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Development and Validation of the Parent Satisfaction Scale for
Child Life Services (PSS-CLS): A Pilot Study
Dr. Sushma Gopalan
1
, Elham Subair
2
, Shanu Arun
3
, Shivangee Gupta
4
, Vaishnavi Ravindran
5
, Ishika
Mittal
6
, Dr. Chetan Ginigeri
7
1
PhD, Psychology, Psychologist/Child Life Specialist, Department of Pediatrics, Aster CMI Hospital,
Bengaluru
2,3,4,5
Msc. Clinical Psychology, Psychology Intern, Department of Pediatrics, Aster CMI Hospital,
Bengaluru
6
Msc. Counselling Psychology, Psychologist/Child Life Therapist, Department of Pediatrics, Aster CMI
Hospital, Bengaluru
7
MD (PGI), Consultant, Pediatrics & Pediatric Intensive Care, Aster CMI Hospital
DOI: https://doi.org/10.51584/IJRIAS.2025.101100065
Received: 24 November 2025; Accepted: 30 November 2025; Published: 13 December 2025
ABSTRACT
Child Life Services play an important role in supporting the emotional and psychosocial needs of hospitalized
children and their families. However, currently there is no validated tool to measure parental satisfaction with
CLS. This study describes the development and validation of a Parent Satisfaction with Child Life Services
Scale (PSS-CLS).
An initial pool of 31 items was created based on the experience of child life specialists. A panel of five experts
reviewed each of these items for their clarity and relevance. Content validity indices (CVI) were calculated and
repetitive items were revised. The resultant 24-item scale was pilot tested with a sample of 60 parents in an
Indian private hospital. Reliability was assessed using Cronbach’s alpha and validity was assessed using face
validity and exploratory factor analysis (EFA).
Expert ratings deemed a strong content validity (I-CVI = 0.80-1.00; S-CVI/Ave= 0.974; S-CVI/UA= 0.871).
The scale also showed very high internal consistency (Cronbach’s α= 0.949). Face validity was supported by
parental reports that the items were clear and required no modifications. EFA gave a five-factor structure that
explained 70.1% of total variance. The resultant factors represented major domains of CLS: (1) parental
empowerment, support, and confidence in medical care (2) emotional health and advocacy of children (3)
counselling effectiveness and communication (4) engaging and individualized therapies, and (5) play-based
therapies and the restoration of normalcy.
The PSS-CLS is a reliable and valid instrument for evaluating the parental satisfaction with CLS.
Keywords: child life services, parental satisfaction, pediatric care, child psychology
INTRODUCTION
Child Life Services (CLS) is a specialized program within pediatric healthcare that focuses on addressing the
psychosocial concerns of children and families (Romito et al., 2021). These services are delivered through
trained professionals who use various developmentally appropriate techniques (play, education, psychological
preparation, distraction, and relaxation) to help children and their families cope with the medical environment
(Bezuidenhout et al., 2021). Their main aim is to minimize the possible trauma that the child and their
caregivers could experience due to hospitalization (Bezuidenhout et al., 2021). This is done through the use of
therapeutic activities, normalization, and providing specific information about the child’s hospitalization
(Burns-Nader & Hernandez-Reif, 2015)
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CLS professionals address the emotional and psychological needs of hospitalized children, consequently
minimizing the anxiety, fear, and trauma that is associated with medical procedures (Burns-Nader &
Hernandez-Reif, 2015). These interventions can help in maintaining healthy development by reducing mental
and emotional disruptions caused by illness (Committee on Hospital Care, 2000). The care provided by CLS
Specialists is family-centered in nature. They support the families along with the patients by improving coping,
communication, and overall satisfaction with medical care (Wong et al., 2022). Research evidence shows that
CLS interventions can help in reducing need for sedation, improve patient cooperation during procedures,
shorten stay, and improve the overall experience of families (Hummel et al., 2023; Kinnebrew et al., 2020;
Munshi et al., 2024).
Studies have shown that parents experience more satisfaction when CLS support is involved (Cristal et al.,
2018; Day et al., 2024). This is related to them feeling more supported and perceiving less distress in their
children (Cristal et al., 2018; Day et al., 2024). CLS is an emerging concept in India and research on the same
is very limited. Most studies that are currently available, focus on general pediatric care, not on CLS programs.
Parental feedback can help in identifying the areas for improvement and strengthen the case for expansion of
CLS programs (Leblanc et al., 2014).
Validated tools like the PROMIS Pediatric Life Satisfaction item banks and other custom assessments have
been used to evaluate child and parent experiences with respect to overall hospitalization (Forrest et al., 2017;
Leblanc et al., 2014). Several studies have used 5-point Likert scale surveys to examine parental satisfaction,
perceived pain in children, and the overall experiences with CLS interventions (Baughn et al., 2022; Day et al.,
2024; Tyson et al., 2014).
Child Life Specialists play a very important role in improving healthcare experiences for pediatric populations.
Parental satisfaction acts as both: a crucial outcome and a driver for improvement of service. There are
currently no universally adopted measures of CLS interventions and parent satisfaction with CLS (Leblanc et
al., 2014). Therefore, there is a need or validated satisfaction tools made specifically for CLS to promote
continuous evaluation and systematic quality improvement. This paper tries to bridge this gap by developing
and validating a Parent Satisfaction with Child Life Services Scale (PSS-CLS).
MATERIAL AND METHODS
Tool Development Process and Scoring
Due to the non-existence of a validated Child Life Services scale, the initial items were generated on the basis
of the experience of the researchers as existing child life specialists. This resulted in an initial scale consisting
of 31 items. Expert feedback was obtained from a panel of five experts (child life specialists, pediatricians, and
psychologists). The Content Validity Index (CVI) was calculated and expert feedback to reword and reduce the
number of items was incorporated. This led to a revised 24-item scale that was pilot tested with a sample of 60
parents to examine its reliability and validity. The parents reported that the items were clear and the scale was
easy to understand. They did not make any suggestions for modification. Therefore, this revised 24-item
version of the Parent Satisfaction with Child Life Services Scale was retained as the final version.
The 24 items of the CLS scale are rated on a 5-point Likert scale with the responses being coded as 1 =
“Strongly Disagree”, 2 = “Disagree”, 3 = “Neutral”, 4 = “Agree”, and 5 = “Strongly Agree”. A 5 -point likert
scale was chosen because of its ability to balance sensitivity and simplicity while also providing space for
varying levels of agreement (Joshi et al., 2015). The total score is calculated by totalling all the item scores,
resulting in a possible score range of 24-120. Higher scores indicate greater parental satisfaction. This scoring
system was adapted in line with expert directions and confirmed through pilot testing.
Content Validity
Content Validity was assessed by using expert reviews. The panel consisted of 5 experts, consistent with
recommendations in scientific literature which suggest that 3-10 experts are adequate for the assessment of
content validity (Lynn, 1986; Polit & Beck, 2006). The 5 experts consisted of: 2 pediatricians, 2 Certified Child
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Life Specialists (CCLS), and 1 pediatric psychologist. Each of these experts had more than 5 years of
experience in their fields. They rated the relevance of each item on a 3-point Likert scale (0-Not Relevant, 1-
Relevant, 2-Highly Relevant). Their ratings were used to calculate the Content Validity Index (CVI). The Item-
Level Content Validity Index (I-CVI) and Scale- Level Content Validity Index (S-CVI) were also calculated.
Two measures, S-CVI/Ave (Average of all I-CVIs) and S-CVI/UA (Proportion of items with I-CVI = 1) were
used to evaluate the scale level content validity.
Pilot Testing
Post the expert review and refinement, the preliminary version of the scale was pilot tested with a sample of 60
parents of children who had received CLS support in a private hospital in Bengaluru, India. The pilot study
aimed at evaluating the clarity, ease of administration, and relevance of the scale within the target population. It
also generated preliminary data for psychometric evaluation of the scale. Informed consent was obtained from
the parents and the scale was administered. After completing the tool, parents were asked to provide brief
feedback on the clarity and relevance of the items to assess face validity. Data collected from the pilot study
was used to examine the internal consistency reliability and construct validity.
Face Validity
Face Validity was examined by gathering feedback from parents after they completed the assessment. Parents
were asked about the understandability, clarity, and relevance of the items as per their experience with CLS.
During the pilot testing, the parents found the scale to be clear and relevant to their experiences. The tool was
retained in the existing form as the parents did not recommend any modifications.
Reliability Testing
Internal consistency testing was done by calculating the Cronbach’s alpha for the 24-item Parent Satisfaction
Scale for Child Life Services. An 𝛼 value of ≥ 0.70 is considered to be acceptable for new tools (Nunnally &
Bernstein, 1994; Tavakol & Dennick, 2011)
Construct Validity
Construct validity was examined using Exploratory Factor Analysis (EFA). This was done to understand if the
items group into meaningful domains. The suitability of the data for EFA was assessed using the Kaiser-
Meyer-Olkin (KMO) Measure of Sampling Adequacy (Kaiser, 1974) and Bartlett’s Test of Sphericity (Bartlett,
1954). Principal component analysis was applied as the extraction method and Varimax rotation was used to
enhance interpretability. Items having factor loadings ≥ 0.40 were considered to be meaningful for
interpretation. Factor retention was determined using the Kaiser criterion (eigenvalues >1) and by inspecting
the scree plot (Tabachnick & Fidell, 2018).
RESULTS
Content Validity
Table 1 lists the CVI results for the PSS-CLS.
Table 1 Content Validity Indices
Measure
Value
No. of items reviewed
31
Items retained (after revision)
24
I-CVI range
0.80-1.00
S-CVI/Ave (Average of all I-CVIs)
0.974
S-CVI/UA (Proportion of items with I-CVI=1)
0.871
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The initial 31 items were reviewed by 5 experts. I-CVI ranged from 0.80 to 1.00, showing that the expert
strongly agreed that each item was relevant. All items were interpreted as being content valid as per the
acceptance level of ≥ 0.78 (Lynn, 1986).
Similar to the item-level measures, scale-level measures also showed high content validity. S-CVI/Ave was
0.974 and S-CVI/UA was 0.871. As per the expert recommendations, certain redundant items were removed
and wording was refined.
Sample Characteristics
A sample of 60 parents participated in the pilot study. The sample included mothers and fathers of children
who had received CLS care in a private hospital in Bengaluru, India. The sample consisted of 29 mothers and
31 fathers with a mean age of 37.1.
Face Validity
The sample of parents reported that each of the 24 items was clear, understandable and relevant to their
experience with CLS in the hospital. They did not suggest any modifications, indicating that the scale had
strong face validity.
Reliability
Table 2 lists the reliability of the PSS-CLS. The scale demonstrated exceptionally high internal consistency
with a Cronbach’s alpha of 0.949. This result indicates that the items were highly interrelated. The mean total
score was 108.9 while the standard deviation was 9.58.
Table 2 Reliability of the 24-item Parent Satisfaction Scale for Child Life Services
Scale
Number of Items
Cronbach’s α
Mean ± SD of Scale
Overall Scale
24
0.949
108.9 ± 9.58
SD: Standard Deviation
Construct Validity
Construct Validity was examined using Exploratory Factor Analysis (EFA). Table 3 lists the results for the
same.
Table 3 Construct Validity of the Scale (EFA Results)
Test/item
F1
F2
F3
F4
F5
Sampling Adequacy
Kaiser–Meyer–Olkin (KMO) = 0.848
Bartlett’s Test: χ² = 1030.3, p < 0.001
Variance Explained
Eigen Values
11.286
1.693
1.495
1.292
1.064
% of Variance
47.026
7.055
6.229
5.382
4.435
Cumulative %
47.026
54.081
60.311
65.692
70.127
Rotated Factor Loadings (abbreviated items ≥0.40)
Item 1
0.184
0.668
0.159
0.338
0.126
Item 2
0.262
0.478
0.433
0.306
0.36
Item 3
0.046
0.152
0.044
0.441
0.758
Item 4
0.255
0.263
0.223
0.679
0.119
Item 5
0.057
0.388
0.325
0.591
0.231
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Item 6
0.313
0.073
0.07
0.731
0.375
Item 7
0.08
0.355
0.562
0.14
0.548
Item 8
0.372
0.71
0.165
-0.037
0.246
Item 9
0.192
0.293
0.711
0.283
-0.122
Item 10
0.722
0.298
0.392
0.142
0.124
Item 11
0.264
0.65
0.499
0.116
-0.018
Item 12
0.217
0.122
0.827
0.039
0.146
Item 13
0.335
0.253
0.466
0.249
0.401
Item 14
0.274
0.025
0.417
0.006
0.394
Item 15
0.45
0.476
0.245
0.523
-0.108
Item 16
0.522
0.616
-0.088
0.43
0.024
Item 17
0.835
0.225
0.158
0.06
0.13
Item 18
0.499
0.524
0.012
0.282
0.156
Item 19
-0.017
0.72
0.224
0.2
0.152
Item 20
0.397
0.532
-0.084
0.003
0.525
Item 21
0.483
0.192
0.276
0.251
0.353
Item 22
0.712
0.141
0.249
0.327
0.14
Item 23
0.733
0.199
0.386
0.218
0.076
Item 24
0.468
-0.022
0.545
0.271
0.082
The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was found to be 0.848, while Batlett’s test of
sphericity gave significant results (χ² = 1030.3, p < 0.0001). These findings confirmed that the data was
suitable for factor analysis.
Principal component analysis and Varimax rotation resulted in a five-factor solution that explained 70.13% of
the total variance. Factor loadings ≥0.40 were considered to be meaningful. The 5 factors corresponded to
coherent domains: (1) parental empowerment, support, and confidence in medical care (2) emotional health and
advocacy of children (3) counselling effectiveness and communication (4) engaging and individualized
therapies, and (5) play-based therapies and the restoration of normalcy.
DISCUSSION
The current study describes the development and initial validation of the Parent Satisfaction Scale for Child
Life Services. This is the first tool of its kinds to be developed and tested in an Indian hospital setting. The
scale demonstrated excellent reliability, content validity, and clear factor structure. These properties indicate
that the tool is highly effective in assessing parental satisfaction with CLS.
A high Cronbach’s alpha of 0.949 suggests that there is high internal consistency. This is in line with the
recommended threshold for new tools (Nunnally & Bernstein, 1994; Tavakol & Dennick, 2011). Although this
result could possibly reflect some overlap among items due to the huge number included, it also suggests that
the items are highly interrelated and reliably measure parental satisfaction.
Content Validity Indices show that the panel of experts strongly agreed on the high relevance and clarity of the
items (I-CVI ranged from 0.80 to 1.00). All items were deemed to be content valid as per the acceptance
criteria of ≥ 0.78 (Lynn, 1986). Some items had a comparatively lower agreement (I-CVI = 0.80) but satisficed
the acceptability requirement. Majority of the questions received unanimous approval with an I-CVI = 1.00.
Two measures, S-CVI/Ave and S-CVI/UA were used to evaluate the S-CVI of the 31-item scale. Overall, the
experts deemed the items as very relevant. With a S-CVI/Ave of 0.974, the scale exhibited very high content
validity. The percentage of items with perfect agreement among the experts (I-CVI = 1.00) was 87.1% (S-
CVI/UA = 0.871). Both indices show that the scale has excellent overall content validity even though the S-
CVI/UA is slightly lower than the S-CVI/Ave. However, this is expected, given the tighter requirements for
reaching 100% agreement among the experts.
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Construct validity was evaluated using Exploratory Factor Analysis (EFA). A five-factor model, which aligns
with the multidimensional nature of Child Life Services, was identified. These factors were- (1) parental
empowerment, support, and confidence in medical care (2) emotional health and advocacy of children (3)
counselling effectiveness and communication (4) engaging and individualized therapies, and (5) play-based
therapies and the restoration of normalcy. These five domains provide an in-depth overall understanding of
parental satisfaction and can be used to guide the evaluation and improvement of services.
This study has several strengths. The items were designed on the basis of both, expert opinion and real
experiences of parents, making it practical and reliable. It identified five key factors which aptly reflect what
parents truly value in CLS. Finally, the scale is also short, simple and easy to fill, making it suitable for regular
use in hospitals.
However, the study also has certain limitations that need to be acknowledged. It involved a relatively small
sample (n=60) from a single private hospital, leading to a limited generalizability of results. Moreover, Test -
retest Reliabilty and Confirmatory Factor Analysis (CFA) were not conducted. Although EFA suggested 5
domains, domain-level scores and reliability was not checked.
Despite these limitations, the findings indicate that the PSS-CLS is a valid and reliable measure of parent
satisfaction with CLS. Future studies can include a larger and more diverse sample for more generalizability.
Confirmatory factor analysis (CFA) and Test-Retest Reliability can be checked to strengthen the scale’s
validity. Domain level scores and reliability can also be calculated in future studies to give a better
understanding of the different areas of parent satisfaction.
This scale can help hospitals understand how parents feel about the support their child and family receive from
CLS. It can be used for routine evaluation and policy development to improve pediatric psychological and
psychosocial care. This tool can help underline the importance of Child Life Services and support the need to
include such programs in other hospitals.
CONCLUSION
This study developed and validated the first scale to measure parent satisfaction with Child Life Services in a
hospital context. The tool demonstrated high internal consistency, content validity, construct validity and face
validity. A five-factor model was also identified using EFA. These findings suggest that the scale is a reliable
and valid measure of parents’ experiences with CLS. The study was limited because of its small, single-site
sample (n=60), lack of test-retest reliability and Confirmatory Factor Analysis (CFA). However, the results
serve as an important base for future research and practice. This scale can be used by hospitals and
practitioners to evaluate and improve child life programs.
AUTHOR NOTE
Correspondence concerning this article should be addressed to Sushma Gopalan, Email:
sushmagopalan@gmail.com, Phone: 6362383084, Address: Address: Flat#G1, Sudha Mansion, Narayana
Reddy Layout, 1st Cross Horamavu, Bangalore 43
Keywords: child life services, parental satisfaction, pediatric care, child psychology
STATEMENTS AND DECLARATIONS
Funding: No funding was received for conducting this study.
Financial Interests: The authors declare they have no financial interests
Conflict of interest of each author or contributor: There is no known conflict of interest to disclose.
Ethics Approval: Ethical clearance was obtained from the Institutional Ethics Committee, Aster CMI
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Hospital, Bengaluru (Dated 30/05/2024). A copy of the same is attached in Appendix B.
Consent to participate: Written informed consent was obtained from all the participants of the pilot study
ACKNOWLEDGEMENTS
We would like to express our sincere gratitude to all the parents and caregivers who participated in this study
and shared their valuable experiences. Their input was essential to the development and validation of the Parent
Satisfaction Scale for Child Life Servicess (PSS-CLS).
We are also grateful to the interns, psychologists, Child Life Specialists and hospital staff who supported the
data collection process. Their collaboration and commitment to family-centred care made this research
possible.
Special thanks to Dr Chetan Ginigeri who initiated the concept of Child Life – this paper is a culmination of his
vision and Aster Hospital for accepting and launching this project. Grateful to the Clinical research team
headed by Dr Surinder Kher and statistician Mr. Sadashiv for their assistance with data analysis.
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APPENDIX
Appendix A
Parent Satisfaction Scale for Child Life Services (PSS-CLS)
Child Life Services (CLS) plays an important role in reducing stress, promoting emotional well-being, and
setting a sense of normalcy during hospitalization. This tool aims to assess parent satisfaction with CLS.
Please rate your level of agreement with each statement by selecting one of the following options: Strongly
Disagree, Disagree, Neutral, Agree, or Strongly Agree. Your answers will help us to understand your
experience better. There are no right or wrong answers. We assure you that all answers are confidential and
will be used only for research and feedback.
Name: Date:
SI
Item
Strongly
agree
Agree
Neutral
Disagree
Strongly
disagree
1.
The involvement of Child Life Services greatly reduced
concerns about my child's emotional well-being during
their hospital stay
2.
Child Life Services effectively addressed my child's
emotional needs during their hospital stay.
3.
The play based interventions offered by Child Life Services
effectively engaged my child during their hospital stay
4.
Child Life Services tailored their interventions to meet
the specific needs and preferences of my child.
5.
The interventions provided by Child Life Services helped
my child cope with the challenges of being in the hospital.
6.
The materials and techniques used in therapy sessions
were accessible and stimulating for my child
7
My child found the sessions led by Child Life Services to
be both engaging and beneficial.
8.
The interventions provided by Child Life Services
allowed my child to creatively express their feelings and
experiences.
9.
The counseling sessions provided by Child Life Services
addressed my child's emotional concerns and helped them
express their feelings about their hospitalization
10.
Child Life Services offered valuable emotional support
and guidance to me as a parent/caregiver during
my child's hospitalization.
INTERNATIONAL JOURNAL OF RESEARCH AND INNOVATION IN APPLIED SCIENCE (IJRIAS)
ISSN No. 2454-6194 | DOI: 10.51584/IJRIAS |Volume X Issue XI November 2025
Page 709
www.rsisinternational.org
11.
I felt confident in the expertise and competency of Child
Life Services to address my child's emotional needs and
provide appropriate support during their hospital stay.
12.
I appreciated the transparent and communicative
approach of Child Life Services in addressing any concerns
or questions I had regarding their services.
13.
The materials and activities provided by Child Life
Services were engaging and age-appropriate for my child.
14.
Child Life Services demonstrated a high level of
professionalism in their interactions with me and my child
throughout the hospitalization process.
15.
Child Life Services enhanced your sense of partnership
with the hospital staff in your child's care
16.
Child Life Services contributed to enhancing the overall
quality of care your child received in the pediatric ward.
17.
The involvement of Child Life Services increased my
confidence in the overall care provided by the medical team
for my child
18.
The availability of Child Life Services improved my
overall experience as a parent/caregiver during my child's
hospitalization
19.
I would recommend Child Life Services to other parents
with children in pediatric wards based on my experience.
20.
Child Life Services played a significant role in fostering a
sense of normalcy and routine for my child during their
hospital stay.
21.
Child Life Services had a positive impact on my coping
mechanisms and emotional well-being during my child's
hospitalization
22.
I felt supported and empowered as a parent or a caregiver
by the interventions and guidance provided by Child Life
Services.
23.
Child Life Services empowered me to actively participate
in my child’s care and decision-making
24.
Child Life Services effectively addressed my concerns and
answered any questions I had about my child's condition
during counseling sessions
