There Is No “One Right Way”: Perfectionism, Imposterism, and Well-being in Child Life Training and Practice

Child life specialists must integrate myriad skills into their work, tailor appropriate interventions with diverse clients of all ages, and be adaptable in their support and advocacy in stressful or traumatic situations. The pressure to meet high standards in their work may contribute to increased risk of burnout and impaired well-being. This mixed-methods study examined characteristics of perfectionism and imposterism among 151 child life specialists and students and the relationships between those characteristics and various aspects of well-being. Results indicated that characteristics of both perfectionism and imposterism were common among child life professionals, that the traits were associated with lower well-being, and in turn, higher risk of burnout. Qualitative data revealed that perfectionism and imposterism can negatively affect child life training, professional practice, and well-being, and may be a barrier in promoting diversity within the field.

Perfectionism is a trait widely studied in the psychological literature (Samfira & Maricuţoiu, 2021) and is comprised of at least two dimensions: personal standards and evaluative concerns (Dunkley et al., 2012).Gaudreau (2019) suggests that high personal standards may foster striving for perfection or striving for excellence.Pursuit of excellence can be considered adaptive and is associated with leadership (Shim & Fletcher, 2012), emotional intelligence (Gong et al., 2017), emotional regulation (Hill & Davis, 2014), less burnout and stress (Moate et al., 2016), and higher self-esteem (Lo & Abbott, 2013).The "evaluative concerns" dimension of perfectionism is related to fear of criticism and making mistakes, self-doubt, negative selfevaluation, and contingent self-worth (DiBartolo et al., 2007).Although self-critical perfectionists often equate acceptance with success, they are unlikely to feel pride around success and often feel shame or guilt around failure (Stoeber, Hutchfield, et al., 2008) which is negatively associated with self-efficacy and confidence (Stoeber, Kempe, et al., 2008).Perfectionists are likely to experience hypervigilance with negative feedback (Levine et al., 2017), rumination, and ineffective use of stress reduction techniques (Azam et al., 2015).The evaluative concerns dimension of perfectionism is more consistently considered maladaptive (e.g., Wang et al., 2014), but individuals who rate highly in either dimension report negative mental health outcomes (Limburg et al., 2017), stress and distress (James et al., 2015), burnout (Childs & Stoeber, 2012), and low self-esteem (Aldea et al., 2010).Hewitt and Flett (1991) emphasized that perfectionism may present as self-oriented (pressure for perfection from within), other-oriented (expectations that others should aim for perfection), and socially prescribed (perceiving that others expect perfection).

Perfectionism Among Helping Professionals
Most perfectionism research uses quantitative data from undergraduate student participants (e.g., Gong et al., 2017).However, a few studies have examined perfectionism among helping professionals.Among teachers, perfectionism was related to exhaustion and cynicism; whereas, among healthcare professionals, perfectionism was associated with role stress and inefficiency (Childs & Stoeber, 2012).For therapists, perfectionism was associated with lower treatment efficacy and client retention (Presley et al., 2017).Chang (2017) found that for nurses, maladaptive perfectionists frequently reported perceived personal failure.In other words, maladaptive perfectionism may negatively impact well-being, professional engagement, and job performance.

Perfectionism, Imposterism, and Child Life Specialists
Although existing studies suggest perfectionism can be detrimental for helping professionals, there is no research regarding such characteristics among child life specialists.However, Framarin (2021) discussed factors related to imposter phenomenon (IP) in the field; the broad scope of child life practice requires learning a great deal on the job to build on clinical training and establish expertise as authoritative healthcare professionals.Further, Ehinger and Bales (2023) found that among child life specialists, IP and burnout experiences were positively related, and the impact of COVID-19 on Certified Child Life Specialists (CCLS) predicted levels of burnout.Imposterism is a common concern among social workers (Urwin, 2018) and is significantly related to perfectionism, particularly evaluative concerns, need for approval, rumination (Cokley et al., 2018;Dudău, 2014), fear of failure (Ross et al., 2000), and doubts about actions (Pannhausen et al., 2020).Hutchins and colleagues (2018) found that people who experience high levels of IP are likely to use avoidant coping strategies and experience emotional exhaustion and low job satisfaction.Imposterism is also associated with risk of compassion fatigue and burnout (Clark et al., 2021).Burnout and impaired well-being are not only concerns for child life specialists (Hoelscher & Ravert, 2021;Lagos et al., 2022), but even students are at risk for both during their clinical training experiences (Gordon, 2022).The pressure to meet standards of perfectionism may be an additional burden for child life professionals who identify as Black, Indigenous, and people of color (BIPOC).Fields and Cunningham-Williams (2021) found that some Black women who worked as social work faculty in an academic setting were hesitant to present as their authentic selves due to concern over colleagues' perceptions and stereotype threat.Factors such as stereotype threat, low racial representation, and pressure to be a role model for others are related to imposterism (Stone et al., 2018).Lambert and colleagues (2014) suggested that racial discrimination was associated with socially prescribed perfectionism.This current study works to understand the relationship between experiences of IP and burnout in the context of perfectionism to promote better quality of life for child life students and professionals.

Purpose of the Study
This mixed-method study examined perfectionism and imposter characteristics among child life students and professionals.Specifically, we examined the following research questions:

Recruitment and Eligibility
Participants needed to be either CCLS or individuals pursuing certification who were 18 years or older.They were recruited using convenience sampling through 12 advertisements on social media and completed an online survey through Qualtrics between November 2021 to January 2022.Respondents provided contact information if interested in participating in a follow-up interview, and all interested participants were invited to schedule a 90-minute virtual interview.

Participants
In total, 151 participants fully completed the online survey.Of those participants, 58 (38.4%) indicated a willingness to participate in a follow-up study, and 22 participants completed the interview portion of the study.

Measures
Perfectionism.Perfectionism characteristics were assessed using two subscales (20 items) from the Frost Multidimensional Perfectionism Scale (FMPS; Frost & Marten, 1990): "Concern over mistakes and doubts about actions" (13 items; e.g., "I should be upset if I make a mistake"; α = .90)assessed evaluative concerns perfectionist characteristics and "excessively high personal standards" (7 items; e.g., "If I do not do as well as other people, it means I am an inferior being;" α = .81)assessed personal standards perfectionism.Participants responded using a semantic differential scale from 1 (strongly disagree) to 5 (strongly agree).Items were averaged to make subscale composite scores, where higher scores indicated more endorsement of perfectionism characteristics.The FMPS has been used widely and has demonstrated validity (Frost et al., 1993(Frost et al., , 1997) ) and reliability (Purdon et al., 1999).
Imposter Characteristics.Imposter characteristics were assessed using the 20-item Imposter Phenomenon Scale (Clance, 1985), which has demonstrated validity and reliability in previous studies (Chrisman et al., 1995;Holmes et al., 1993).Respondents indicated how true each statement was of them (e.g., "I can give the impression that I'm more competent than I really am") using a scale from 1 (not at all true) to 5 (very true).Items were added together to form a composite scale (α = .92)ranging from 20 to 100 where higher scores indicated more frequent and serious interference of imposter characteristics in the participant's life.Scores between 61 to 80 indicated frequent imposter experiences, and scores higher than 80 indicated intense imposter experiences.
Well-being.Participants' well-being was assessed using the short version of the Depression, Anxiety, and Stress Scale (DASS-21; Antony et al., 1998;S. H. Lovibond & Lovibond, 1995).Depression, anxiety, and stress were each assessed with 7-item subscales.Participants indicated their experiences in the last week using a scale from 1 (Did not apply to me at all) to 4 (Applied to me very much, or most of the time).For each subscale, items were added together to form composite scores ranging from 7 to 28 where higher scores indicated more symptoms of depression, anxiety, or stress.All subscales demonstrated acceptable reliability in this study (depression: α = .83;anxiety: α = .80;stress: α = .81),and the measure has demonstrated strong validity and reliability across many previous studies (P.F. Lovibond & Lovibond, 1995;Norton, 2007) Burnout.Burnout was assessed using the 7-item workrelated burnout subscale of the Copenhagen Burnout Inventory (Kristensen et al., 2005), which is well-validated in previous studies (Montgomery et al., 2021;Walters et al., 2018).Participants responded to items (e.g., "My work feels emotionally exhausting") using a scale from 1 (never/ 1. Are perfectionism and imposter characteristics associated with reports of well-being and burnout among child life students and professionals? 2. What are the mechanisms through which perfectionism and imposter characteristics are associated with well-being?
There Is No "One Right Way": Perfectionism, Imposterism, and Well-being in Child Life Training and Practice The Journal of Child Life: Psychosocial Theory and Practice Note.All demographic characteristics that were significantly associated with variables in the model were included as covariates in the tested model.
almost never) to 5 (almost always).Items were added together to form a composite score (α = .91)from 7 to 35, where higher scores indicated more burnout.
Interview.The semi-structured interview guide included three broad questions about fit in the field of child life, self-assessment and feedback from others, well-being, and one additional question about whether participants identified as perfectionists (see Appendix).Interviewers attempted to make interviews conversational and asked follow-up questions only when participants did not address them in their initial open-ended responses.

Data Analysis
The parallel mixed method analysis involved a concurrent, iterative process of examination of qualitative and quantitative data (Kroll & Neri, 2009).Before beginning quantitative analyses, qualitative interview transcripts were analyzed by the research team using thematic content analysis (Braun & Clarke, 2006).Each author individually read the transcripts to become immersed in the data, and initial impressions and patterns were discussed as a group.Initial impressions were used to develop the theoretical path analysis which was examined quantitatively (see Figure 1).Following quantitative analyses, the qualitative data were used to contextualize and deepen quantitative findings.During this process, authors re-read transcripts, coding specifically for mentions of perfectionism, imposterism, well-being, and burnout.Discussions of codes and identification of illustrative quotes resulted in the final themes presented in this paper.
In terms of quantitative analysis, first descriptive statistics were conducted to determine the prevalence of perfectionism and imposter characteristics in the analytic sample and to determine if they varied based on demographic characteristics.Demographic characteristics which were significantly associated with perfectionism or imposter characteristics were included in subsequent analyses as covariates.Next, correlations were computed to examine whether per-fectionism and imposter characteristics were associated with well-being or burnout variables.
Finally, the path analysis developed based on initial qualitative analysis (Figure 1) was tested in AMOS 29.0 (Arbuckle, 2006) to examine associations between perfectionism and imposter characteristics, well-being variables, and burnout.Good model fit is indicated when chi-square values are nonsignificant (p > .05),and by a comparative fit index (CFI) of 0.90 or higher and a root mean square error of approximation (RMSEA) of less than 0.05 (Kline, 2011).In order to identify the most parsimonious model with the fewest parameters, nonsignificant paths were removed from the final model.To handle missing data, Full Information Maximum Likelihood (FIML) which provides less biased information than ad hoc procedures by estimating participants' missing responses based on each participant's available data were used (Schafer, 1997).Following the path analyses, the significance of the indirect pathways was tested using bootstrapping procedures in AMOS (Preacher & Hayes, 2008).
Participants also discussed perfectionism and imposterism during the qualitative interviews.For many, high personal standards led to performance pressure and anxiousness around self-assessment and feedback.One participant said, "I wish I was able to not internalize feedback and expectation so much.I…put a lot of pressure on myself."Another stated that upon receiving feedback, "I get defen-sive…because I have such a high standard."One person discussed difficulty celebrating successes: "I pretty regu-larly…diminish whatever my success is." Participants reported internalizing negative feedback as feelings of shame and doubt and had difficulty letting go of perceived failure.One CCLS talked about her efforts to "[not allow] opinions of others…to get under my skin.I may be good at not reacting in the moment, but I fixate and can't get it out of my brain for several days."Another shared, "If it was negative feedback, I was the worst.And I couldn't ever do anything right…the world was falling apart."One participant mentioned that high personal standards at work and parenting resulted in feeling "like I can never be good at either place.If I was good in one, I was failing at the other." Many expressed active attempts to avoid any degree of failure.One person said, "it can be the smallest mistake and it can be insignificant to other people.Other people may not even see it at all.But I see it… I know I made a mistake.And I don't like making a mistake."Another reported, "I definitely beat myself up mentally with that…negative self-talk… 'you should have done better…you could have done better.'" Participants also worried about potential consequences of mistakes or imperfection on patient coping: "I'm always afraid I'll get in trouble…if I do something really wrong…it may not be life or death, but it can injure [patients] in some way."One participant said, "if I was perfect at my job, I would be able to help this kid going through a hard time."However, "being a perfectionist can have a downside, be-cause…staying too rigid can really take away from what the child needs…that can be probably even more detrimental than if everything was going perfectly the way you wanted it to be." In addition to unrealistic personal expectations, many participants perceived pressure associated with socially prescribed perfectionism, including expectations of perfection from colleagues or as a standard in the child life field.For example, "Perfectionism is almost looked at as something you should try and attain when it comes to child life…it is almost celebrated, that you…do things above and beyond, and you're always so happy and you're always…just a perfect version of yourself, always on…that is a very dangerous mindset." One participant expressed concern that the pressure for child life specialists to say and do the right thing all the time leads to missed opportunities for learning and growth."I think that everybody [in child life] feels like they have to be perfect 100% of the time: they have to say the right thing…do the right thing…provide…the right amount of support, and…there's a fear of doing something wrong… it's less about learning, and it's more about just getting it There Is No "One Right Way": Perfectionism, Imposterism, and Well-being in Child Life Training and Practice The Journal of Child Life: Psychosocial Theory and Practice right."Other participants discussed hesitancy to try new things in their practicum or internship."I was nervous to try new things, because I didn't want to fail."Others expressed fear of making a mistake in front of multidisciplinary colleagues because they worried about judgment regarding their competence."I live in a constant fear of, 'Am I doing enough?Is this good enough?'" Other-oriented perfectionism can also lead to unrealistic expectations and judgment of others.One participant shared, "I have a really strong work ethic and I…expect the same of other people…that is a problem at times for me, because my work ethic and someone else's work ethic can be very different…it certainly can create some distrust and divisiveness in the team." Participants who identified as BIPOC shared experiences related to their child life journey, including pressure to succeed."So many people have high expectations for me and I'm afraid I will disappoint them and myself by not doing well."Another participant discussed their perception that there is a narrow view of who can be successful in child life: "I think almost anyone can be a good child life specialist.Anyone that is compassionate, quick thinking, strong, and happy is usually thought of as an 'ideal' child life specialist, but there are lots of others, including myself, who are not all of those things that are still good child life specialists.I think it is more beneficial to have these differences because we serve different types of patients and families."Another shared: "I knew I had to be just that much better than everybody else.So that nobody said that I got it because they just wanted…some diversity on their team.I didn't want anybody to be able to say that about me.I got the job because I'm well qualified for it and I was the best candidate."

Correlates of Perfectionism and Imposter Characteristics
Reports of both types of perfectionism characteristics were associated with reports of more imposter characteristics (EC: r = .71,p < .001;PS: r = .28,p < .001),and qualitative data highlighted common experiences of imposterism.For example, one participant said, "When I observe other CCLS's, I often feel as if I am not nearly as qualified or as strong of a child life specialist as they are."Another listed worries about "not being good enough, being a fraud, not knowledgeable enough, not knowing what to do to help a patient or family."One participant shared, "Even though I've been a CCLS for almost 12 years, and my work performance has always been good, I still have feelings that I don't know what I'm doing or I should be doing better."Another said they wished they were "more confident in my abilities to supervise students and not feel imposter syndrome."One participant said: "I take this job very personally.When…nothing that I am trying is working I frequently feel like a failure.I am constantly worried about doing something wrong or getting into trouble over something small.Sometimes I feel as though my child life skills are not good enough…I really struggle with comparing myself to other specialists in my department even when I receive validation that I'm doing a good job."
Participants linked their experiences of perfectionism and imposterism to well-being: "I constantly pour from my cup…I will take care of people over taking care of myself…I come home, and I can't sleep, because I'm thinking about work, or I don't want to do things…because I've overextended myself."Qualitative reports also illustrated the connection between feelings of imposterism and burnout."Before I left child life because of burnout…I assumed everyone else was better at this than me."

Discussion
This study examined the experiences of perfectionism and imposter characteristics among child life students and specialists.On average, participants reported high levels of personal standards perfectionism, putting them at risk for burnout (Childs & Stoeber, 2012) and poor mental health outcomes (Limburg et al., 2017).Approximately a quarter of participants endorsed the evaluative concerns dimension of perfectionism, which tends to be associated with exhaustion, cynicism, and reduced work performance (Childs & Stoeber, 2012).In the current study, both dimensions of perfectionism were negatively related to well-being and positively related to burnout.While CCLS who have been in the field for five or fewer years were particularly at risk, 43% of all survey participants experienced frequent or intense experiences of imposterism, putting them at risk for emotional exhaustion, low job satisfaction, and use of avoidant coping strategies, which includes perfectionism (Hutchins et al., 2018).In turn, avoidant coping is associated with compassion fatigue and burnout among CCLS and negatively related to compassion satisfaction (Lagos et al.,

Figure 2. Final model illustrating associations between perfectionism and imposter characteristics, well-being, and burnout
Note.Standardized path coefficients are presented.Only significant paths and covariances are included in figure.Age and years of experience were each significantly correlated with perfectionism and imposter characteristics, but coefficients are not presented here.Student versus professional status was also examined as a covariate but was not significantly associated with any variables in the model, so it was removed from this final model.

2022
). Clark et al. (2021) found that compassion satisfaction is negatively related to imposterism and warned that mental health professionals who experience IP are less likely to experience the rewarding aspects of their work.Further, they emphasized that compassion satisfaction may promote a sense of belonging and validation for clinicians and may reduce experiences of IP.Both imposterism and maladaptive perfectionism tend to be associated with fear of failure (Ozbilir et al., 2015;Ross et al., 2000), and many participants shared how this negatively impacted their work.Receiving constructive or negative feedback, self-evaluation, or making even small mistakes led to rumination, negative thoughts, and anxiousness.To avoid failure, judgement, or negative feedback, many reported engaging in avoidance behavior, including not trying new skills in front of others.Multiple participants identified difficulty accepting even positive feedback from others.Stoeber and colleagues (2014) found that socially prescribed perfectionism predicted higher levels of anger and depression after experiencing failure, and higher levels of anxiety with both failure and success.Self-critical perfectionists are likely to attribute success to external factors or other people (Levine et al., 2017).Urwin (2018) suggested that imposterism can be conceived as interpersonal attribution error, assuming one's ability is unstable and out of one's control, leading to reduced self-efficacy.
Perfectionism is associated with competitiveness (e.g., Klein et al., 2020) which is an important consideration given the competitive nature of the child life field, particularly for students during their academic and clinical training.Many participants reported pressure to prove their worth, always do and say the right thing, and maintain the persona of an "ideal" child life specialist.Furthermore, perfectionism was associated with unrealistic standards for others.This finding is supported by previous studies (e.g., Presley et al., 2017) and may negatively impact the work culture amongst child life teams, creating a negative and competitive dynamic (e.g., Rice & Liu, 2020).On the other hand, fostering quality relationships with child life colleagues is protective against burnout and emotional exhaustion (Hoelscher & Ravert, 2021).
Having standards of perfection for others also may negatively impact students and trainees if supervisors have unrealistic performance standards, and this study found that students reported fear of risking failure in front of supervisors.DeCandia Vitoria (2021) emphasized the pressure associated with training while concurrently supporting vulnerable patients.For teachers in training, perfectionism was found to be a barrier in their ability to be flexible in their interactions with children and to thoughtfully reflect on their strengths and weaknesses (van Ginkel et al., 2018).Interns may be further impacted if their supervisors struggle with imposterism.Some CCLS may feel resistance to mentoring students due to imposterism, and doubts about one's expertise and effectiveness, a common experience shared by participants in this study, may impact their ability to provide strong mentorship to students in developing competence and confidence in their clinical skills.
Perfectionism and imposterism may be a particular concern for BIPOC child life students and specialists; maladaptive perfectionism is significantly negatively correlated with cultural diversity awareness (Wang et al., 2014).The perception of a narrow "ideal" persona for child life specialists is not conducive to supporting diversity within the field.Okun (2021) argues that inequity is perpetuated by perfectionism and a belief that there is "one right way" that emphasizes conformity.Both may impact hiring practices and performance evaluations.Trainees who do not have mentors or role models who reflect their identities may feel they do not belong in their chosen career (Samora et al., 2023).Implicit messages and bias may drive child life professionals of color to work even harder to prove themselves (Gourley et al., 2022) and may result in higher rates of burnout, impaired well-being, and reduced sense of belonging (Peteet & Montgomery, 2015).Indeed, Ehlinger and Bales (2023) found that minoritized CCLS experienced more burnout than their White counterparts.
Among participants in this study, both perfectionism and imposterism were associated with symptoms of poorer well-being, and in turn, a higher risk of burnout.The evaluative concerns dimension of perfectionism was positively related to depressive symptoms, which was associated with higher risk of burnout.On the other hand, personal standards perfectionism was indirectly associated with burnout through an association with stress.Imposter characteristics were positively correlated to both anxiety and stress but only indirectly associated with burnout through stress symptoms.Taken together, child life specialists' well-being may be significantly and negatively impacted if they experience characteristics of perfectionism and/or imposterism.Increased risk of burnout may lead to helping professionals leaving their field (Urwin, 2018).

Limitations and Suggestions for Future Study
Although these findings have significant implications, the study is not without limitations.The cross-sectional methodology does not allow for inferences about causal relationships among perfectionism, imposterism, well-being, or burnout.For example, poor well-being may contribute to more feelings of imposterism.Further, all measures relied on self-reports and may be subject to social desirability bias.
Future research should investigate systemic factors that may contribute to perfectionism and imposterism for child life students and professionals.For example, social workers are at greater risk for IP when they do not receive adequate practice supervision or constructive feedback and when they are evaluated mainly on measurable outcomes of their job rather than interpersonal skills (Urwin, 2023).Environmental mastery is negatively correlated with imposterism (September et al., 2001), and future studies should address perceived adequacy of training for the myriad skills required of CCLS.The influence of students' experiences as they complete their child life academic coursework should also be addressed, as both perfectionism and imposterism have been identified as concerns in academia (e.g., Holden et al., 2021), particularly among first-generation students (e.g., McCarthy et al., 2023) who may be targeted for recruitment to increase diversity within the profession.Further assessment is also needed regarding broader organizational culture, systems, or processes that may perpetuate expectations of perfectionism or what Okun (2021) refers to as "one right way" of being successful.

Conclusion
Child life students and professionals who experience negative effects of perfectionism may benefit from normalization of feelings of imposterism, supportive mentorship (Hutchins & Flores, 2021), and practices promoting self-compassion (Ferrari et al., 2018) and mindfulness (Koerten et al., 2020).Cognitive behavioral approaches are effective in decreasing perfectionism and increasing self-esteem and well-being (Egan et al., 2014;Rozental, 2020).Changing language and attributions around success and failure may be particularly important to counteract imposterism (Hutchins et al., 2018;Urwin, 2018).Academicians and clinical supervisors can promote a growth-mindset for students and professionals (Mrazek et al., 2018); encourage willingness to be vulnerable and receptive to feedback (Samora et al., 2023); explicitly teach adaptive coping strategies that engender positive self-appraisals and increased self-efficacy (Bernard et al., 2020;Ogunyemi et al., 2022); and foster a culture of support, inquiry, and appreciation (Okun, 2021).

Figure 1 .
Figure 1.Hypothesized model of associations between perfectionism and imposter characteristics, well-being variables, and burnout.
There Is No "One Right Way": Perfectionism, Imposterism, and Well-being in Child Life Training and PracticeThe Journal of Child Life: Psychosocial Theory and Practice

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Is No "One Right Way": Perfectionism, Imposterism, and Well-being in Child Life Training and Practice The Journal of Child Life: Psychosocial Theory and Practice

There
Is No "One Right Way": Perfectionism, Imposterism, and Well-being in Child Life Training and Practice The Journal of Child Life: Psychosocial Theory and Practice Submitted: March 31, 2023 EDT, Accepted: July 24, 2023 EDT This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CCBY-4.0).View this license's legal deed at http://creativecommons.org/licenses/by/4.0 and legal code at http://creativecommons.org/licenses/by/4.0/legalcodefor more information.There Is No "One Right Way": Perfectionism, Imposterism, and Well-being in Child Life Training and Practice The Journal of Child Life: Psychosocial Theory and Practice
There Is No "One Right Way": Perfectionism, Imposterism, and Well-being in Child Life Training and PracticeThe Journal of Child Life: Psychosocial Theory and Practice