editor at [email protected] information on how to proceed.

Transformation of Conference Abstractsand Presentations into Articles: The editorial panel encourages all members who submitted an abstract or presented atconference to consider the value of revisingtheir ideas into an article to share with thegreater membership.

Research-Based Content: The editorialpanel would also like to encourage the sub-mission of research-based articles. As ademonstration of our commitment to evi-dence-based practice, in Focus, we look for-ward to presenting an increased number ofresearch review articles, as well as originalresearch findings completed at the under-graduate, graduate or professional level. Weaspire to creating more space in Focus for thepresentation of research studies related tochild life practice.

It is an honor and a privilege to step up intothe ranks of child life leaders who have editedthe Bulletin and nurtured its growth from asmall newsletter to a vital clinical publication.I look forward to including new and emergingauthors on its pages. The Bulletin/Focus existsto serve the interests of the membership bypresenting a range of administrative, clinicaland empirical information that best representsthe status of the profession at a given point intime. Please contact the Managing Editor [email protected] to offer your suggestionsfor content or features that you would like tosee in the future.

Bulletin Transitions:CONTINUING THE TRADITION OFVISIONARY LEADERSHIP, GROWTH AND CHANGE

Joan Turner, PhD, CCLSExecutive Editor, CLC Bulletin and Focus

FROM THE EXECUTIVE EDITOR



Therapeutic Play in Pediatric Health Care: The Essence of Child Life Practice

CHILD LIFE COUNCIL EVIDENCE-BASED PRACTICE STATEMENTCompleted for the Child Life Council by

Donna Koller, PhD, Academic and Clinical Specialist in Child Life, Project Investigator, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada

Rebecca Mador, research assistant at the Hospital for Sick Children, is gratefully acknowledged for her contributions inthe preparation of this statement.

PREAMBLE

The purpose of this statement is to present empirical findings regarding the value ofplay for children in the hospital and to assert that play constitutes an integral componentof evidence-based practice in child life. This statement is based on a review of the bestavailable research from the year 1960 to December 2006. The following search engineswere used: i) PsycINFO, which records literature from psychology and related disciplinessuch as medicine, psychiatry, nursing, sociology, and education; ii) MEDLINE, whichfocuses on biomedical literature; and, iii) CINAHL, the Cumulative Index to Nursing &Allied Health Literature, which covers literature relating to nursing and allied health pro-fessions. A variety of keywords and combinations such as “therapeutic play,” “hospitalizedchildren,” “recreation,” and “pretend play” were used to conduct the search with the assis-tance of a medical librarian. (See Table 1 for a complete list of keywords used).

Searches revealed 62 articles pertaining to therapeutic play in pediatric settings. After theresults were sorted to exclude repeats and non-empirical based literature, 41 articlesremained, of which 26 were eliminated because their topics were beyond the scope of thisreview (e.g. pet therapy, music therapy, and video games). The remaining 15 articles werescored by one of two independent raters. For the quantitative studies, “The Quality ofStudy Rating Form”1, 2 was used. Articles that received a rating of at least 60 out of 100points were selected for inclusion. Any article that scored between 55 and 65 points wasre-scored by a second rater to confirm inclusion or exclusion. For the qualitative studies,the Qualitative Study Quality Form2 was used.

A total of 10 studies (nine quantitative and one qualitative) is included in this state-ment. Children involved in these studies ranged from 3 to 12 years of age and were hospi-talized for a variety of reasons, including dental surgery, cardiac catheterization and tonsil-lectomies. Eight quantitative studies3-10 used a randomized experimental design to examinethe effects of therapeutic play, while one11 provided a descriptive content analysis of inter-views involving play. The single qualitative study examined the process of play when chil-dren engaged in expressive arts12 (see Table 2 for a list of studies included in this review).

Since evidence-based practice represents an integration of both clinical experience2 andthe best available research13, this statement was also reviewed by Certified Child LifeSpecialists across North America in order to ensure clinical applicability. In addition, evi-dence-based practice acknowledges patient preferences and needs when determining themost appropriate clinical applications for a child and family.


INTRODUCTION TO THECHILD LIFE EVIDENCE-BASEDPRACTICE STATEMENTS

The Child Life Council is very pleased to offer the second in a series of evidence-based practice statements on therapeuticplay in pediatric health care. The CLCExecutive Board commissioned the devel-opment of this statement, with the inputof the Evidence Based Practice andProfessional Resources Committees, inorder to provide members with document-ed validation for best child life practice.

Child life specialists recognize that clinical care and decision-making must be grounded in research-based evidence.CLC has supported the review and analy-sis of outcome research that specificallyaddresses child life practices in order togive child life professionals the evidencethey need to continually advance qualityof practice and to communicate with others on the healthcare team about child life work.

Child Life Council will publish one morestatement in 2009, and it is our hope thatthese will help and encourage members tocontribute to the body of research necessaryfor professional growth and recognition inhealthcare settings.

This statement is available in printer-friendly form on the CLC Web site. Weencourage child life specialists to reviewthe statement and consider, as individualsor teams, the implication for practice.

Editor’s Note: Readers of Focus areaccustomed to seeing articles here presentedin APA format. In the case of theEvidence-Based Practice Statements only,because of the nature of the material, theauthor has elected to use the UniformRequirements for ManuscriptsSubmitted to Biomedical Journalsto make for easier reading.

continued on Focus page 2

THE VALUE OF PLAY

Children from all cultures play. Even incultures where young children are expectedto assume adult work responsibilities, anthro-pologists cite examples of how children man-age to integrate play into their daily tasks14.This suggests that play is not only universalbut essential to human development. Indeed,research has repeatedly shown that the bene-fits associated with play are profound andwide-ranging. Following a meta-analysis of800 studies, Fisher concluded there wascogent evidence for the positive impact ofplay on children’s developmental outcomes15.Play was found to significantly promote cogni-tive and social aspects of development and theseeffects were magnified when adults participatedin play with children. Accordingly, childhoodplay is understood to be critical to children’sdevelopment for multiple reasons, includingthe opportunity to communicate feelings,misunderstandings and concerns in theirown language using both verbal and behav-ioral expression9. Since play teaches childrenhow to handle the world and the social rolesin it, play is the predominant context in whichchildren interface with their environment.

WHAT IS THERAPEUTIC PLAY?Play can be broadly defined as any activity

in which children spontaneously engage andfind pleasurable16. For children in the hospi-tal, specific forms of play can provide an

effective venue for personal development andincreased well-being. In particular, therapeuticplay refers to specialized activities that aredevelopmentally supportive and facilitate theemotional well-being of a pediatric patient.

The discourse on play acknowledgesimportant distinctions between therapeuticplay and play therapy. Although these termsare often used interchangeably, the focus oftherapeutic play is on the promotion of con-tinuing ‘normal development’ while enablingchildren to respond more effectively to diffi-cult situations such as medical experiences17.In contrast, play therapy addresses basic andpersistent psychological issues associated withhow a child may interact with his or herworld. Therefore, therapeutic play, in a lessstructured way, focuses on the process of playas a mechanism for mastering developmentalmilestones and critical events such as hospi-talization.

Since therapeutic play comprises activitiesthat are dependent on the developmentalneeds of the child as well as the environ-ment, it can take many forms9. For example,therapeutic play can be delivered throughinteractive puppet shows10, creative or expres-sive arts12, puppet and doll play7, and othermedically oriented play3-6, 8, 9, 11. It can bedirective or non-directive in approach andmay include re-enactments of medical situa-tions to facilitate children’s adaptation tohospitalization3, 4, 16, 17.

Regardless of the form that therapeuticplay takes, the child life specialist (CLS)ensures that the play is developmentallyappropriate while using language that isunderstandable to the child4, 5, 7. Duringtherapeutic play children are encouraged toask questions to clarify misconceptions andexpress feelings related to their fears and con-cerns3-9. In this way, therapeutic play acts asa vehicle for eliciting information from chil-dren while also sharing information aboutwhat to expect from medical procedures andwhat sensations may be experienced4.

Therapeutic play typically consists of atleast one of the following types of activities:1) the encouragement of emotional expression(e.g. re-enactment of experiences throughdoll play), 2) instructional play to educatechildren about medical experiences, and 3)physiologically enhancing play (e.g. blowingbubbles to improve breathing)16. The studiesreviewed here predominantly address med-ically oriented play, including emotionalexpression and instructional play forms.

RESEARCH ESPOUSING THE BENEFITSOF THERAPEUTIC PLAY

Psychological and Behavioral Outcomes

Several studies have shown that therapeu-tic play is effective in decreasing anxiety andfears for children from the time of admissionto immediately after surgery and to the timeof discharge4, 5, 8-10. In one qualitative study,Wikstrom investigated how children in thehospital experienced expressive arts throughthe use of clay, paint and textile. The pri-mary finding from this study was that thechildren spontaneously described themselvesthrough their art by expressing emotionssuch as fear and powerlessness12. Thus, adefining feature of therapeutic play is its abil-ity to elicit emotional expression leading togreater psychological well-being for a child inthe hospital4, 5. Accordingly, in studies wherechildren were offered therapeutic play, theyexhibited greater cooperation during stressfulprocedures4, 5 and were more willing to returnto the hospital for further treatment7.

In one study, Schwartz, Albino andTedesco found that medically related thera-peutic play was more effective than medicallyunrelated therapeutic play4. The authorsexamined the effects of preoperative prepara-tion on stress reduction in 45 children aged3 and 4 years. The children were randomly


FOCUS SUMMER 2008

continued from Focus page 1

TABLE 1. LIST OF KEYWORDS USED TO CONDUCT LITERATURE SEARCH

PSYCINFOCATEGORY SEARCH WORDS

Therapeutic play Play therapy, childhood play behavior, games, recreation, toys, pretend play, anatomically detailed dolls, childhood play development, children’s recreation games, doll play, role playing

Hospitalized Children Hospitalized patients (limit to childhood and adolescence)

MEDLINECATEGORY SEARCH WORDS

Therapeutic play Art therapy, dance therapy, music therapy, play therapy, role playing, play and playthings,illustrated books, recreation, anatomic models

Hospitalized Children Inpatient (limited to all child), hospitalized child, hospitalized adolescent

CINAHLCATEGORY SEARCH WORDS

Therapeutic play Art therapy, dance therapy, music therapy, pet therapy, play therapy, play and playthings, games,anatomic models, recreational therapy, role playing

Hospitalized Children Hospitalized infant, hospitalized children, hospitalized adolescent, inpatients (limit age from 0 to 18)

assigned into one of three groups: a controlgroup, a medically unrelated play therapygroup, and a medically related play therapygroup. The medically related play includedproviding information to the child and par-ent and a role play that resembled actualmedical procedures with hospital toys.Results from the study concluded that chil-dren in this group were more cooperativeand less upset than children in the other twogroups, which suggests that medically relatedplay can be more effective in alleviating stressthan unrelated play.

Studies have shown that therapeutic playproduces benefits not evidenced with alterna-tive types of play or methods of preparation.Rae and colleagues compared the effects ofplay on the psychosocial adjustment of 46children, aged 5 to 10 years, who were hospi-talized for an acute illness. They randomlyassigned the children to one of four groups:therapeutic play, diversionary play, verbalsupport, and no treatment. The therapeuticplay consisted of playing with medical andnon-medical materials as well as puppets,dolls and toy animals. During this non-directive play, the facilitator encouraged re-enactments of experiences while allowingthe child to reflect and interpret feelings.Results showed that children who engaged in therapeutic, non-directive play showed asignificant reduction in self-reported hospitalfears in comparison with children from othergroups8.

Only one study did not show a statisticallysignificant decrease in anxiety for childrenfollowing therapeutic play. Fosson, Martinand Haley6 investigated the effectiveness ofguided medical play in reducing anxiety inlatency-age children. Fifty children, aged 5 to9 years, were randomly assigned to either thecontrol group, where the child watched TVwith a recreational therapist for 20 minutes,or the experimental group, where a recre-ational therapist facilitated medically-orient-ed play with the child. This study found thatalthough the mean levels of anxiety of chil-dren in the experimental group decreasedmore than children in the control group, thedifference was not sufficient to reach statisti-cal significance. In order to explain thesefindings, the authors noted that the interven-tion consisted of only one 30-minute playsession and the control group had access toother forms of play during hospitalization.

Physiological Outcomes

In addition to relieving psychologicalstress, therapeutic play is also effective inreducing apprehensive physiological respons-es, such as palm sweating, excessive bodymovement, escalating pulse rate and highblood pressure5. In two studies, childrenwho were provided opportunities for thera-peutic play showed less physiological distress,as indicated by lower blood pressure andpulse rate and shorter time between surgeryand first voiding3. They also exhibited lesspalm sweating than children who did nothave opportunities for therapeutic play10.

GAPS IN CURRENT LITERATURE

Although there is considerable literatureconcerning play in hospitals, much of thismaterial is anecdotal and non-empirical.From an evidence-based practice perspective,this is problematic. For instance, little isknown about the process and developmentof therapeutic play. How does play evolveover the course of a child’s hospitalization,and should more complex forms of play (i.e.medically related) be offered only after atrusting relationship has been establishedwith the child? Also, to what extent doestherapeutic play rely on non-directiveapproaches? In terms of timing the introduc-tion of therapeutic play, Young and Fu foundthat regardless of whether needle play took

place before or after the blood test, childrenwho received therapeutic play showed signifi-cantly lower pulse rate five minutes after theblood test when compared to those who didnot3. Although the timing of medical playdid not alter its effectiveness in reducingpulse rate, additional studies should be con-ducted in order to verify these findings acrossdifferent forms of therapeutic play.

The majority of research in this areaaddresses the use of medically related play,while areas such as creative arts, body imageactivities and tension-release forms of playare understudied. Not only is the comparisonof various forms of therapeutic play lacking,but also the suitability of specific types ofplay for particular age groups, gender types,or anxiety levels. As well, it is unclearwhether group or individual therapeutic playis generally more effective for children inhospital.

Perhaps most importantly, there is a limit-ed understanding of how children perceivetherapeutic play through their own descriptionsand experiences. The paucity of research withchildren (participatory) rather than on chil-dren (non-participatory) is recognized asproblematic by those working in the field 18-21.Inherent complexities also are associated with how play is studied and evaluated. For instance, the way in which a child life


FOCUS SUMMER 2008

TABLE 2. FINAL SELECTION OF STUDIES INCLUDED IN THIS REVIEW

• Cassell, S. (1965). Effect of brief puppet therapy upon the emotional responses of children undergoing cardiac catheterization. Journal of Consulting Psychology, 29(1): 1-8.

• Clatworthy, S. (1981).Therapeutic play: Effects on hospitalized children. Journal of Association for Care of Children’s Health,9(4):108-113.

• Ellerton, M. L., Caty, S., & Ritchie, J. A. (1985). Helping young children master intrusive procedures through play.Children’s Health Care, 13(4):167-173.

• Fosson, A., Martin, J., & Haley, J. (1990). Anxiety among hospitalized latency-age children. Developmental and BehavioralPediatrics, 11(6):324-327.

• Johnson, P. A., & Stockdale, D. F. (1975). Effects of puppet therapy on palmar sweating of hospitalized children.The Johns Hopkins Medical Journal, 137, 1-5.

• Rae,W. A.,Worchel, F. F., Upchurch, J., Sanner, J. H., & Daniel, C. A. (1989).The psychosocial impact of play on hospitalizedchildren. Journal of Pediatric Psychology, 14(4):617-627.

• Schwartz, B. H., Albino, J. E.,Tedesco, L. A. (1983). Effects of psychological preparation on children hospitalized for dentaloperations. Journal of Pediatrics, 102(4):634-638.

• Wikstrom, B-M. (2005). Communicating via expressive arts:The natural medium of self-expression for hospitalized children. Pediatric Nursing, 31(6):480-485.

• Young, M. R., & Fu,V. R. (1988). Influence of play and temperament on the young child’s response to pain.Children’s Health Care, 16(3): 209-215.

• Zahr, L.K. (1998).Therapeutic play for hospitalized preschoolers in Lebanon. Pediatric Nursing, 23(5), 449-454.


specialist facilitates play can determine thedegree of therapeutic value and the establish-ment of trust with the child. Qualitativestudies which are more suitable for exploringhealth care issues with children shouldaddress the following questions: how do chil-dren experience therapeutic play with theirCLS and what types of activities are mostmeaningful to them?

SUMMARY

A central goal in pediatric health care is tofacilitate the emotional and physical well-being of children in the hospital16. Researchprovides evidence for the effectiveness oftherapeutic play in reducing psychologicaland physiological stress for children facingmedical challenges. Therapeutic play offerslong-term benefits by fostering more positivebehavioral responses to future medical expe-riences. Since childhood play transcends cul-tural barriers, play opportunities should beprovided for children of all ages and back-grounds.

Despite a large amount of literature pur-porting the value of play, research gaps existregarding the evaluation of therapeutic playin health care settings. Future research mustaddress the play preferences and perspectivesof children if evidence-based practice is toreflect the needs of pediatric patients. Sincetherapeutic play embodies the essence of thechild life profession, it should remain thefocus of ongoing critical analysis and empiri-cal investigation.

Approved by the Child Life Council Executive Board April 2008

REFERENCES1. Gibbs LE. Quality of Study Rating Form: An

Instrument for Synthesizing Evaluation Studies.Journal of Social Work Education. 1989;25(1):67.

2. Gibbs L. Evidence-based practice for the helping pro-fessions: A practical guide with integrated media.Pacific Grove, CA: Brooks/ Cole an Imprint ofWadsworth Publishers; 2003.

3. Young MR, Fu VR. Influence of play and tempera-ment on the young child’s response to pain.Children’s Health Care. 1988;16(3):209-215.

4. Schwartz BH, Albino JE,Tedesco LA. Effects of psy-chological preparation on children hospitalized fordental operations. Journal of Pediatrics.1983;102(4):634-638.

5. Zahr LK.Therapeutic play for hospitalizedpreschoolers in Lebanon. Pediatric Nursing.1998;23(5):449-454.

6. Fosson A, Martin J, Haley J. Anxiety among hospi-talized latency-age children. Developmental andBehavioral Pediatrics. 1990;11(6):324-327.

7. Cassell S. Effect of brief puppet therapy upon theemotional responses of children undergoing car-diac catheterization. Journal of ConsultingPsychology. 1965;29(1):1-8.

8. Rae WA,Worchel FF, Upchurch J, Sanner JH, DanielCA.The psychosocial impact of play on hospitalizedchildren. Journal of Pediatric Psychology.1989;14(4):617-627.

9. Clatworthy S.Therapeutic play: Effects on hospital-ized children. Journal of Association for Care ofChildren’s Health. 1981;9(4):108-113.

10. Johnson PA, Stockdale DF. Effects of puppet therapyon palmar sweating on hospitalized children. TheJohns Hopkins Medical Journal. 1975;137:1-5.

11. Ellerton M-L, Caty S, Ritchie JA. Helping young chil-dren master intrusive procedures through play.Children’s Health Care. 1985;13(4):167-173.

12. Wikstrom B-M. Communicating via expressive arts:The natural medium of self-expression forhospitalized children. Pediatric Nursing.2005;31(6):480-485.

13. Institute of Medicine. Crossing the quality chasm:A new health system for the 21st century.Washington: DC: National Academy Press; 2001.

14. Schwartzman HB. Transformations : the anthropolo-gy of children’s play. New York: Plenum Press; 1978.

15. Fisher EP.The Impact of Play on Development:A Meta-Analysis. Play & Culture. May1992;5(2):159-181.

16. Vessey JA, Mahon MM.Therapeutic play and thehospitalized child. Journal of Pediatric Nursing.1990;5(5):328-331.

17. Oremland EK, Oremland, J.D. Protecting the emo-tional development of the ill child.The essence ofthe child life profession. Madison, CT, PsychosocialPress; 2000.

18. Alderson P. Children’s consent to surgery.Buckingham [England]: Open University Press;1993.

19. Darbyshire P. Guest editorial: From research on chil-dren to research with children. Neonatal, Paediatricand Child Health Nursing. 2000;3(1):2-3.

20. Eiser C. Chronic childhood disease: An introduction topsychological theory and research. New York, NY, US:Cambridge University Press; 1990.

21. Morrow V, Richards M.The Ethics of Social Researchwith Children: An Overview. Children & Society. 61996;10(2):90-105.


FOCUS SUMMER 2008


About the ViewsExpressed in FocusIt is the expressed intention of Focus toprovide a venue for professional sharingon clinical issues, programs and interven-tions. The views presented in any articleare those of the author. All submissionsare reviewed for content, relevance andaccuracy prior to publication.

REVIEW BOARDEstelle Argie Hawley, MEd, CCLS

Metro Health Medical Center,Cleveland, OH

Jaime Bruce, MA, CCLSMonroe Carell Jr. Children’s Hospital atVanderbilt, Nashville, TN

Julie Cooley-Parker, MS, CCLSThe University of Southern Mississippi,Hattiesburg, MS

Jane Darch, CCLSSickKids, The Hospital for Sick Children,Toronto, ON, Canada

Suzanne Graca, MS, CCLSChildren’s Hospital Boston, Boston, MA

Diane Hart, MA, CCLSBC Children’s Hospital, Vancouver, BC, Canada

Kimberly Stephens, MPA, CCLSUniversity Hospitals of Cleveland,Cleveland, OH

Michael Towne, MS, CCLSUCSF Children’s Hospital, San Francisco, CA

Child life specialists work with children inhealth care settings to help promote typi-cal development and minimize the nega-

tive effects of the medical experience on chil-dren and their families (American Academyof Pediatrics, 2006). Research specificallydeveloped to investigate parents’ perceptionsof their involvement with child life specialistscan serve to inform child life professionalpractice. The Joint Commission monitorshospital quality improvement programs, andas a result, many hospitals request feedbackfrom the families of their patients as amethod to monitor the quality of serviceprovided (Child Life Council, 2006). Thestudy presented here explores parents’ percep-tions of the child life services they receivedduring the hospitalization of their child.

The standards for practice established bythe Child Life Council (2006) serve to pro-mote quality child life programming throughdefined criteria. Standards cover areas ofservice related to the provision of psychoso-cial care. Planning, administration and spe-cific child life services described include childlife activities related to patient and familycare, such as play activities, preparation, sup-port, and education, as well as administrativeactivities like collaboration, documentation,and research. Quality improvement researchactivities accessing the perceptions of parentsmay reveal discrepancies relative to the stan-dards of care of the Child Life Council thatcan lead to improvement in the services pro-vided to patients and families.

Child life specialists are members of thehealth care team responsible for providingdevelopmental support for hospitalized chil-dren and families. Trained to apply a devel-opmental perspective, they use their expertiseto encourage typical growth and develop-ment for children in health care settings. Tothis end, a variety of services for hospitalizedchildren are provided. Age appropriate activ-ities, such as infant stimulation, developmen-tal playgroups, arts and crafts, playing games,and computer activities help children copewith their medical treatments. Patient edu-cation is provided for patients regarding

diagnosis, treatments, or upcoming medicalprocedures. Child life specialists function aspart of a support system for families, oftenoffering specific programs such as siblingsupport groups or parent meetings.

Although the services of the child life pro-fession are clearly described in the literature(e.g. Rollins, Bolig & Mahan, 2005), thedegree to which these services are distributedand provided to patients and families mayvary across programs. Quality improvementactivities conducted by individual programs,such as program reviews or patient and fami-ly surveys may remain internal to the pro-gram and may not be shared beyond the spe-cific program. However, related researchactivities such as the survey by Cole, Diener,Wright, and Gaynard (2001) contribute tothe profession by pointing out areas wherechild life programs can improve the servicesthey provide in the health care setting.

Cole et al. (2001) surveyed health careprofessionals, including nurses, doctors,social workers and administrators for theirviews of the role of child life professionals.Many health care professionals ranked childlife specialists as the most important staffwhen it came to the psychosocial well beingof hospitalized children. However, this var-ied relative to the level of contact the profes-sional had with child life staff, and with theprofessional affiliation of the responder.Consistency was found between child lifeand other health care professionals in relationto the perception of child life staff providingpreparation and orientation. In contrast,health care professionals reported that childlife specialists amuse and entertain (e.g. pro-viding services such as age appropriate activi-ties at the bedside or in a playroom) morefrequently than child life specialists them-selves reported those activities. Similarly,rankings of family support, advocacy, andeducation (e.g. support groups, advocatingfor children to the medical staff, providingdiagnosis or procedure education) were notconsistent. The authors suggest these find-ings are important indicators of where childlife specialists can improve in areas related to

cross-disciplinary communication and pro-fessional education. The collection and useof feedback to improve care is in line withthe concept of patient- and family-centered-ness as advocated by the Institute for Family-Centered Care.

Quality improvement activity conductedthrough the implementation of a survey forparents of hospitalized children is one way tocheck the consistency of perceptions andexperiences between parents and the stan-dards of child life practice. Although typical-ly surveys are conducted and applied inter-nally to a specific health care facility, researchcan be conducted in the community byaccessing parents of children who had previ-ously been hospitalized. The internet is onecontemporary network that allows for theidentification of potential study participantsand is increasing in popularity in the field ofhealth (Whitehead, 2007). Programs thatoffer parent-to-parent support such as onlinesupport groups are valid points of contact forconducting research with families(Whitehead, 2007).

One concept of patient- and family-cen-tered care is the practice of collaborationamong health care professionals, patients andfamilies (Hollon & Palm, 2007; Institute ofFamily-Centered Care, nd.). The perceptionfamilies have of the care they receive is a coreelement of the practice of family-centeredcare (Institute for Family-Centered Care).As such, the inclusion of parents in researchstudies provides a voice that should informprograms and practices. According toHollon and Palm,

Our challenge is to continually strive tobetter understand and apply these ele-ments within our daily practice to improveindividual patient/ family experience, thecare delivery system and organizationalpolicy. Through concrete, and demonstra-ble acts we turn philosophy into qualitycare experience for all members of thehealth care partnership (2007, p. 3)


FOCUS SUMMER 2008

Parents’ Perceptions of Child Life Programs: A SurveyHeather Dubrule, MEd, CCLS

Heather graduated from the University of La Verne in California with a Master of Education, special emphasis in Child Life. This research was completed as a component of her graduate coursework. She is currently working in Stonington, Connecticut as a middle school special education teacher.


One way to assess whether patients andfamilies are receiving the child life servicesthey feel they need is to ask them. Alongwith asking questions relative to the actualservices they experienced, it is important alsoto request their opinions about their experi-ence. Without ongoing access to this infor-mation, the health care system, along withchild life services, will not be able to ade-quately attend to the real needs of thepatients and families they serve (Institute forFamily-Centered Care). For example, ele-ments of the service provided, such as timeli-ness, accuracy, and effectiveness must be con-sidered (CLC, 2006). When patients andfamilies are provided a voice and their viewsare being heard, we are demonstrating theability to learn through the experiences ofothers and improve the care we provide forfuture patients and families.

This research approach reflects a qualityimprovement method whereby stakeholders(families) are accessed and provided a voice.The purpose of the study was to review theperceptions of parents whose child had beenpreviously hospitalized. Standard X of theStandards of Clinical Practice (CLC, 2006)emphasizes the use of evidence-based practiceactivities to “continually update and enhancetheir understanding of the children and fam-ilies they serve” (CLC, 2006, p. 11).Engagement in the process of research alsorepresents an element of ethical practice inthe continuing development of the child lifeprofession.

OVERVIEW

Parents of previously hospitalized childrenwere surveyed during the spring of 2006.Survey responses were analyzed usingdescriptive statistics and reflect the percep-tions of the respondents of their experienceswith child life services. Approval for theresearch project was granted by the courseprofessors.

PARTICIPANTS

Sixteen of the 196 initial respondents indi-cated they had not had contact with a childlife specialist during their child’s hospitaliza-tion. Therefore, the analysis presentedincludes 180 parents of a child who had pre-viously been hospitalized and had contactwith child life services.

When asked to indicate a category for

their child’s diagnosis, 60% (108) of therespondents indicated a cancer diagnosis,12.8% (23) indicated a chronic illness, and 27.2% (49) indicated other diagnosis.The child’s age at diagnosis ranged frominfancy through adolescence (Table 1). Themajority of respondents (37.7%) werereporting about a hospitalized infant (lessthan 12 months of age).

PARENT SURVEY

Respondents completed a pen and pencilsurvey developed by the author that consist-ed of 12 questions. Both forced-choice andopened-ended questions were included.Participants were asked if they had receivedservices from a child life specialist when theirchild was in the hospital. If they had, theywere asked what kinds of services theyreceived, which services they felt were benefi-cial, and how the child life specialist impact-ed their hospital experience.

PROCEDURE

Participants were recruited through solici-tation of a variety of Web sites related topediatric health care support groups (i.e.Association of Online Cancer Resources,Chronic Childhood Illness Group).Additionally, some participants passed on thecontact information to friends who alsoagreed to participate. The researcher invitedparents interested in participating in thestudy to contact her. Interested parents sub-sequently received a survey to complete anda letter of consent describing the researchpurpose, tasks, commitment and assurance ofanonymity. Surveys were returned by mailor email.

RESULTS

OVERVIEW

Survey data was coded and analyzed usingdescriptive statistics. The age at diagnosis

variable was recoded and formed four agegroups for analysis: infants (0 – 1 year), tod-dlers (2 – 3 years), preschool (4 – 5 years)and school-aged/youth (6 to 17 years).

FREQUENCY OF COMMONCHILD LIFE SERVICES

Respondents were asked (yes/ no) whethera child life specialist had provided a varietyof child life services. Table 2 presents theresults and indicates that most of the childlife services were experienced by the partici-pants. Almost 90% of the respondents indi-cated receiving age-appropriate activities fortheir child. Only school-reentry, procedure/treatment accompaniment, and grief/bereavement support were not reported to be experienced by the majority of the par-ents. When the school-reentry variable wasexamined by age group, distinctions wereobserved: 88% of the respondents indicatingthey had not received school re-entry serviceswere parents of infants, toddlers orpreschoolers.

Some respondents chose to respond to thecategory ‘other’ by listing services providedby child life. These included referrals to outside programs, such as Make-a-WishFoundation, summer camps, or communitysupport resources; goal-setting for tasks orbehavioral issues; out of hospital experiences(field trips, baseball games); technology pro-grams (use of laptop computers, use of sup-portive Web sites); and encouragement toattend school functions.


FOCUS SUMMER 2008

TABLE 1. DIAGNOSIS CATEGORYBY AGE GROUP

AGE GROUPS DIAGNOSIS CATEGORY (RAW NUMBERS)Cancer Chronic Other Total

IllnessInfant 16 12 40 68

Toddler 40 6 6 52

Preschool 25 0 2 27

School-aged/Youth 27 5 1 33

Total 108 23 49 180

TABLE 2. COMMON CHILD LIFESERVICES RECEIVED

DID THE CHILD LIFE SPECIALIST PROVIDE ANY OF THE

FOLLOWING SERVICES?Yes No

Procedure/Diagnosis 108 (60%) 72 (40%)teaching

Medical play 107 (59.4%) 73 (40.6%)

Procedure/Treatment 82 (45.6%) 98 (54.4%)accompaniment

Distraction 103 (57.2%) 77 (42.8%)

Age appropriate activities 161 (89.4%) 19 (10.6%)

School re-entry 30 (16.7%) 150 (83.3%)

Family support 120 (66.7%) 60 (33.3%)

Grief/ Bereavement support 12 (6.7%) 168 (93.3%)


PARENT PERCEPTIONS OFCHILD LIFE SERVICES

Respondents were asked if they felt childlife services were beneficial to their child.Responses indicate the majority of parents(91.7%) found the services to be beneficial.Analysis by age group indicated that of the 12respondents indicating the services were notbeneficial, 7 were parents of infants, 3 wereschool-aged/youth, and one parent from thetoddler and preschooler group respectively.Follow-up questions were not provided.

Parents were provided a list of child lifeservices and asked to check those servicesthey found most and least beneficial.Additionally, a ranking of those services indi-cated as most beneficial was compiled (Table3). The category age-appropriate activity wasranked first by the majority of parents(22.8%). Also presented in Table 3 are therankings for least beneficial services. Of allthe respondents, 110 parents did notrespond to the question. Medical play anddistraction were the highest ranked at 7.2%each. Analysis by age group indicated that ofthe 13 parents indicating medical play wasleast beneficial, five children were infant ortoddler aged and three were school-aged/youth. All of the 13 parents who indi-cated that distraction was the least beneficialhad children preschool aged or younger.

Parents were asked a series of questionsabout their relationship with child life special-ists. The majority, 74.4%, of parents reportedthey felt the child life specialist was able tospend enough time with their child. Half ofthe parents, 51.7%, indicated they saw thesame child life specialist each time they werein the hospital. Seventy percent of parentsagreed that their child established a trustingrelationship with the child life specialist.

Two Likert-type questions were completedby the parents. When asked about theimpact of child life services on their child’shospital stay, the majority of parents, 64.4%,indicated that child life made their child’sstay a lot better. In response to the questionabout the need for child life services, 95%indicated that child life services should beoffered to all hospitalized children.

QUALITATIVE ANALYSIS

Two open-ended questions were presentedto the respondents. Parents had many com-ments regarding what other services could beprovided by child life staff. Education

regarding the potential effects on a child afterhospitalization/treatment was mentionedmost frequently. Parents of children withrare chronic illnesses requested more educa-tion regarding their child’s illness.Alternative services, such as art therapy, pettherapy and music therapy were requested byparents. Parents also requested more organ-ized activities, such as playgroups, teen socialgroups, or arts and crafts in the playroom, aswell as more services for the oldest andyoungest children, adolescents and infants.Finally, many comments indicated that par-ents wanted more time with the child lifespecialist, or more services to be offered tothem, such as procedure support, distraction,and school re-entry.

Ninety percent of the respondents com-mented on their experience with child life.There were a wide range of comments, frompositive experiences with an individual childlife specialist and more detailed explanationsof the child’s hospitalization, to commentsoffering suggestions on ways to improve serv-ices. Frequently positive comments praisedchild life, including “We love child life!They not only are there to help with thechildren but they are great with the entirefamily!” and “Child life has been one of themost helpful parts of this experience for ourfamily.” Several parents commented on notknowing exactly what the role of the childlife specialist was. These comments includ-ed, “I would have liked to have been moreeducated on what the child life specialists doand exactly what they are there for,” and “I

also wish the services that are offered bychild life specialists were better explained toparents.” Finally, suggestions for improvementincluded, “Be conscious that sometimes lessis more. There are times families/patientsdon’t want any interference.”

DISCUSSIONThe purpose of the study was to review

the perceptions of parents whose child had aprevious hospitalization. The standards ofchild life practice and patient- and family-centered care present child life practitionerswith criteria for quality care. The questionsincluded in the survey were developed specif-ically to assess areas of services that directlyimpact patients and families. Results offerinformation to child life specialists on theareas of care that parents found to be benefi-cial and those areas that may not be recog-nized by parents as valuable or appropriatefor their child.

The survey response of 180 parents of hos-pitalized children provides for the review of arange of parent perspectives. Although thedistribution of diagnosis and age was limited,some analysis provided insight into select cat-egories of care. Most parents indicated that avariety of child life services were available fortheir child. Age-appropriate activities werereceived by most families as well as activitiesrelated to procedural preparation and support(e.g., medical play, distraction). Family sup-port was reported by two- thirds of the par-ents. School-reentry and grief/ bereavement


FOCUS SUMMER 2008

TABLE 3. RANKING OF MOST AND LEAST BENEFICIAL SERVICESREPORTED BY PARENTS

Most Beneficial: Rank Least Beneficial: Rank

Procedure/Diagnosis teaching 14 (7.8%) 4 10 (5.6%) 2

Medical play 14 (7.8%) 5 13 (7.2%) 1

Procedure/Treatment accompaniment 10 (5.6%) 6 10 (5.6%) 2

Distraction 19 (10.6%) 3 13 (7.2%) 1

Age appropriate activities 41 (22.8%) 1 6 (3.3%) 5

School re-entry 5 (2.8%) 7 7 (3.9%) 4

Family support 29 (16.1%) 2 8 (4.4%) 3

Grief/Bereavement support 0 1 (0.6%)

All/multiple services selected 16 (8.9%) 1 (0.6%)

No response 0 110 (61.1%)

Other listed 10 (5.6%) 1 (0.6%)

Total 180 (100.00%) 180 (100.00%)


services would be appropriate only for certaingroups to the exclusion of others; this wasreflected in the data. However, the categorygrief/ bereavement support was experiencedby few of the parents and may have beeninterpreted narrowly, as necessarily related tothe loss of a child but not in relation to diag-nosis or injury. These findings indicate thatthe standard of child life practice requiringthe provision of a range of opportunities andservices for families was met for most of thefamilies surveyed.

The majority of parents agreed that childlife services were beneficial for the child.This is a positive result indicating the servic-es of child life are valued and recognized asimportant to families. However, the experi-ence of the 12 respondents who indicatedthat child life services were not beneficial wasnot explored. As professionals, an awarenessof the negative experiences of parents needsto be extended through an exploration of thedetails that surround the parents’ perception.Giving voice to families who have percep-tions contrary to our perception of services isan exercise that must be taken on in order tolegitimately claim to engage in ethical andpatient- and family-centered practice.

The distribution of rankings for most ben-eficial services was wide. Age-appropriateactivities were ranked as the most beneficialwith family support ranked second. Theserankings highlight those services commonlyassociated with child life practice, play andsupport (family and procedural) and rein-force the understanding that these servicesmeet a need for the entire family and notjust the hospitalized child.

The least beneficial services were alsoranked; however, most parents chose not torespond. Given the distribution of youngchildren in the sample, the selection of med-ical play and distraction may reflect parents’opinion or the need for increased communi-cation regarding the function and value ofspecific activities. Child life specialists needto consider how activities and interventionsare presented to parents, how to assess par-ents’ understanding of the value of theseservices, and how to respond to parents’ needfor education in areas related to developmen-tal practice.

The respondents who answered the open-ended questions provide more insight into

the perceptions of parents of hospitalizedchildren. Satisfaction with a number ofchild life programs that provide a unique setof services was apparent: summer camp pro-grams, referrals to other community services,out of hospital experiences and technologyprograms were valued by those parents whosechild had been involved. Some families whohad not had these experiences mentionedthem as programs they would have likedtheir child to experience. Additionally, par-ents indicated a need for more opportunitiesfor education from the child life specialists –about child life, hospitalization, and specificdiseases. Parents also suggested more alterna-tive programs, organized activities, and serv-ices specifically targeted to the infant andadolescent populations. Finally, althoughthree-quarters of the parents indicated theyfelt the child life specialist was able to spendenough time with their child, many suggest-ed they would like more time with the childlife specialist.

Survey research that accesses participantsvia the internet has both advantages and dis-advantages (Whitehead, 2007). In the caseof the present study, one advantage wasaccessing a specific population which may bewidely dispersed geographically.Additionally, as the researcher was not affili-ated with any specific health care facility, it isassumed that feelings of anonymity may beenhanced. As well, any sense of loyalty orobligation to a specific program was reduced.Disadvantages include sampling bias, as onlythose parents who were active in specific sup-port groups and had access to the internetwere involved. Additionally, the questionspresented to the respondents were limited inresponse categories and follow-up queries.Missed opportunities to explore the less thanideal or limited experiences of some of therespondents are apparent as the data isreviewed. This is an important outcome as itbrings home the importance of conductingfuture research with consideration for thepursuit of the views of families who feel theirneeds were not met.

APPLICATIONThe information derived from this study

has a number of implications for child lifespecialists. First, this study represents thestandard of practice related to the impor-tance of developing and applying researchskills as a method to inform professionalpractice. The results of the study provide

encouraging details about the perceptions ofparents of hospitalized children and encour-age us to take a closer look at those familieswho may not have positive perceptions oftheir experience with child life specialists.Giving voice to parents is only one step inthe process of collaboration with parents. Inorder to truly collaborate, the perceptions ofthe parents must be acknowledged and actedupon. Although the profession strives forcontinued quality and improvement of serv-ices to patients and families, considerationfor all views and experiences must be wel-comed. Learning from the parents about theimpact of child life services on their childrentells child life specialists what we may bedoing right, and where we have room toimprove. Reviewing results and commentsfrom parents can inform child life specialistsin the determination of how best to meet theneeds of their patients. Additionally, it ishoped the results of this survey encourageothers to develop a more comprehensive, in-depth study to determine parents’ percep-tions of child life programs.

REFERENCESAmerican Academy of Pediatrics, Committee on

Hospital Care (2006). Child Life Services. Pediatrics,118(4), 1757-1763.

Child Life Council (2006). Guidelines for theDevelopment of Child Life Programs in HealthcareSettings.Wilson J., Palm S., & Skinner, L, Eds. 4th Ed.Rockville, MD: Child Life Council.

Cole,W., Diener, M., & Wright, C. & Gaynard, L. (2001).Health care professionals’ perceptions of child lifespecialists. Children’s Health Care, 30(1), 1-15.

Hollon, E., & Palm, S. (2007). Patient- and Family-Centered Care: Does your practice measure up?Child Life Focus, 25 (1), 1- 4.

Institute for Family-Centered Care. Advancing thePractice of Patient- and Family-Centered Care: Howto Get Started Retrieved May 6, 2008 fromhttp://www.familycenteredcare.org/resources/pin-wheel/index.html

Rollins, J. A., Bolig, R., & Mahan, C. C. (2005). MeetingChildren’s Psychosocial Needs Across the Health-CareContinuum. Pro-Ed:Texas.

Whitehead, L. C. (2007). Methodological and ethicalissues in Internet-mediated research in the field ofhealth: An integrated review of the literature.Social Sciences and Medicine, 65, 782-791.


FOCUS SUMMER 2008


model. “We thought only a few peoplewould be there, since we were presenting inone of the last sessions,” Mary laughs.

Mary recalls some of the lively discussionsduring that session about whether child lifespecialists belonged in the treatment room.Some attendees argued that the child life spe-cialist should always be perceived as “the goodguy,” and therefore should not be present in thetreatment room during difficult procedures.“Our argument was that child life absolutelybelonged there as part of an interdisciplinaryteam – that [child life specialists] were instru-mental in helping to guide the parents/care-givers and children, and ensuring that the pro-cedure is accomplished with the least amountof trauma to the child,” says Mary. “Itwas really helpful to have Barbara thereto provide her perspective as aRegistered Nurse. She would alwayssay, ‘we do our job best when child lifespecialists are there to help us.’”

The previous thinking was thatparents were the original “good guys”and should not participate in painfulinterventions, and that children weresimply passive participants. Maryrecalls that the medical staff felt thatparents would be in the way or, evenworse, faint. They also worried thatthe parents would be tainted by theirassociation with the pain the childwas experiencing. In a similar vein,children were seen as unable toactively cooperate.

Within a year, the pharmaceuticalcompany AstraZeneca approached Mary andBarbara to collaborate on the development ofeducational materials about the ComfortMeasures/Positioning model. Over thecourse of the next seven years, AstraZenecaalso underwrote their travel costs to presentthe model at more than 100 physician andnursing grand rounds and medical and inter-disciplinary conferences nationwide. Maryoften used her personal vacation time tomake these trips. “Helping children wasimportant enough to me to take my owntime to make sure the message got outthere,” she says.

For Mary, convincing the skeptics hasbeen one of the most rewarding aspects of

her work over the years. She keeps lettersfrom child life specialists around the countrywho have thanked her for bringing ComfortMeasures to their hospitals. One of herfavorites is from a child life specialist whodescribes a nurse that had been openly skep-tical about the effectiveness of having chil-dren sit upright. The letter described thenurse as a “big woman, known for her ‘hold-ing abilities.’” Once Mary and Barbara hadpresented to the staff, the same nurse endedup being one of the biggest advocates forusing comfort positions. “It’s that kind offeedback that kept us going,” says Mary.

Mary and Barbara went on to co-authortwo internationally-recognized articles on themodel. The materials they produced withphotographs and suggestions of positions forchildren in the treatment room are still usedin hospitals throughout the world.

According to CLC Executive Board memberand international child life advocate AndreaStandish, CCLS, “One of the reasons theComfort Measures are so successful throughoutthe world is that they require a big heart butnot a big budget. Healthcare providers incountries with limited healthcare resources suc-cessfully use these child friendly techniques toimprove the experience for the patient, parentand healthcare provider. I have seen excellentoutcomes in Brazil, Nicaragua, China, Jordanand the Republic of Georgia.”

“In pediatrics, these techniques have beenwidely accepted, and they’ve had a hugeimpact wherever they have been implement-ed,” says Toni Millar, former director of the

child life program at Rainbow Babies andChildren’s Hospital. “More than 90% of theinvitations to present on the model camefrom child life specialists throughout thecountry, and they are the ones who single-handedly promoted Comfort Measures. Thesuccess of their [Mary’s and Barbara’s] collab-orative effort has helped child life specialistscontinue to partner with other disciplines toprovide comfort techniques that improve thepatient experience.”

Andrea Standish adds that Mary Barkey hasbeen influential in mentoring child life special-ists so that they become adept at dealing withthe skeptics and overcoming their objections.As a result, many more child life specialists are able to successfully integrate ComfortMeasures into practice at their hospitals.

For Mary, interdisciplinary collaborationwas a key factor in the development of the

Comfort Measures model. “Child lifespecialists can’t make major changesalone,” she says, stressing the impor-tance of Barbara’s participation, inaddition to the physicians, nurses, andmany other team members who wereopen to new ways of doing things.Embracing interdisciplinary collabora-tion in the implementation of ComfortMeasures has always been equallyimportant. After an initial learningcurve, Mary and Barbara screened therequests for a presentation. “We wouldonly present if there was an interdisci-plinary team already in place [at thefacility in question],” says Mary, “Weknew that was the only way that therewould be a chance for those changes[to be] put into practice.”

Mary considers the development ofComfort Measures to be more “a solution toa problem” than true research, but, “it gaveus a great deal of satisfaction.” For child lifespecialists who aspire to follow Mary’s lead indeveloping practical approaches that willbenefit children and families, she has a fewpieces of concrete advice:

1. If something isn’t appropriate for family-centered care and child development,look at options to approach it differently;then speak up.

2. Reach out beyond your own disciplineand collaborate with others; it will giveyour project added dimension and give it

Comfort Measurescontinued from page 1



continued on page 6

Comfort Measures pioneers Barbara Stephens, RN, MN, (left) and Mary Barkey, MA, CCLS (right)

CLC HQ Staff Welcomes Sharon L. Ruckdeschel

We are pleased to announce thatSharon L. Ruckdeschel has joined theheadquarters staff as MembershipDatabase and Web Coordinator.Sharon is responsible for managing the Child Life Council membershipdatabase and Web site integration, most commonly referred to as CLCOnline. In this role, she will be themain contact for you, our valued members, in addressing issues related to your CLC User Profile, membershippayments, and benefits.

Sharon has over 14 years of associa-tion and nonprofit experience. Beforejoining the Child Life Council, Sharonwas a database manager at the American

Pharmacists Association in Washington,DC and a membership programs analystat the World Wildlife Fund, also locatedin Washington, DC. Sharon has a bach-elor’s degree in Economics from theUniversity of Maryland, College Park.

Sharon can be reached via email at [email protected] or at 1-800-CLC-4515, extension 11.Please help us welcome her to the child life community.

the potential to reach a wider audience.

3. Making changes takes twice as long andcosts twice as much as you think it will,but it’s worth it.

4. When undertaking this kind of project,do research and collect hard data as youare trying out new techniques, so thatyou will have a basis of comparison toback up your findings.

The child life profession owes a great debtof gratitude to Mary, an innovative pioneerwhose commitment to “making things bet-ter” has touched the work of so many childlife specialists practicing today. We thank hernot only for the enduring legacy of theComfort Measures model, but also for settingan example of interdisciplinary collaborationthat will continue to benefit children andfamilies in ways yet to be realized.

REFERENCESStephens, B., Barkey, M., & Hall, H. (1999).Techniques

to comfort children during stressful procedures.Advances in Mind-Body Medicine, 15 (1), 49-60.



Comfort Measurescontinued from page 5

CLC Executive Board Election ResultsThe CLC Nominating Committee is pleased to report the election of the following new

members to the CLC Executive Board:

President-Elect: Ellen Good, MSEd, CCLSManager, Child Life Department Yale-New Haven Children’s Hospital New Haven, Connecticut

Secretary: Chris Brown, MS, CCLSDirector, Child Life and Family Centered Care Dell Children’s Medical Center Austin, Texas

Members-at-Large: Patricia “Trish” Haneman Cox, MSEd, CCLSAdjunct FacultyUniversity of New Hampshire, Portsmouth School District LEANewfields, New Hampshire

Nicole Graham Rosburg, MS, CCLSChild Life Specialist Texas Children’s Hospital/St. Luke’s Community Medical Center Houston, Texas

Child Life Certifying Committee Chair Year 1:Kitty O’Brien, MA, CCLSChild Life Clinical Manager Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio

THANK YOU TO ALL WHO VOTED IN THE FIRST-EVER ONLINE ELECTIONS IN 2008!


CLC Child Life SalarySurvey Results Are In!

Thank you to the more than 1,600 child life specialistswho completed the 2008 Child Life Salary andBenefits Survey. We can see by the great response

rate (44.8%) that this is an important topic to many pro-fessionals. Just to give our members an idea of thedemographic statistics on survey participants:

AGE• 39% are younger than 30

• 37% are 30-39

• 24% are 40 or older

CREDENTIALS• 58% have bachelor’s degrees

• 38% have master’s degrees

• 90% have their CCLS credential

POSITION HELD• Child Life Specialist - 49%

• Child Life Specialist with Leadership Responsibilities -30%

• Director/Manager/Leader of Child Life Program - 11%

A profile of the three position types, along with anoutline of the salary results for each, is presented in theSummary of the 2008 Child Life Profession CompensationSurvey Results, now available on the CLC Web site. Thesummary includes detailed demographic information foreach group of survey respondents, breaking the informa-tion down by education, years of experience, and geo-graphical location.


PRACTICE ANALYSIS

The Child Life Certifying Committee (CLCC) is currently in the process of conducting aPractice Analysis Study, to update the current examination content outline from 2002.A 12-member task force of child life experts met earlier this year to review the current ExamContent Classification System. The resulting changes are being validated by a survey of1,500 practicing child life specialists. The CLCC is working in collaboration with our testingagency, Castle Worldwide, to compile the information collected to create the new ExamContent Outline. Any changes will be reflected on the Child Life Professional CertificationExam, beginning with the Spring 2010 exam.

ITEM BANK REVIEW

As a result of the Practice Analysis Study and updated Exam Content Outline, the Child LifeCertifying Committee (CLCC) will be conducting a major review of the Item Bank (examquestions), and seeking a large number of volunteer CCLSs to assist in the review of all questions in the Item Bank. This process will take place in 2009, at a location yet to bedetermined. Please consider participating in the Item Bank review, and making a majorimpact on the quality of future examinations. For more information, please contact [email protected].

RECERTIFICATION

Applications to recertify through Professional Development Hours were due on June 30,2008. Applicants will be notified if more information is needed, or if their application hasbeen randomly selected for audit. After the applications have been reviewed and the auditsare complete, approved applicants will receive new certificates by mail late in the summer.

If you have not submitted an application to recertify by PDH, and your five-year certificationcycle will expire on December 31, 2008, you can still recertify through PDHs, as a result of arecent CLC Board-approved policy allowing late submissions through October. Candidateswho apply for recertification between June 30 and October 31 are required to pay a $50 latefee and submit all supporting documentation (e.g. certificates of attendance) of the PDHssubmitted. Late applications cannot be completed online.

As always, recertification candidates may also recertify by taking and passing the November8, 2008 Certification Exam.

FALL 2008 EXAM ADMINISTRATION

The following cities have been designated as sites for the November 8, 2008 Child LifeProfessional Certification Exam:

• Atlanta, Georgia • Boston, Massachusetts • Phoenix, Arizona • St. Louis, Missouri • Toronto, Ontario (Canada)

Applications for this exam are due to CLC by August 31, 2008 for anyone educated within theU.S.or Canada and by June 30, 2008 for those educated outside the U.S.and Canada.

CERTIFICATION COMMUNICATIONS

If you have not already done so, please log in to your User Profile through the CLC Web siteto ensure that your contact information is accurate. Please make sure that you have anactive email address in the system that you check regularly, as we are now using email asour primary means of communication with Certified Child Life Specialists. If you do nothave your username and password, please visit the following link to be emailed a reminder:http://ams.childlife.org/members_online/members/password.asp

Please contact Ame Enright at [email protected] with certification questions.

CERTIFICATION CORNER

MILESTONESIN THE NEWS: Fox 19 News in Ohio recently featured CLC membersKatrina Baliva and Sharon McLeod, and the Cincinnati Children’sHospital Medical Center “Josh Cares” program.The programemploys Child Life Fellows like Katrina to support children whosefamilies cannot be with them during their stay in the hospital.The story aired on May 26, and can be accessed by visiting thePress Room section of the CLC Web site.

IN THE NEWS: NBC Nightly News honored the life and work ofMyra D. Fox, Director of Child Life Services at Children’s HospitalBoston, in a feature entitled,“Hospital Worker Helps Kids in WaysMedicine Can’t.”The story aired on April 9, and can be viewed bysearching the archives of the NBC Nightly News Web site.For a directlink, please visit the Press Room section of www.childlife.org.Congratulations Myra!


CLC CalendarJUNE

30 Deadline for recertifying by Professional Development Hours (PDHs)

30 Deadline for applications for the November administration of the Child Life Professional CertificationExam for those educated outside the U.S. or Canada

JULY15 Deadline for Bulletin and Focus articles for Fall 08 issue

15 Deadline for abstract proposals for the 27th Annual Conference on Professional Issues

AUGUST31 Deadline for applications for the November administration of the Child Life Professional Certification

Exam for those educated within the U.S. or Canada

OCTOBER15 Deadline for written requests to withdraw from November Administration of the Child Life

Professional Certification Exam

NOVEMBER8 Child Life Professional Certification Exam Administration

11820 Parklawn Drive, Suite 240Rockville, MD 20852-2529

RETURN SERVICE REQUESTED

2009 Call for PapersInterested in presenting at CLC’s Annual

Conference? In 2009, Child Life Council’s

27th Annual Conference on Professional

Issues will be held at The Westin Boston

Waterfront in Boston, Massachusetts,

May 21-24. CLC will accept abstracts

through the online abstract submission

process up until July 15, 2008. The 2009

Call for Papers information can be found

under the Annual Conference Section of

the CLC Web site.

Documents

Comfort Measures for Invasive Procedures: A Major Paradigm