Chaplain capabilities.

The authors developed a 14-item scale informed by the Spiritual and Religious Care Capabilities and Competences for Healthcare Chaplains framework by the UK Board of Healthcare Chaplaincy [31] and the ACPEI CPE Learning Outcomes [13] to assess how participants’ chaplaincy competences changed as a result of CPE. To date, this scale has not been validated. Respondents indicated on a 5-point scale, from 1 (not at all) to 5 (extremely), how capable they felt of effectively using each spiritual care skill with most individuals over the next week. Average scores were calculated for each item and the entire scale.

Emotional intelligence (EI).

The Self-Report Emotional Intelligence Test (SREIT) was used to measure respondents’ characteristic adaptive emotional functioning [26, 27]. This 33-item instrument, based on the Salovey and Mayer EI model (1990), assessed how individuals characteristically appraise emotions in themselves and others, express emotions, regulate emotions in themselves and others, and utilise emotions. Respondents rated the extent to which each statement described them on a 5-point scale from 1 (strongly disagree) to 5 (strongly agree). The total score was the sum of all items after reverse coding three items, with higher scores indicating greater emotional intelligence (ranging 33–165). We also calculated subscale and overall results by using average scores to allow for comparing scales with varying numbers of items [27].

Counselling self-efficacy.

To measure counselling self-efficacy, we used Part 1 and Part 2 of the Counselor Activity Self-Efficacy Scales (CASES) [28]. CASES assessed participants’ beliefs about their ability to perform various helping and counselling skills. Respondents reported their level of confidence in their ability to use helping and counselling skills effectively on a 10-point scale from 0 (no confidence) to 9 (complete confidence). Average scores were calculated for each CASES scale assessing Helping Skills Self-Efficacy, including Insight Skills, Exploration Skills, and Action Skills, and Session Management Self-Efficacy.

Statistical analysis.

Descriptive statistics were generated to describe the participant characteristics and survey responses using Microsoft Excel and JASP version 0.18.3. Categorical data are presented as frequencies (percentages) and continuous data as medians (interquartile ranges [IQR]) with ranges. Instruments were scored as described under each scale. These statistics were also used to generate the respective tables and figures. Due to the small sample size, there was no effort to draw quantitative inferences and test whether changes in scores on the scales were statistically significant.

Qualitative analysis.

We performed reflexive thematic analysis as an inductive approach to examine patterns of meaning related to our research questions in focus group data [32, 33]. The focus group sessions were recorded and transcribed. The first author (CS) performed the analysis and reflexively considered his location related to the participants and the research topic. He is an ACPE Certified Educator, chaplain, and researcher with graduate degrees in Divinity, Education, and Management, and is a European male living in the USA. He did not supervise this group of CPE students and had no interactions with them except for the focus group sessions. He familiarised himself with the data, inductively coded the transcripts using ATLAS.ti Version: 23 qualitative data analysis software, and generated initial themes. He defined themes and developed a thematic frame regarding participants’ perceptions. Although a single coder is typical in thematic analysis [34], the other two authors (MN and DN) reviewed the data and the development of themes to ensure interpretive depth, internal coherence, and meaningful reflection of participant views regarding the research questions. DN served as the CPE supervisor/educator for the participants, and MN acted as the main link between ACPEI and NHS for the CPE pilot.

Confidence.

Participants described gaining confidence during CPE across four domains: personal, professional, leadership, and teamwork (Fig 4). Developing confidence in these arenas was one of the most consistent themes.

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Fig 4. Confidence development in Clinical Pastoral Education (CPE).

Fig 4 provides a joint display comparing qualitative themes with exemplary quotes and survey results with Chaplain Capabilities Scale mean scores. The 14-item CCS was developed by the authors and was informed by the Spiritual and Religious Care Capabilities and Competences for Healthcare Chaplains by the UK Board of Healthcare Chaplaincy [31] and the ACPEI CPE Learning Outcomes [13].

https://doi.org/10.1371/journal.pone.0310085.g004

Self-Confidence. Participants reflected on cultivating self-confidence: "I’m feeling much more confident just in who I am, in the fact that I’m a chaplain in A&E [i.e., Accident & Emergency Department], and a lot more confident in just being there." It involved increasing their ability to trust themselves more fully. One participant noted, "for me, it was trusting my own intuition. I would do that much more now." They felt more poised to express their authentic self and bring it into interactions with others as chaplains. CPE equipped them "to be able to take 100% of me to whomever else I am seeing." Another interviewee highlighted, "I just sense that I would be able to voice or express myself, where previously I might not have felt so confident in doing that."

Confident Professionalism. Participants highlighted significant ways in which they gained confidence in their professionalism and identities as healthcare chaplains. A participant offered an example of asserting their voice on the multidisciplinary team (MDT) from a stance of self-assured professionalism:

"I certainly feel more confident in my professional identity when I am talking to the members of the MDT. … pre-CPE, … I would have felt not so confident. I am sure about how valuable my role could be. … because CPE has helped me to really deal with this difficult situation with a lot of professionalism. I don’t think I would have said what I said if I didn’t have this confidence that I get from the CPE."

Participants gained a deeper appreciation of their role’s value to patient care and the team:

"I feel I undervalued myself in comparison to the other members of the multidisciplinary team. … But with the CPE, … it changes how I value myself and how I value the chaplaincy work we do. We really are doing very hard work, and it’s because we are professional, we are able to do it."

Leadership. Building on self-assurance and professionalism, participants more readily took leadership actions in their chaplain roles and collaborations with colleagues. They recognised that leadership is integral to chaplains’ professional identity and practice, noting: "I’m a leader in spiritual care because that is my professional identity." Participants described leadership stemming from being the spiritual care specialist within the team: "it was a realisation of that in CPE that I do have a leadership role, because I’m leading in spiritual care in that environment. … I have a leadership role in owning that."

Participants also described how they successfully exercised leadership with fellow chaplains and colleagues. An interviewee said, "I am more confident, with … the chaplaincy team, so I would be able to participate more freely and take leadership within that team when it was necessary." Another commented, "I think pre-CPE, I would have just been assisting my colleague in this staff support, but now I felt that we were co-leading it and that I had just as much stuff to bring as my colleague."

Confident Teamwork. Participants learnt to exercise more confidence, professionalism, and leadership in working with multidisciplinary and chaplaincy team members: "it’s to do with having more of a voice in MDTs and feeling confident … this is my domain." CPE directly enhanced their capacity for teamwork with multidisciplinary teams (MDT), as a participant called it, "claiming my space in the MDT." They developed more of an equal standing when communicating and collaborating with colleagues. “[CPE] gave me more confidence in the role of chaplain.” Recalling a debriefing session for staff, the participant continued:

“Maybe before, I would have just listened to the consultant facilitate that debriefing session, but I think I intervened a lot more than I would have done, with questions, or with the nurses who are struggling with how to address that question… I wouldn’t have done that before CPE. I would have taken a back seat. I was much more proactive than I would have been in the past."

CPE helped them become more adept at communicating and asserting the chaplain’s contribution to whole-person care with greater clarity.

"CPE has really taught me that you can be leadership within your own role… I think sometimes we’ve not always had the confidence to put our opinion out there … or what we can bring from the patient perspective. … bringing the spiritual aspect into it is about looking at the holistic approach. … And when we show that confidence, [the clinicians are] definitely keen to get us involved.”

Furthermore, on the Chaplain Capabilities Scale, participants reported an improved ability to understand relational dynamics and collaborate effectively within chaplaincy, multidisciplinary, and other healthcare teams (Fig 4).

Reflective practice.

CPE helped participants grow as reflective practitioners who integrate continuous reflection on themselves, their interactions with care recipients (i.e., patents, family, caregivers, staff, or others receiving chaplaincy care) and colleagues, and their spiritual care work. This development stemmed from the critical and in-depth reflection CPE asked students to do in their peer group and learning activities. Participants’ survey responses also showed an improved capacity to critically reflect on their own personal and chaplaincy skills and limitations, reflect on themselves and their chaplaincy work from a theological/philosophical perspective, and use supervision on practice to pursue personal and professional development (Fig 5).

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Fig 5. Reflective practice development in Clinical Pastoral Education (CPE).

Fig 5 provides a joint display comparing qualitative themes with exemplary quotes and survey results with Chaplain Capabilities Scale (CCS) mean scores. The 14-item CCS was developed by the authors and was informed by the Spiritual and Religious Care Capabilities and Competences for Healthcare Chaplains by the UK Board of Healthcare Chaplaincy [31] and the ACPEI CPE Learning Outcomes [13].

https://doi.org/10.1371/journal.pone.0310085.g005

Self-Awareness. CPE processes fostered participants’ personal and professional self-awareness. They were learning about the deeper layers of their personal histories, feelings, personhood, and what they brought into their spiritual care practice. Growing self-awareness had a widespread influence on participants’ interpersonal, clinical, and team functioning as chaplains. As a participant explained:

"If I didn’t have this deep self-awareness that I have gained in CPE, I would be less attentive in a way with other people in the room. … CPE really made me aware of what I am feeling right now, what I am sensing right now, what I am experiencing right now."

As a key impact of CPE, a participant described their process exploring the complexities of their personal stories and how it related to care recipients.

"There are characters and people in our stories. From people we see, we relate back to our stories, don’t we? I was made more aware of those connections and feelings that I get that are part of me. … I’m much more aware of how my story impacts how I relate to others in certain circumstances.

Participants carried their growing self-awareness into their spiritual care practice, leading into their clinical awareness: "[CPE] was challenging in terms of self-awareness and finding out those things about you that you do take into the room that you didn’t realise you took into the room when you see people."

Clinical Awareness. A common view among participants was that CPE increased their self-awareness to produce a clearer understanding of why they do what they do as chaplains and how those actions impact their care recipients. It helped them become "more aware of how I am through the whole session with the patient." It improved their capacity to reflect on emotions (in themselves and others), spiritual concerns, and interpersonal dynamics more easily in clinical care, helping them to be more deliberate in their interventions. A participant described:

"[I]t was about being very self-aware of how I am when I’m going to visit a patient, or how I’m with a colleague in terms of my attention span or what might be said across my face. Just making myself really aware of … what I am going into, and how I am responding."

Another participant noted how clinical self-awareness enhanced reflective practice when they sought consultation on a particularly difficult spiritual care case.

"… pre-CPE, [I] would have just talked about the clinical practice I did …. Whereas this time, we talked about the routine, the clinical practice, but also, I felt I knew the benefit of thinking about how this had impacted me emotionally and therefore how it shaped me. I just felt much more self-aware about how I felt with the [care recipients]. … Self-awareness is a really helpful thing for me to be more robust in tense situations as they arise."

Boundaries. CPE participants noted their increased awareness and ability to create appropriate professional and personal boundaries.

"[T]he cycle that I am experiencing is [that] I was able to identify and acknowledge of what I am bringing as a person into the chaplaincy, then it gives me a lot of confidence to be able to communicate and draw boundaries when boundaries need to be drawn."

Another participant described that learning emotional self-differentiation enhanced their capacity to be collected and respond in crisis situations:

"I would say I generally got better at being more in tune with how I am [feeling] at any given moment in a day. And then that gives me, I suppose, a bit of emotional distance. If I’m going into a crisis situation, then maybe I’m more … grounded in how I am, and therefore better able to respond, I think, probably, from a place of calmness within myself."

Others also commented on their increased capacity to maintain boundaries in emotionally intense situations. This allowed them to be more effective in the moment and then in caring for themselves afterwards. Furthermore, survey results reflected respondents’ increased competence in communicating with individuals in a variety of complex spiritual care situations that involve traumatic events, breaking bad news, difficult questions, or strong emotions.

Emotional intelligence.

Participants described a substantial development in their emotional intelligence (EI)–the capacity to perceive, utilise, understand, manage emotions in self and others [35] (Fig 6). They commonly highlighted the application of their EI skills in their clinical work. “It’s a thing that I learnt from CPE, … in whatever I do, to consider myself and what I’m feeling, and also trying to connect to the service users and what they are feeling.” Furthermore, self-awareness, clinical awareness, and emotional intelligence were strongly interconnected in enhancing CPE participants’ chaplaincy practice. A participant reflected the impact of gaining the critically important skill of being in touch with their emotions, combined with their reflective practice: "Self-awareness is the big thing … with the intense situations that I’ve been in. I’m able to reflect better afterwards … because I’m able to dig deep into what I’m feeling or what I did feel at the time."

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Fig 6. Emotional intelligence development in Clinical Pastoral Education (CPE).

Fig 6 provides a joint display comparing qualitative themes with exemplary quotes and survey results with Self-Report Emotional Intelligence Test (SREIT) mean scores. The Self-Report Emotional Intelligence Test (SREIT) results, for overall emotional intelligence and four subscales, were calculated by using mean scores to allow comparison of scales with varying numbers of items [26, 27].

https://doi.org/10.1371/journal.pone.0310085.g006

Increased emotional intelligence was also evidenced by respondents’ improved SREIT scores, moving from 125.3 to 134 total scores (7%; 3.8 to 4.1 average scores. SREIT subscales showed that respondents had the greatest gain (11%) in the Managing Own Emotions domain, followed by 6% each on the Perception of Emotion, Managing Others’ Emotions, and Utilization of Emotion subscales (Fig 6 and S2 Table).

Listening and attending skills.

CPE participants learnt to listen and attend to individuals’ feelings and stories more effectively and help them explore at a deeper level. Participants highlighted they made progress with their listening skills, especially their ability to create a safe space and “not to be afraid of feelings, to listen to them and to stay.” CPE fostered their capacity to remain present with the emotions, distress, and painful experiences of others more fully rather than trying to fix these emotions or move away from them.

"[In CPE], we were being encouraged to listen to the emotion that was being expressed. … To stay with the emotion is what we became quite good at in our IPG sessions. Obviously, not rushing to fix the problem, but to stay with it. I found that I am really looking for that when I am with service users now. I’m thinking about the emotion and whatever that emotion is. I’m acknowledging that, and staying with it, and giving it space rather than moving on to something else. I think that is a big takeaway for me."

Another participant described gaining more skills to deepen spiritual care conversations and help clients explore their thoughts and feelings by attending and using intentional silence:

"I got bolder allowing more silence. I kind of stopped myself sometimes from asking even quite good open-ended questions. I realised if I waited longer, often giving them that time and space enabled them to find their way forward within the conversation rather than me thinking I had to help them, which might have taken them off in a direction you didn’t particularly want to go. … It is now much more a part of my practice to just wait a bit longer, rather than feeling like I’ve got to step in to help somebody.”

Respondents’ counselling self-efficacy increased on all CASES scales (Fig 7), which confirmed their development in this area. They had the largest gains on the Session Management Self-Efficacy subscale (15%). This scale assessed skills to help clients explore their thoughts, feelings, and concerns and consider goals and actions. It also ascertained respondents’ capacities to know what to say next, respond with the best helping skill, keep sessions on track and focused, and remain aware of their intentions, purposes, and interventions. This was followed by gains in Action Skills Self-Efficacy to employ direct counselling interventions (13%) and Insight Skills Self-Efficacy to help clients better understand their thoughts and feelings (12%). The smallest increase (4%) was in the Exploration Skills Self-Efficacy to ask open questions, listen, reflect feelings, restate, use intentional silence, and attend, which already had the highest baseline (7.3) and still reached the highest post-training levels (7.6).

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Fig 7. Listening and attending skills development in Clinical Pastoral Education (CPE).

Fig 7 provides a joint display comparing qualitative themes with exemplary quotes and survey results with the mean scores of the Counselor Activity Self-Efficacy Scales (CASES) Part 1 and Part 2 [28].

https://doi.org/10.1371/journal.pone.0310085.g007

Diversity in chaplaincy care.

Participants agreed that CPE greatly increased their ability “to provide support to service users that may have different beliefs, religion, or faith from myself." Consistent with the survey responses (Fig 8), this theme entailed their growing capacity to explore a wide range of attitudes, worldviews, beliefs, values, and concerns related to health and to provide effective spiritual support to persons with diverse faith or secular/non-religious perspectives and different beliefs or philosophies from their own. This area also included improving collaboration with appropriate chaplains or faith leaders concordant with the individual’s faith or worldview when needed. Participants with different religious and non-religious identities grew in this area:

"I think it is connecting on a human level with everybody, because I’m non-religious. I did struggle a little bit with people of faith. If I take that away, I can connect as a human being and add that in after as it were. I found that I’m much better at that now than I was."

"[B]efore CPE, if there were any Muslim patients around, without ministering to them and listening to them, I would have told them that we do have Muslim chaplains and would they like me to refer them. Now, I would listen to them and, if necessary, refer. It was a huge shift for me."

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Fig 8. Diversity in chaplaincy care competency development in Clinical Pastoral Education (CPE).

Fig 4 provides a joint display comparing qualitative themes with exemplary quotes and survey results with Chaplain Capabilities Scale (CCS) mean scores. The 14-item CCS was developed by the authors and was informed by the Spiritual and Religious Care Capabilities and Competences for Healthcare Chaplains by the UK Board of Healthcare Chaplaincy [31] and the ACPEI CPE Learning Outcomes [13].

https://doi.org/10.1371/journal.pone.0310085.g008

Participants also identified the diversity of the CPE group as a catalyst for gaining confidence in providing spiritual care to persons with diverse religious and non-religious backgrounds.

"There were lots of conversations about Muslim patients from people on the team asking questions, probably because I was a Muslim in the [CPE] group. For me, the flip side of that is how much I was learning from my colleagues. … I think, what made it so unique was that we were a mixed group. … It built my confidence in terms of pastoral support and the spiritual support I could offer to service users… that aren’t necessarily from my own faith tradition. It gave me that little bit more confidence actually, that it’s okay for me to do that."

Spiritual assessment.

CPE improved participants’ competencies in conducting spiritual assessments, formulating ongoing care plans, and documenting spiritual care. They developed more robust skills and language to identify and address spiritual struggle. Survey results further showed gains in several skills related to spiritual assessment (Fig 9), such as assessing spiritual or existential issues, resources, and spiritual distress, exploring individuals’ sense of meaning and purpose, and developing spiritual care plans. Interestingly, another item on the ability to document spiritual and religious assessments and care plans did not show pre-post change, in contrast with qualitative data.

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Fig 9. Spiritual assessment practice development in Clinical Pastoral Education (CPE).

Fig 9 provides a joint display comparing qualitative themes with exemplary quotes and survey results with Chaplain Capabilities Scale (CCS) mean scores. The 14-item CCS was developed by the authors and was informed by the Spiritual and Religious Care Capabilities and Competences for Healthcare Chaplains by the UK Board of Healthcare Chaplaincy [31] and the ACPEI CPE Learning Outcomes [13].

https://doi.org/10.1371/journal.pone.0310085.g009

A participant explained that discussing clinical experiences and cases in the CPE group “facilitates [the practice] to identify the spiritual struggle that the service users have, and the confidence of exploring it more, and the reflective practice of wanting to plan for the next visit and reassess it again and see if the spiritual needs have changed." Another one echoed,

"Spiritual assessment had become much clearer, and the question I’m asking myself and honing in on what are this person’s spiritual needs, can I identify them. In that sense, yes, [CPE has] altered my practice, in that I’m much more aware of actually asking myself that question during encounters. It’s always there."

Furthermore, participants recognised the benefits of care planning and incorporated it into their practice:

"Just trying [care planning] rather than going ad hoc and then seeing where it is going to go after the initial assessment. I’m trying to get better at care planning with me picking [it] up from CPE … for the sessions to be more productive."

Moreover, some noted improvements in their practices of documenting their care, "I would be much more conscious of recording after a visit."

2.1. Interpersonal group process (IPG) in CPE.

Participants agreed with each other that the interpersonal group process of CPE (i.e., IPG) was instrumental in their development. One participant said, "the IPG sessions were completely on the top of the list in terms of exploring myself, my vulnerabilities, and being able to share within the group. And the feedback from others that were in my IPG group was really important." The group provided the relational context with peers and the supervisor, in which they observed and practised working with vulnerabilities, feelings, interpersonal dynamics, and listening. They experienced being listened to and received feedback and consultation. They applied their learnings from the group setting to their professional identities and interactions as chaplains. "Within the group, you are able to have a sense of awareness and part of your identity as a chaplain, but it has to be done in a group."

Vulnerability and Self-Exploration. The group sessions encouraged participants–and even challenged them–to explore areas of their vulnerabilities, identities/self, and life stories: "having the opportunity to explore my own areas of vulnerability within a supportive group was really powerful for me." It also taught them to skilfully help patients do the same in the clinical context.

"Things that I have put away for a very long time, that I have not wanted to deal with and stored in these boxes, which are really dusty. [I] was to be able to bring them to the forefront of my vulnerability … and think about what that means for me and how I’m dealing with that. [It] equip[ed] me to be able to take 100% of me to whomever else I am seeing as well. It was a tough one, but I think it was the best part of the process for me. It helped become a healing journey for myself."

Connecting with oneself more deeply allowed participants to connect with and be available to care recipients more fully:

"CPE … allowing me and giving a space for me to connect to my deeper self and bring that into the ministry that I do or the chaplaincy work that I do. That is very helpful because then I become a gift to them in my limitations, and for them as well, to have this full attention that they deserve to have at these moments of their life. Because I am in touch with what I am feeling at that moment."

Safe and Trusted Space. Participants felt that the expectation of vulnerability was challenging at first, but having a safe and trusting group environment allowed them to lean into the group process.

“It was challenging in terms of the first week we didn’t know one another, did we, at all, in any way shape or form. Me personally, I didn’t really know what to expect either at all. The fact that you share your story from week one was challenging from the offset really. … It was a safe and trusted place to do that, and it stayed a safe place. … From that first week, when we really shared our stories, we were then able to share and to talk in IPG on a different level all together, which made it a very special place. Challenging but safe.”

Listening Space. The development and practice of listening skills in IPG was crucial for the students. They learnt to listen to their peers and learnt from being listened to and observing how group members listened to each other. They directly carried over these developing skills to their clinical practice.

"IPG sessions, which is where we had a chance to talk and listen to each other. I think that was a really helpful environment for us to try out our listening skills to each other. I think they improved weekly. … I personally felt, anyway, I was listened to incredibly well, so I understood what it was like to be listened to. I was really keen to have that reciprocated to others to try and hold our space, and hold some silence, and stay with somebody’s feelings in the group, so that we could help them to feel heard. That [has] definitely come over into my clinical practice. I think my clinical skills [and] my listening skills have improved.”

Diversity in the CPE Group. Participants understood that engaging the diversity of CPE group members helped them develop their capability and confidence to support care recipients with diverse beliefs and backgrounds.

"I also think the fact that it was a mixed group, and we weren’t all from the same faith tradition, … was brilliant in terms of how it was structured. … It actually confirmed a lot of things that we might not even thought of in the past. We don’t need to be chaplains to our own so to speak. I think it just gives a little bit more confidence in terms of some of the generic pastoral work that we do as well."

Hearing each other reflect on their different beliefs, theologies, or philosophies cultivated a greater understanding of diverse viewpoints. "It also really helped to actually look at my peers’ theological reflections as well and helped greatly in understanding other sources of wisdom and other traditions as well."

2.2. Verbatims (case discussions).

Discussing clinical cases and receiving feedback from the supervisor and peers (i.e., verbatim sessions) helped participants learn about themselves as chaplains and critically evaluate and expand their clinical skills. "The use of verbatim I found really useful in terms of learning about me, in terms of looking at what the chaplain is thinking, what the chaplain is doing." Another participant added:

"Hearing from the peer in the verbatim the different approach of providing support is very helpful to equip me with skills that are useful every time I go and visit the patients. And because of that, it gives me more confidence, and validation, as well."

2.3. Exploring emotions to build emotional intelligence (EI).

Participants were encouraged to explore and work with emotions in themselves and others during the IPG and verbatim sessions. This approach fostered participants’ EI, which they put into practice in spiritual care. They made a clear connection between gaining EI in the CPE group and increasing EI in chaplaincy practice.

"Throughout our sessions, was it the beginning and end of each day [our CPE supervisor] would ask us how we are feeling? And so, we just got quite used to reflecting on how we were feeling at any given time. And he would push us sometimes, too. If we came out with a fairly banal word, he would say, ’So what does that mean?’ and would push us a bit. So, I think I would say I generally got better at being more in tune, with how I am at any given moment in a day."

2.4. Reflection.

CPE spurred participants to reflect and enhance their reflective capacities, preparing them as reflective practitioners: "We had to reflect on how we were… how we were feeling, what was going on for us." As a source of growth, participants highlighted the vigorous critical reflection on their identities, belief systems, life stories, relationships, and spiritual care interactions that occurred in group sessions and learning activities.

"I think it helped me to probably be more aware than I was before CPE of how I am when I go into an encounter because, when we were doing the verbatims, we had to reflect on how we were, where, what time of the day it was, how we were feeling, what was going on for us."

3.1. Endorsing CPE as uniquely suited for chaplaincy training.

Participants unanimously endorsed the sentiment that "everybody should do CPE in thoughts of being a chaplain." They added that CPE may equally benefit novice and experienced chaplains: “it’s a really valuable tool for people coming into chaplaincy. … From my perspective, I also think it’s invaluable for more experienced chaplains.” Notably, some of this cohort were experienced chaplains and some were relatively new to chaplaincy, yet all felt they had developed as chaplains and benefited in their clinical practice because of CPE.

Moreover, participants were eager to identify aspects that made the CPE model different and uniquely beneficial.

“CPE brought something completely different to chaplaincy and exploring. … Because it really brings insight into how we manoeuvre with the patients and how we get down to a deeper level, rather than just going in, asking if they would like prayers or not like prayers, or about rulings. … It can completely change the focus on getting people to think about what chaplaincy is about.”

Additionally, results on the post-CPE Net Promoter Score (NPS) item underscored this sentiment. All responses fell in the “promoter” category when asked how likely it is that they would recommend CPE to their chaplain colleagues or others in chaplaincy training (six rated 10 and one 9). It produced an NPS of 100, a valid indication of not only a high level of satisfaction but also a strong enthusiasm for the value of CPE for others.

3.2. Integrating personal and professional identity.

Participants concurred that CPE simultaneously addressed the interdependent domains of personal identity and who they were as professional chaplains: "the individual, the pastoral, the professional identity was really well balanced in a way that I don’t think exists in other training courses.” They recognised this element as instrumental for chaplain development. Participants saw this interplay as a distinctive benefit of CPE over other educational models.

"[CPE] integrated the personal, pastoral, and professional identity. That was a huge revelation for me, the fact that you can’t have one without the other. That was just brilliant. The fact that I had to bring my personal identity into this, because I was able to become more self-aware and think about my personal identity, I was able to carry that across as a pastoral practitioner. It also made me more confident in my professional identity."

3.3. Integrating experience, competency, and theory.

Participants viewed CPE as a comprehensive training model because it leveraged experiential learning, built competencies, and incorporated relevant theories for chaplaincy. These aspects worked together to promote participants’ growth.

"I really valued the fact that we were reflecting on our experience all the time and on our practice, and developing that, and sharpening that up, and practicing our skills together in the IPG sessions, then having the theoretical input as well. It is just such a good balance of theory, experiential, the reflection together."

Fig 11 provides quotes to illustrate each of the experiential learning, competency building, incorporating theory aspects of CPE.

3.4. Balancing group and individual learning.

Participants pointed to CPE’s advantage of utilising both small-group learning and individualised learning. "You talk very much about the importance of the group early on, but at the end how the learning was individualised. There is somehow this coming together of those two aspects. It seems to be key in the learning." Another participant added:

"You can’t have one without the other. You are able to develop your own individual identity because of the group, but then also the dynamics of the group really improve, if we share our own identity as well. They both go together. That is what works really well."

4.1. Challenging yet worthwhile.

Participants said that the CPE course felt both challenging and worthwhile. They perceived the challenges more keenly as they began the process. However, they gradually understood how to make use of those elements. For instance, the IPG group process was seen as especially challenging and new at the beginning but ultimately became a powerful vehicle for transformational learning: "challenging but safe," as a participant put it.

"As much as there were challenges at the beginning, I felt like there were a lot of rewards at the end, in terms of the process of CPE and what that meant for me. At the beginning, I thought, ’I don’t think I’m going to last very long in this process.’ Interestingly, I came out completely different at the other end. I think it really helped. It came with its challenges but with its rewards too."

4.2. Balancing CPE and job demands.

Participants underscored that CPE required high-level commitment and workload, which was challenging to fit with the competing demands of their full- and part-time jobs during CPE.

"[I]t was just juggling and keeping up with the demands with my job at the same time as the demands of the course. It was pretty intense, actually. I mean, I’m very glad I’ve done it, but it was quite demanding to do that."

Some participants also shared the sentiment of "I had no idea," meaning that, not having done CPE before, they could not have fully and accurately anticipated the extent of work and energy involved in the CPE unit. The participant continued, "it probably would have been better for me if I would have just had a clearer idea in my mind of the degree of commitment that was needed, because it was a high degree of commitment really."

4.3. Managing the pace of the CPE unit.

Participants shared their views on the advantages and disadvantages of the CPE unit’s pace. They felt that, while extending the unit over a longer period could have eased the pressure, they were not convinced it would have been beneficial.

"I felt that it was just full on. It was relentless one week, and then we would have to do another written work as soon as we handed in one more. I think we suggested that it would be great if it was twice as long…. There are pros and cons to that, because then it would just be drawn out for far too long. I think maybe you would get really fed up with being in CPE for such a long time. On reflection, I think it is better that it is quite an intense three or four months."

In fact, some felt that the fast pace and structure kept them engaged and motivated and prevented the course from dragging on unnecessarily.

" I’m glad we did it the way that we did it. I can’t believe I am saying that. I just feel like that structure makes such a big difference. … it was challenging, but if it was stretched out any longer, we would have still had the same amount of work to do. … And I don’t think the impact would have been the same. There were challenges that came with it. It worked."

4.4. Balancing in-person and online learning.

Although acknowledging online sessions enabled them to participate from different locations, participants found long online sessions to be taxing. Moreover, they agreed with the opinion: "I would have preferred more in-person sessions," whereas noted travelling can be challenging. Participants thought that meeting in person was especially beneficial at the beginning when relationships formed in the CPE group.

"It’s really important that it has to be face to face around the first couple of days and face to face at the end of the whole class. It is really important that we are all together when we are sharing our personal stories right at the start. I think it would have been really difficult online."

Ultimately, participants agreed that there is not a perfect solution for the course’s pace and meeting patterns. “It’s just hard to fit in that number of hours of training over however many weeks it is, so I don’t think there’s any easy answer.”