In recent years, Certified Child Life Specialists (CCLSs) have reported experiencing substantial workplace stress and burnout (Ginter et al., 2024; Tenhulzen et al., 2023). Reasons for departing from the child life field include burnout, low salary, and seeking jobs that better support work-life balance (Ginter et al., 2024). In general, studies on burnout among healthcare providers suggest that supportive supervisors might play a role in helping providers better cope with stress. The Child Life Certification Commission’s (CLCC, 2023) Child Life Code of Ethics states: “CCLSs accountable for the supervision and training of others (e.g., staff, students, volunteers) assume responsibility for teaching ethical professional values and providing optimal learning experiences” (p. 3).[1] Less is known about how CCLSs perceive their supervisors’ support. The purpose of this study was to explore how CCLSs make meaning from their relationships with their supervisors, how they perceive their supervisors ameliorating or exacerbating their workplace stress and burnout, and how they have articulated their workplace concerns to their supervisors.
Literature Review
A seminal article on CCLSs’ burnout found that CCLSs who possess positive relationships with their supervisors are less likely to experience burnout (Hoelscher & Ravert, 2021). The authors recommended further research into such relationships. There are numerous risk factors for healthcare professionals’ burnout, including low pay (Ginter et al., 2024), imposter syndrome (Ehinger & Bales, 2023), and time spent in the field (Robins et al., 2009).
One important dichotomy is compassion fatigue and compassion satisfaction. Compassion fatigue is a combination of secondary traumatic stress and burnout (Figley, 1995) and a vital component to an individual’s professional quality of life (Branch & Klinkenberg, 2015; Hoelscher & Ravert, 2021; Lagos et al., 2022). Compassion satisfaction refers to the pleasure experienced by supporting others (Stamm, 2005). When a helping professional cannot achieve compassion satisfaction, they may be at greater risk for compassion fatigue (Dehlin & Lundh, 2018). Lower rates of compassion satisfaction have been observed in pediatric intensive care unit (PICU) nurses alongside higher rates of secondary traumatic stress and burnout (Branch & Klinkenberg, 2015). Greater number of years working in direct care and empathetic engagement are related to the experience of compassion fatigue and burnout among children’s hospital providers (Robins et al., 2009). In other studies, risk factors for nurses’ and CCLSs’ compassion fatigue include possessing less work experience, experiencing imposter syndrome as well as unsupportive coworker relationships, and frequently working 12-hour shifts (Berger et al., 2015; Ehinger & Bales, 2023; Hinderer et al., 2014). A provider’s exposure to chronic stress has been found to predict higher rates of compassion fatigue (Meyer et al., 2015). Protective factors against nurses’ compassion fatigue include having effective leadership, having over twenty years of experience, group cohesion, and staff support (Berger et al., 2015; Forsyth et al., 2021). Like these identified resources, a survey of pediatric nurses examined factors that contributed to higher rates of job satisfaction. Respondents frequently suggested the importance of positive colleague relationships and a supportive work environment (Wyatt & Harrison, 2010).
Research Questions
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How do CCLSs describe their relationships with their supervisors?
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How do CCLSs describe communicating with their supervisors about their workplace stress?
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What role(s) do CCLSs perceive their supervisors fulfilling with respect to workplace stress and burnout mitigation?
Method
This manuscript comes from a larger study on the professional burnout perspectives of early career CCLSs. Ginter and colleagues (2024) contains further details on recruitment, data collection, and data analysis.
Recruitment and Eligibility
Eligibility criteria included being 18+ and a child life professional (identified as a child life intern or someone who worked as a CCLS in the last five years). Participants were recruited via purposive and snowball sampling through the ACLP website and other child life online forums. Towson University provided IRB approval for this study.
Data Collection
Nineteen participants took part in telephone interviews that lasted 50 minutes on average. Interviewers asked questions from a semi-structured interview guide, using grand tour questions and probing questions (Appendix A). All participants consented to having their interviews audio recorded. Interviewers explained to participants that for the purpose of this study, the term “supervisor” encompassed child life managers, preceptors, and directors. Participants were asked to talk about the person who most closely supervised them. In this study, all participants stated that their supervisors were CCLSs.
Data Analysis
The authors identified prevalent themes (Braun & Clarke, 2006) via scrutiny techniques (Ryan & Bernard, 2003) among the varying supervisor experiences of CCLSs navigating the profession. After the researchers independently read the interview transcripts, they met in small groups (n = 3) to discuss their generally congruent themes and to resolve minor discrepancies. A final meeting was held to consolidate the small groups’ list of themes and subthemes into a single codebook.
The coders (n = 9), including four child life professionals, spoke at multiple junctures of data collection, analysis, and manuscript preparation about their reactions to the data. The interviewers achieved credibility by establishing rapport with participants prior to their interviews. Interpretive member checking ensured co-constructed meanings of descriptions during the interviews. All researchers practiced reflexivity by noting their experiences and thoughts during data collection and analysis (Morrow, 2005). Additional details about the group’s data analysis steps were previously published (Ginter et al., 2024).
Results
Nineteen participants took part in interviews with the researchers. At the time of their interviews, 13 participants were working as CCLSs in hospitals, two were working as CCLSs in rehabilitation facilities, and four were no longer working as CCLSs. On average, participants had begun their first CCLS position 2.75 years prior to their interview. The four themes were 1) lack of support from supervisors, including establishing boundaries, 2) generational differences between supervisees and supervisors, 3) supervisors are also struggling, and 4) need for acknowledgment and advocacy from supervisors.
Lack of Support from Supervisors
Participants reflected on their experiences with supervisors. Some participants stated that their supervisors were inaccessible, which took the form of being unsympathetic regarding participants’ concerns. This in turn led to participants feeling unable to ask for support. One participant explained:
I think what feels not empathetic is when [my supervisor] gets frustrated about something [we bring to her], it’s like she snaps really quick at all of us in a meeting and will just be like, “Well, why aren’t you trying harder? Why aren’t you trying to fix this problem?” Then we all kind of shudder and shut down and just don’t respond.
Four participants referred to their supervisors as “lacking bedside manner.” Many participants described supervisors who were sympathetic but caught in the hospital’s systemic issues, and therefore unable to sufficiently support them. One participant recalled:
[Manager] was very, very much like the epitome of the “open-door” policy. She was always available if you had an issue, and always there if you needed to talk because she had been in the role of child life specialist for so long and especially at [hospital] … And on top of that, she understood the struggles of wanting to have more recognition and wanting to get paid more and so she strongly advocated for those things for us within the department … Unfortunately, those things didn’t happen in her time while she was there as manager.
Participants suggested that their supervisors’ unsupportive practices were rooted in policies that were not being applied to all CCLSs. One participant described an experience they had during their first week when preparing a child for a dressing change:
I was so anxious about it, and we came up with a plan and we finally got him to agree to do it and I was midway through supporting him and my preceptor came in and she said “It’s 5:30; it’s time for you to go, you have to go.” And I was like, “well, I’m in the middle of supporting him, we just built up this trust, now you’re going to tell me to leave,” and I went home, and I just cried. … I know that you’re trying to encourage me not to stay late every day, I get that. But also, I just built up this trust with this kid and now I’ve left in the middle of supporting him so he’s not going to necessarily trust that I’m going to stay next time if he needs me. And I knew that they had a policy within their staff where they could like somewhat flex their time like if they had to stay a little bit late to support for something, they would leave 20 minutes early the next day or something like that to make up for that time, and we hadn’t discussed it beforehand and so she just came in the room and was like “You need to leave.” And I was so frustrated, and I went home that night … this is not how this is supposed to be.
Establishing Boundaries
Sixteen participants talked about the need to establish boundaries with their supervisors. There was variation in how much participants and supervisors had directly discussed their boundaries. Boundaries included communicating outside of work, spending time together outside of work, and what topics were appropriate to discuss. Some participants set boundaries pertaining to physical space, which allowed them more breathing room throughout the workday. One participant said, “I really felt like it was important for me to eat separately from the supervisors at the hospital just to give everybody a break.” Participants also described setting boundaries regarding what they would discuss with their supervisors. Sometimes, this was due to a mutual understanding of what was or was not appropriate to discuss at work. For example, one participant said, “We focus mostly on stuff at work [in our conversations].” Another participant explained, “We do set really firm boundaries. … It’s good professional support.” However, other times it was the participants who set boundaries to self-protect. One participant remarked:
I don’t know that we necessarily have [boundaries] as far as what is or isn’t appropriate to discuss, but I think as far as being comfortable discussing it, I generally don’t discuss things with her that are, how should I put it, that makes me feel vulnerable, you know, situations that might be more emotionally tolling or things like that. I tend to discuss with other people, and not with her because I don’t feel that it will be met with true understanding or empathy.
When boundaries were crossed (as reported by six participants), participants usually attributed the breach to their supervisors (n = 5). One participant recalled:
I feel like our supervisor kind of broke a lot of boundaries of like complaining to us about the director and just like making comments about other staff members. You could hear from the tone of her voice, that she might not have liked how one staff member works well with another staff member, which should never have been the case because she’s our supervisor and we shouldn’t know how she feels about our coworkers. But it was very clear as to like what comment frustrated her, like who frustrated her…and she would just…she was in our space a lot which was fine at times, but I feel like there was definitely a lot of boundaries that were broken, and we shouldn’t have had that experience with her.
As seen in the above quote, crossing boundaries could lead to negative experiences.
Sometimes, a more permeable boundary provided insight into the inner workings of the hospital and child life team. Even when they described feeling uncomfortable with the lax boundary, participants acknowledged that benefits came with a supervisor who was outspoken. As one participant recalled:
[My supervisor and I] hung out outside of work and so there definitely were times where there were probably things that were shared with me that should not have been necessarily, because maybe they were about other individuals on our team or maybe you know about how a meeting went with her superiors that were probably, information should not have trickled down to us, but I think in some ways, it was like good to know that information. And it definitely in some ways maybe impacted like my decision to leave and just maybe knowing what some of my other coworkers either were doing or weren’t doing which maybe made me feel frustrated.
Generational Differences Between Supervisees and Supervisors
Ten participants attributed their supervisor-related frustration to the fact that their supervisors had entered the field of child life at a different time and therefore could not relate to life as a CCLS presently. One participant commented, “I think it’s related generationally.” Another participant compared her experiences working with two supervisors:
My second preceptor has only been in the field for three years and is a lot closer in age to me and because of that I felt very supported by her individually because she remembered what it was like to be in my shoes … That was very different from with my first preceptor, who was an intern before I was born, so she doesn’t necessarily remember what that was like then, and also, it’s totally different now from what it was like then. It’s a completely different world pursuing this field from the way it was just five years ago. My preceptors definitely had a lot of valuable knowledge to share, but they were all very much in different stages of their careers and I think that that influenced their understanding of where I was at.
Nine participants described a “hands off” approach that their supervisors chose to set. This approach was attributed especially to supervisors that, once in a managerial role, did not routinely interact with patients. One participant reflected:
[My supervisor] works remote a lot. She’s hidden away in her office a lot. She’s not always willing to run to you or run to your unit or be present. She … actually doesn’t do any patient care. She’s strictly a manager, so that is also really hard because I feel like that she doesn’t understand and that she doesn’t remember. From being on the units and working with people so the almost 20 years that she’s been at my hospital, she’s only been in the managerial role. So sometimes it feels like there’s this really big disconnect. I’ll say something in supervision about something that happened, and her mind will be absolutely blown that that kind of situation would occur.
Similarly, another participant said about their supervisor, “She does not understand what I do on a day-to-day basis and is very out of touch from the bedside care.”
One participant recognized where the main difference from supportive managers and more distant managers may lie, saying “…we have a very close relationship. I think it’s very helpful that she’s still practicing on the unit, so she understands what it’s like to be a clinical child life specialist, versus, maybe a manager who isn’t a child life specialist, or has been out of that role for years, so she’s wonderful.”
Supervisors are also Struggling
Participants closely watched how supervisors, their de facto mentors, did or did not model self-care. One participant said, “Having a manager that has a good work-life [balance] … The reality is that we need to care about ourselves too and so I think just emphasizing the importance of self-care continuously over and over and over.” Participants noticed when their supervisors appeared to be suffering. One participant said, “I think it’s important for supervisors to not dump their [own] burnout on their students, which is definitely happening.”
Participants also described observing supervisors who appeared dissatisfied with their job yet seemed unable or unwilling to leave. A participant said about her mentor who was attempting to switch jobs that “she’s just been getting rejection after rejection, which is terrible because she’s stuck in this situation, but she’s trying to change it.” Another participant recalled the frustration of limited communication with her supervisor. She said, “I gave her a chance and … didn’t hear back from her for a week. I really try [to understand] when they talk about like burnout, I mean, you’ve been in the field for 15 years. I can see that.”
At the time of embarking upon her own career change, one participant reflected about her child life colleagues:
[When] I already had one foot out the door, I observed my colleagues being much more open with me about their true feelings around the field, and I found that to be really interesting. And honestly, I think that played a part in in me deciding to pursue other ventures because some of my colleagues had been in the field for 15 years, over a decade, and hearing them [say], “This is all I know how to do, I can’t leave it.” So, I was like I don’t know if I want to be trapped in that way because I saw the way that it has affected them over the years.
As this participant noted, her colleagues shared this only as she was about to leave. Participants understood when their supervisors were experiencing workplace stress and burnout; not addressing it made things harder for everyone on the team. As another participant said, “There is so much power being vulnerable with staff.”
Need for Acknowledgment and Advocacy from Supervisors
Although there was no identified direct solution to burnout, participants stated that supervisors’ acknowledgment and advocacy would go a long way towards improved well-being. Participants recalled when their supervisors had done this (as one said, “Praising me for the things I’m doing outside of work to try to enhance my work-life balance”) and when they felt an absence of validation from their supervisors. One participant said:
I feel like at the end of the day really the most that a supervisor can do, “one of the biggest things they can do,” is really listen to their staff. I think it really depends on the environment that the child life staff is working in. If it’s a really small team with two or three child life specialists, then larger scale changes can be made and the supervisor or manager can be the one to advocate and push for that, then that’s wonderful … even having a manager who really advocated for us and really dedicated her time of work to attempt to make change in the department and within the hospital … that was kind of the biggest thing for us because we didn’t necessarily feel like we were crazy. We didn’t feel like it was unreasonable, the experiences we were having and the feelings we were feeling.
One participant in this study who reported feeling unsupported by their supervisors stated, “I felt very alone in having to advocate for my place within the healthcare team, and it was this very–there was a very like individualistic culture that was cultivated at my last workplace, so it was very exhausting having to advocate for myself constantly at every turn and advocating for myself within the child life team too.”
Twelve participants acknowledged their supervisors’ efforts, but found them still lacking:
I think you got to do more than, like, hand out stickers. I think sometimes they try to do Band-Aids by like bringing donuts. Those things are nice, you know, it’s nice to bring donuts or pizza or whatever but I feel like people need to feel genuinely valued and cared about and that takes a lot of hard work. I think that that is knowing your staff as people, recognizing this, what they’re doing, being supportive when there needs to be improvements.
Another participant reflected, “So I think validating and having more flexible and open schedules would be really helpful, and I feel like those are two pretty small things to ask.”
Along with feeling supported, four participants said that supervisors needed to recognize that patient-related stressors can be overwhelming regardless of the CCLS’s experience level or the unit they agreed to work in. As one participant explained:
I think that a lot of managers might get lost in the sense of when people pick the stereotypical units that experience death or trauma, like the ICUs or hospice, “Well you did sign up to work here so you should be able to make it,” but that doesn’t make it less hard, it doesn’t make it easier for me to handle that, to process that situation, so I think just if management had the ability to recognize again, that we are people and we have feelings.
Five participants reported having positive experiences with supervisor-led practices that acknowledged their contributions:
We have employee recognition every morning where we like, just recognize, and thank members of our team for even small things that they’ve done and highlight that we appreciate them and that they did something really cool and helpful. The overarching things besides the whole employee wellness program, which is really big here.
One participant described their ideal supervisor by wishing they would say, “I don’t know the answer to this but let me tell you how I’m going to try to figure this out for you. I don’t know what we need to do to help you, I’m going to check these resources, and I’ll get back to you.”
Discussion
This study’s primary purpose was to explore CCLSs’s perspectives on their relationships with supervisors. CCLSs described feeling frustrated by a lack of support from some supervisors, feeling that supervisors were absent, unaware of, or unresponsive to their concerns. Many participants conceded that supervisors were also stressed and possibly feeling burned out. Finally, participants described what they would need to feel better supported by their supervisors.
Hoelscher and Ravert (2021) previously reported that CCLSs who perceive positive relationships with their supervisors are less likely to experience professional burnout. Moreover, nurses’ perceived supervisor support is associated with higher organization commitment (De Regge et al., 2020). These findings bear relevance to this study, as participants largely described unsupportive relationships with their supervisors as well as feeling burned out. Supervisor-employee boundary maintenance experiences varies within and across discipline (Cook et al., 2018; Sorour et al., 2024; Yasir & Majid, 2019).
Participants of this study discussed the perceived generational differences between themselves and their supervisors. Previous research on health care providers has noted that generational diversity offers strengths and challenges to the workplace, including different perspectives on rewards and recognition (Bachus et al., 2022). In a study on nurses, turnover intention was more likely to be reported by Millennial nurses than Baby Boomer or Generation X nurses (Rutledge et al., 2024). In a study on surgeons and the surgical physician associates they supervised, surgeons’ burnout predicted their associates’ stress and burnout (Smith et al., 2024).
The sociocultural context of substantial workplace stress and professional burnout (Fisackerly et al., 2016; Ginter et al., 2024; Hoelscher & Ravert, 2021; Lagos et al., 2022; Tenhulzen et al., 2023) indicates that CCLSs need more support, and their supervisors may be best positioned to listen to their concerns and help them seek resources. In the absence of substantial information about child life supervisors’ perspectives, it may be useful to consider other healthcare professions. For instance, Dehlin and Lundh (2018) reported that among psychologists, those that had access to supervisors and engaged in reflective stances were less likely to report experiencing burnout. Similarly, Quigley et al. (2023) reported that pediatric nurses who reported unit-level open communication (including with their supervisors) experienced less burnout. Just as participants of this study discussed the need for acknowledgement and advocacy from their supervisors, employees across numerous disciplines have stated the need for emotional availability, motivating language, and advocacy from their supervisors (Thelen et al., 2022).
Limitations
Not all participants responded to the demographic questions, citing concerns that in such a small field, they could be identified easily. Of those who did respond, there lacked racial, ethnic, and gender diversity. Demographic data about disability and sexual orientation were not collected. Although White women predominately make up the child life discipline, CCLSs with other racial and ethnic backgrounds experience the child life profession differently (Gourley et al., 2022). This includes how comfortable they feel communicating workplace stressors to their supervisors (Gourley et al., 2022, 2023). Future research ought to explore the CCLS-supervisor relationship of CCLSs and/or supervisors with marginalized identities. Additionally, contexts such as geographic region (both within and outside the United States) and length of practice should be further explored. Another limitation of this study is the potential for participant bias: people less satisfied with their supervisors might have been more likely to participate. Finally, in this study, all participants stated that their supervisor was also a CCLS. Not all CCLSs are supervised by another CCLS; future research might consider the experiences of CCLSs supervised by other healthcare professionals.
Future Practice Implications
Previously, the ACLP has addressed mindfulness and other reflective processes that CCLSs should employ to protect themselves from burnout (ACLP Bulletin, 2023). A review of ACLP-developed webinars showcases a focus on what CCLSs should do for themselves. There is less information on how supervisors can talk to CCLSs about workplace stress and burnout, although the ACLP-developed mentorship program for emerging and established CCLSs may address this (ACLP, 2024). However, it remains unknown how often supervisors are engaging with these resources, their perceived barriers to using them, or what supervisors themselves would find helpful in supporting CCLSs.
Conclusion
In this exploratory study on CCLSs’ perceived relationships with their supervisors, many participants referenced absent supervisors, supervisors who themselves were likely experiencing burnout, and the disappointment and stress of not feeling heard by their supervisors. In some cases, the lack of supportive relationships was a precursor to leaving their position. The importance of supportive supervisors has been addressed in previous studies on employees’ well-being, professional burnout, and organizational commitment, both within and outside healthcare professions. Standards of mentorship for child life students and CCLSs should be revisited by the ACLP and by individual child life teams. Though the reasons for CCLSs’ frustration with supervisors are complex and entrenched in a myriad of systemic stressors, there is no time to be wasted in securing additional support for CCLSs. This can only strengthen healthcare teams and the families they seek to serve.