The Impact of Child Life Specialist Collaboration on Pediatric Nursing Care Outcomes

Introduction

Child life specialists are trained professionals who provide developmentally informed psychological preparation, coping support, and distraction for children undergoing medical procedures, with the aim of reducing procedural fear and distress and preserving children’s sense of mastery and control during hospitalization (Association of Child Life Professionals, 2021; Committee on Hospital Care and Child Life Council, 2014). A substantial body of prior research has established that child life involvement is associated with reduced observed and self-reported child distress during procedures such as venipuncture and intravenous catheter insertion, and, in some studies, with reduced need for pharmacologic sedation (Tyson et al., 2014; Brewer et al., 2006).

Much of this literature, however, has evaluated child life involvement primarily in terms of its direct effect on the child, with comparatively less research examining how the structure of child life collaboration, specifically, whether a child life specialist is embedded as a routine, co-planning member of the procedural care team versus available only through ad hoc referral, affects the bedside nurses who deliver procedural care alongside them (Cole et al., 2001). This is a meaningful gap, given that bedside nurses are frequently responsible for both performing procedures and managing the emotional and relational demands of a distressed child and family, a combination associated in broader pediatric nursing literature with elevated moral distress and workload, particularly when adequate psychosocial support is not readily available at the point of care (Rennick & Rashotte, 2009).

Understanding whether the structure of child life collaboration, rather than child life availability alone, meaningfully affects both child and nurse outcomes has direct relevance for how health systems choose to organize and resource child life services, particularly given that embedded collaboration models require greater staffing investment than referral-based availability. The purpose of this study was to evaluate the effect of structured, embedded child life specialist collaboration in procedural care, relative to standard, referral-based availability, on both child procedural outcomes and nurse-reported moral distress, workload, and job satisfaction.

Methods

Design. This study used a prospective, quasi-experimental comparative cohort design, comparing two pediatric inpatient units that had implemented an embedded child life collaboration model against two comparable units continuing standard, referral-based child life availability, with data collected concurrently across all four units over a six-month period.

Setting. The study was conducted across four general pediatric inpatient units within a single academic health system between April and September 2025. Two units had implemented an embedded collaboration model approximately one year prior to data collection, in which a designated child life specialist routinely co-planned procedural approach with the bedside nurse prior to scheduled and unscheduled procedures and was present for procedural support in the large majority of cases. Two comparable units, matched on patient volume, average patient age, and general acuity profile, continued standard practice, in which child life involvement occurred through nurse-initiated referral on a case-by-case basis and was not a routine, structured component of procedural planning.

Child-level sample and procedure. Consecutive eligible procedural encounters involving venipuncture or peripheral intravenous catheter insertion among hospitalized children aged 2 to 12 years across the four units were included, with trained observers, blinded to study hypothesis, rating child distress using a validated observational behavioral distress scale (range 0–20) immediately before and during the procedure. First-attempt success and total procedure duration, from first patient contact to procedure completion, were recorded by the observer. A total of 408 procedural encounters were observed (embedded collaboration units: n = 214; referral-based units: n = 194).

Nurse-level sample and measures. All bedside nurses across the four units were invited to complete an anonymous survey assessing moral distress, using an adapted 0–100 scale derived from the Measure of Moral Distress for Healthcare Professionals, perceived procedural workload, using a 0–100 visual analog scale, and job satisfaction specific to procedural care, using an adapted 5-item scale (range 0–100). Of 168 eligible nurses, 140 completed the survey (83.3% response rate).

Statistical analysis. Child-level continuous outcomes (distress score, procedure duration) were analyzed using analysis of covariance adjusted for child age and procedure type. First-attempt success was analyzed using logistic regression adjusted for the same covariates, yielding an adjusted odds ratio. Nurse-level outcomes were compared between groups using independent-samples t-tests. A two-sided p value of less than .05 was considered statistically significant.

Results

Across 408 observed procedural encounters (214 in embedded collaboration units, 194 in referral-based units), child age and procedure type distribution were comparable between groups (Table 1). Observed procedural distress scores were significantly lower in embedded collaboration units, with an adjusted mean difference of −3.8 points on the 0–20 distress scale (95% CI −4.6 to −3.0, p < .001), as shown in Figure 1 alongside procedure duration.

First-attempt venous access success was significantly higher in embedded collaboration units (74.6% vs. 61.2%; adjusted odds ratio 1.89, 95% CI 1.31–2.72, p < .001), as shown in Figure 2, and procedure duration was significantly shorter (mean 7.4 vs. 9.8 minutes, p < .001), consistent with the interpretation that reduced child distress translated into more efficient, and not merely more comfortable, procedural completion.

Among the 140 nurse survey respondents, nurses in embedded collaboration units reported significantly lower moral distress (mean 38.2, SD 14.6, vs. mean 51.7, SD 16.9, in referral-based units; p < .001), significantly lower perceived procedural workload (mean 42.6, SD 15.8, vs. mean 58.3, SD 17.2; p < .001), and significantly higher job satisfaction related to procedural care (mean 78.4, SD 11.3, vs. mean 64.1, SD 14.7; p < .001), as shown in Figure 3.

Discussion

This prospective comparative cohort study found that structured, embedded child life specialist collaboration was associated with significantly improved child procedural outcomes, including reduced observed distress, higher first-attempt venous access success, and shorter procedure duration, relative to standard, referral-based child life availability. These findings are consistent in direction with prior literature establishing child life involvement’s benefit for child procedural distress (Tyson et al., 2014; Brewer et al., 2006), while extending this literature by demonstrating that the structure of collaboration, embedded and routinely co-planned versus available only through ad hoc referral, appears to matter independently of child life availability in the broader sense.

The improvement in first-attempt success and reduction in procedure duration observed in embedded collaboration units is a particularly notable finding, as it suggests that structured child life collaboration may offer efficiency benefits alongside its more commonly studied comfort benefits. A plausible mechanism is that reduced child distress and improved cooperation directly facilitate technical success on first attempt, reducing the need for repeated attempts that further compound distress and extend procedure time, a self-reinforcing cycle that embedded, proactive preparation may help to interrupt before it begins (Wolfer & Visintainer, 1975; Gursky et al., 2010).

The nurse-level findings represent, to our knowledge, a less commonly examined dimension of child life collaboration’s impact. The significantly lower moral distress and workload, and higher job satisfaction, reported by nurses in embedded collaboration units suggests that the benefit of structured psychosocial support extends beyond the child to the clinician delivering procedural care alongside that support. This is consistent with broader nursing literature linking moral distress to situations in which nurses feel unable to provide the standard of holistic, family-centered care they believe a child deserves, particularly during a distressing procedure performed without adequate psychosocial support (Rennick & Rashotte, 2009). Embedded child life collaboration may reduce this specific source of moral distress by ensuring that developmentally appropriate psychological preparation and support is a routine, reliable component of procedural care rather than a resource nurses must actively seek out, and sometimes forgo, under time pressure.

Several limitations should be considered. Because unit assignment to collaboration model was not randomized, and the embedded model had already been in place for approximately one year prior to data collection, residual confounding by unmeasured unit-level differences, including possible differences in baseline unit culture or nursing staff characteristics that both preceded and coincided with the collaboration model change, cannot be fully excluded. This study was conducted within a single health system, and the specific staffing ratios required to sustain an embedded collaboration model, and the generalizability of the observed effect to health systems with different child life staffing resources, should be considered carefully. The nurse survey, while achieving a strong response rate, relied on self-report of moral distress, workload, and satisfaction rather than external or physiological measurement.

Future research should evaluate the specific components of embedded collaboration, such as routine pre-procedural co-planning versus in-procedure presence specifically, to identify which elements contribute most to the observed child and nurse-level benefits, which would help health systems with constrained child life staffing resources prioritize implementation. Cost-effectiveness research incorporating both the child-level efficiency gains and the potential downstream workforce benefits of reduced nurse moral distress and turnover risk would further support health system decisions regarding child life staffing investment. Taken together, these findings support structured, embedded child life specialist collaboration as a model that benefits not only the hospitalized child but also the bedside nursing workforce responsible for delivering procedural care, suggesting that child life staffing decisions warrant consideration as a nursing workforce support investment alongside their established role in child-centered care.

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