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November 2022 Article of the Month
by John Ehman, Editor, ACPE Research Article-of-the-Month
and Manager for Pastoral Care, Penn Presbyterian Medical Center, Philadelphia PA


den Toom, N., Visser, A., Korver, J. and Walton, M. N. "The perceived impact of being a chaplain-researcher on professional practice." Journal of Health Care Chaplaincy (2022): online ahead of print, 10/20/22.

[Editor's Note: Because this article is available ahead of print, no final page numbers can be cited. References are to manuscript [MS] page numbers.]

SUMMARY and COMMENT: The process of empirical research should be one of bringing a methodology to bear on real-world situations in order to collect data as cleanly as possible, with minimal influence from the individual who happens to be collecting that data (unless that is itself somehow the focus of study). Yet, the individual experience of conducting research hardly leaves researchers unaffected, and this month's article offers a highly valuable perspective on how doing research may affect chaplains' subsequent professional practice. The fact that this study is of a particular group of Dutch chaplains who participated in a specific project only slightly limits the breadth of its relevance to chaplaincy in general, because it proffers a critical and practical way of thinking about the topic. As more and more chaplains participate in research, the question of how our involvement is affecting us is an increasingly pressing one.

This research is a byproduct of first author Niels den Toom's four-year study -- for his Ph.D. -- exploring the question of how chaplains involved in a Dutch Case Studies Project [described briefly on MS p. 3] perceived that experience as affecting their professional expertise and positioning [--see Related Items of Interest, §I and §II, below]. The questionnaire used in the present inquiry was developed in light of the participant observation and in-depth interviews from that larger work. The items from this instrument are worthy of readers' close attention, though the article only highlights items where change was detected in the research. It is organized around the two constructs of expertise and positioning.

As we understand professionalism, as driven by certain central values, a professional's expertise is always directed toward those values (goal-oriented). Furthermore, expertise entails knowledge, theories and methods that professionals usually acquire via an intense, mostly academic training.... The specific character of professional knowledge, however, is that it cannot be applied without reflection, and that professionals therefore need discretion..., which is the power and ability to make a decision about what is best for a client. Thus, indirectly, the expertise of chaplains indicates the quality and aptness of the chaplain's care. Logically, discretion presumes a body of knowledge that helps in discerning he situation of the client, which is usually indicated as assessment. The issue of positioning of professionals pertains to how they collaborate with other professionals and how they legitimate their professional presence.... [MS pp. 2-3]

The featured questionnaire items are well described in the text, along with their theoretical grounding, but it may help readers to see them lined out:

Goal-orientation --
•  whether they value 'setting objectives' less, equal, or more
•  whether respondents used fewer, an equal number, or more objectives in their practice

Use of theory and methods --
•  whether they valued theoretical knowledge less, the same, or more
•  whether they valued working methodically less, the same, or more
•  whether they used theories less, the same, or more
•  whether they used methods less, equally, or more

Focus on meaning and worldview --
•  whether they valued the role of worldview in counseling clients less, equally or more
•  whether the following applied less often, equally often, or more often to their work: "I speak about meaning and world view in the counseling"
•  whether the following applied less often, equally often, or more often to their work: "I focus on meaning in counseling clients"
•  whether the following applied less often, equally often or more often to their work: "I focus in my contacts with clients on aspects of world view"

Assessment -- On a five-point scale (1=totally not, 2=hardly, 3=somewhat, 4=largely, 5=totally) if the following statements applied to them as a consequence of their participation [in the research]:
•  "I can better assess what is of importance to clients regarding meaning making and worldviews."
•  "My understanding of the client has improved."
•  "I am more able to reflect during counseling of clients."
•  "I can go deeper when counseling clients."
•  "I pay more attention to the context of clients and their loved ones."

Discretion -- On a five-point scale (1=totally not, 2=hardly, 3=somewhat, 4=largely, 5=totally) if the following statements applied to them as a consequence of their participation [in the research]:
•  "I make interventions more purposively."
•  "I look more at the outcomes (effects) of my actions for client."
•  "I can make better choices in the care of clients."


Collaboration -- On a three-point scale (1=less often, 2=equally often, 3=more often), how often the following items occurred in their chaplaincy practice:
•  "I collaborate with other professionals concerning a client."
•  "I share information about a client with another professional."
•  "I can demarcate my contribution in contact with other professionals."

Legitimation -- On a three-point scale (1=less often, 2=equally often, 3=more often) to what extent the following applied to them after participation [in the research]:
•  "I can substantiate my work."
•  "I have more vocabulary at my disposal to describe my profession."
•  "I can convince my manager of the added value of my profession."

The online instrument was distributed on 12/12/20, and 48 chaplains responded, for a response rate of 96% (of participants at the time of the survey). "On average, it took respondents 72 min to complete the survey" [MS p. 4]. This was a retrospective assessment of change perceived by the chaplains: essentially a post-test without a real pre-test [--see Related Items of Interest, §IV, below]; and that opens up the potential limitation of how the chaplains' recollections may have been "distorted" [MS p. 11]. Nevertheless, a sense of perceived change is surely significant in and of itself, and this reader would note that chaplains may be an especially good group for such a research methodology, given that the discipline of chaplaincy encourages a honing of skills around self-awareness and reflection.

Among the findings:

The results of the study show that for almost half of the chaplains, participation in research contributed to the importance that is attributed to theory, to methods and setting objectives and to using theoretical knowledge. Also, a considerable number of chaplains reported that participation in the CSP enhanced their discretion to varying degrees, and to a lesser degree, their assessment. Thus, the expertise of chaplains seems to have increased, and thus indirectly the quality of their care. Regarding the positioning, improvement is experienced by the majority of chaplains with regard to their legitimation, while the practice of collaboration has remained the same for most chaplains and was improved for one-fifth to one third of the chaplains. [MS p. 9]

And with regard for particular expectations of the researchers [introduced on MS p. 3], the results break out as follows:

  1. "In line with our expectations, we found a strong positive association between assessment and discretion and moderate positive associations between goal-orientation, knowledge and discretion." [MS p. 9]

  2. "...[T]he findings confirmed our expectation that goal-orientation would be positively associated with collaboration with other professionals." [MS p. 10]

  3. "...[O]ur expectation was confirmed that knowledge -- theory and methods -- would be positively associated with the legitimation of chaplaincy." [MS p. 10]

  4. Plus, while not originally formulated as an expectation, the authors "found by coincidence" that "a focus on worldview and meaning significantly correlated with assessment and discretion" [MS p. 10], and this is addressed in line with their discussion of expectations. "Only part of the chaplains reported a stronger focus on meaning and worldview as the domain of chaplaincy" [MS p. 10].

In sum:

We have found that participation in research contributed to the expertise of chaplains, in its goal-orientation, theoretical and methodical working, assessment and discretion, and their positioning as they try to legitimate their profession. This research also shows that the reinforcement of knowledge is associated both with better assessment and discretion and with a stronger legitimation. Hereby, this study substantiates the presumption that chaplains' engaging in research as chaplain-researcher contributes to the improvement of the quality of chaplaincy care and its legitimation. [MS p. 11]

Central to the article is the authors' sense of key concepts and their theoretical connections as presented on MS pp. 2-3, including the role of expertise in professionalism and how "indirectly, the expertise of chaplains indicates the quality and aptness of the chaplain's care" [MS p. 2]. The connections here are logical, but one concern in the background may be how cleanly they play out in the real world of chaplaincy and in the complexity of the chaplain-patient encounter. The results of the study bear out the expectations of the researchers and broadly support their theoretical grounding (and, implicitly, the perceptive depth of den Toom's original work), but while the data may favor certain conclusions they also may suggest that subsequent research explore further the subtleties of the conceptualizations here. How, for instance, might a statement like, "The specific character of professional that it cannot be applied without reflection" [MS p. 2], be understood in light of the various ways that reflection is understood and operationalized in the course of Clinical Pastoral Education?

A final comment: the authors often use the word enhance to describe the effect of the research experience on chaplains, but at one point they note that "the combination of research and practice changes chaplains and enlivens their practice" [MS p. 2]. The word enlivens seems more personal and poignant, honoring the fully lived experience of chaplaincy. Research, at least for this chaplain, doesn't just yield knowledge but generates an excitement of discovery and inspires my emotional as well as my intellectual engagement with patients. Correspondingly, just as the experience of research can enliven the practice of chaplaincy, one might wonder how the experience of chaplaincy could benefit the practice of research.

There are 48 references in the bibliography.


Suggestions for Use of the Article for Student Discussion: 

This article should be quite readable for most CPE students, and the theoretical and well as evidentiary aspects of it should be interesting. Even the language of "correlation" is contextualized in a way that students not familiar with statistics should easily be able to follow the line of thought. It would be a useful article both for chaplains initially undertaking research and for those who have already been involved in a project, lifting up the potential relevancy of empirical study for professional enrichment, beyond the discovery of data. For students new to research, discussion could begin simply with how much emphasis the group naturally places on keen and systematic observation in the course of their chaplaincy visitation, their process for assessment, and their verbatim work. How are they intentionally relying upon and building their expertise? How do they, in turn, see their position in the multidisciplinary clinical environment? How do the findings from this month's study help them envision ways that research experience could be valuable to their chaplaincy practice? What might be steps they could take toward gaining such benefits? For students who already have research experience, discussion could revolve around how the findings of the present study resonate with them? Which questions from the survey were most striking to them, and which do they see as most important to keep in mind, moving forward? Have they noticed in themselves some effect from their own experience that does not seem to have been captured by the study? Regardless of the make-up of the CPE group, the students could be asked about the theoretical connections that the authors make between the component domains of the survey. How do they personally see the interplay between expertise and positioning in terms of their professionalism? Does this study help them to articulate what substantiates "quality" in chaplaincy practice?


Related Items of Interest:

I.  Niels den Toom's larger study, The Chaplain-Researcher: The Perceived Impact of Participation in a Dutch Research Project on Chaplains' Professionalism, is available online from Eburron Academic Publishers. Also available from Eburon is another publication of interest that is co-edited by den Toom: Learning from Case Studies in Chaplaincy: Towards Practice Based Evidence and Professionalism, edited by Renske Kruizinga, Jacques Korver, Niels den Toom, Martin Walton, and Martijn Stoutjesdijk.


II.  For more on the Dutch Case Studies Project, see the website of the University Center for Chaplaincy Studies regarding the project overall, its organization, publications, and Ph.D. research. Also available from the site is a PDF manuscript of the following article:

Walton, M. and Korver, J. "Dutch Case Studies Project in chaplaincy care: a description and theoretical explanation of the format and procedures." Health and Social Care Chaplaincy 5, no. 2 (October 2017): 257-280. [(Abstract:) The recent surge of case studies in chaplaincy care raises challenges on the comparability of case studies and the degree to which they elucidate the relation between theory and practice. The Dutch Case Studies Project (CSP) addresses these and other issues by use of a set format and procedure and by evaluation in research communities of chaplains and academic researchers. We first place CSP in the context of Dutch chaplaincy and its recent history. The question of selection of a case for a case study then leads to a discussion of a number of methodological issues. That moves into an explanation of the following steps in the procedure: description, evaluation and finalization. Issues for further discussion and a conclusion complete the article.]


III.  The importance of case study research has been well highlighted in our Articles-of-the-Month features. See, for instance, our May 2018 page. For more on case studies, see the October 2021 Transforming Chaplaincy webinar, Case Study Research for Chaplains, presented by Jeanne Wirpsa and Cate Michelle Desjardins, available via YouTube. Also, to contextualize the case study amid the array of methodological options for chaplains, see the chapter on "Choosing Research Methodologies," by Margaret Feuille Bockrath and Kenneth I. Pargament, in An Invitation to Chaplaincy Research: Entering the Process (2014), edited by Gary E. Myers and Stephen Roberts (--note: case studies are addressed on pp. 63-64). And, no consideration of case studies should go without special mention of two fine collections published by George Fitchett and Steve Nolan: Spiritual Care in Practice: Case Studies in Healthcare Chaplaincy (2015) and Case Studies in Spiritual Care: Healthcare Chaplaincy Assessments, Interventions, and Outcomes (2018), widely available from booksellers.


IV.  The present study utilized a retrospective pretest methodology, asking participants to recall a past point (that was prior to an event/intervention) for comparison to a current point, in order to assess change. Our authors reference an article by Tony Lam and Priscilla Bengo ["A comparison of three retrospective self-reporting methods of measuring change in instructional practice," American Journal of Evaluation 24, no. 1 (2003): 65-80], but a short summary of the strengths and weaknesses of the research design is available through the Harvard Family Research Project: "The Retrospective Pretest: An Imperfect but Useful Tool," by Theodore Lamb. And, for a recent and more technical analysis of the approach, see the following article. Note that these resources address the methodology from subject areas other than chaplaincy or spirituality.

Todd D. Little, T. D., Chang, R., Gorrall, B. K., Waggenspack, L., Fukuda, E., Allen, P. J. and Gil G. Noam, G. G. "The retrospective pretest-posttest design redux: On its validity as an alternative to traditional pretest-posttest measurement." International Journal of Behavioral Development 44, no. 2 (March 2020): 175-183. [(Abstract:) We revisit the merits of the retrospective pretest-posttest (RPP) design for repeated-measures research. The underutilized RPP method asks respondents to rate survey items twice during the same posttest measurement occasion from two specific frames of reference: "now" and "then." Individuals first report their current attitudes or beliefs following a given intervention, and next they are prompted to think back to a specific time prior to the given intervention and rate the item again retrospectively. The design addresses many of the validity concerns that plague the traditional pretest-posttest design. Particularly when measuring noncognitive constructs, the RPP design allows participants to gauge the degree of change that they experience with greater awareness and precision than a traditional approach. We review the undesirable features of traditional designs and highlight the benefits of the retrospective approach. We offer examples from two recent, original studies and conclude with the recommendation that the RPP design be employed more broadly. We also conclude with a discussion of important directions for future examination of this design.]



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