provision of pastoral care, the third dimension of role enactment, is the most difficult to discuss. Perhaps the best contribution which a book such as this can make is to frame several crucial issues in providing care. It is not uncommon for ministers to be impressed to the point of intimidation at how concrete and measurable are the tasks performed by most health professionals. In an effort to compensate, I have seen pastors become activists in hospital visitation, expressing anxiety through attempts at humor, taking the patient's dirty laundry home to be washed, or going to the gift shop to purchase a newspaper. These activities generally suggest a lack of clarity in pastoral identity, heightened somewhat by the loss of status and the skilled tasks performed by others. Simply being there as a concerned, caring person does not feel adequate. But it often is.
Few people enter the patient's room with the task of sitting and listening to them. Yet feelings and concerns, values, self-image, and faith issues are a storm inside, needing to be shared. This is the strength of the pastoral role—to be able to sit and listen with understanding. The patient needs to feel blessed by feeling enough worth that someone would be concerned to hear what the illness experience is like. Self-worth that is normally defined by doing or productivity is unavailable to the patient. Discovering worth in simply being is elusive, until you have the experience of being listened to, with its attendant emotions of being accepted and forgiven.
This skill of listening is hard work, because when done well, the ear is informed by good counseling skills, relevant knowledge, and the wisdom of faith. It is a most active process. At the end of the day, however, the minister cannot count incisions, stiches, or medicines prescribed to measure worth. Being clear about the pastoral role is crucial to the enactment of it, particularly during crisis experiences.
Understanding the Organization of the Hospital
The hospital exists in order to provide care for ill persons who cannot be treated on an ambulatory or outpatient basis. A few services, such as the various clinics and departments like radiology, will serve both outpatients and inpatients. Within the institution, one researcher has estimated that over 230 different professional disciplines provide direct or indirect services to patients.3 Some of these disciplines will have personal contact with the patient while others will play a crucial role but never see or even know the patient's name. The physician's diagnosis, for example, was probably confirmed by a lab technologist who also tested for the drug producing the most beneficial response. Yet the patient will not likely know of this person who played such an important role in treatment.
The hospital is organized so that these multiple professions can effectively work together. The aim of each profession is excellence in patient care, but this term “excellence” does not always mean the patient is as comfortable as if s/he were at home. Data must be collected prior to physician rounds, which may mean bathing a patient, changing bed covers, or taking vital signs at 6:00 A.M. Napping patients are often wakened. None of these inconveniences mean the hospital's organization does not serve the patient well. In fact, they are designed for efficiency which, one hopes, lowers the cost of care. For example, it is not pleasant for a patient to wait an extended time for an x-ray or a CAT scan. However, these machines are incredibly expensive and maximizing procedures lowers unit costs. Keeping the machine “waiting” increases costs. These savings are reflected in the patient's bill.
Hospitals functionally organize and schedule activities as if the health care professionals employed there, particularly physicians, were the primary consumers. These professionals attempt to reflect to administration the specific needs they frequently hear expressed by their patients. These express needs, in time, become part of the hospital routine. Examples of such innovations are birthing centers and the availability of gourmet meals. If you have been a hospital patient recently, undoubtedly you were asked to complete an evaluative questionnaire. These efforts reflect the desire of hospitals to please patients, encouraging a return visit should another hospitalization be required.
In a community hospital physician rounds will usually occur early in the morning and late in the afternoon. Most of the daytime hours are reserved for the particular practice of the physician, in his office or perhaps in surgery. In referral and research centers, most often located adjacent to university settings, schedules may vary considerably from the traditional community hospital. This is because the practice of the medical staff is usually confined to hospital and clinic patients. Another difference in the community hospital is that the patient will usually know his physician, perhaps from previous office visits, and this physician may be the only M.D. he encounters during hospitalization. At the research setting, however, the primary or attending physician will make almost all decisions but will not be among the M.D.'s most often seen by the patient. Day to day care will be provided by house staff composed of fellows, residents, and medical students. Because of their availability, consultants from other medical specialties may also be frequently utilized. Initially this can be confusing to a patient, particularly as they learn that medical specialists in different fields can have varying opinions in diagnosing or treating an illness.
During the early morning physician rounds, orders for the day's care plan may be continued or altered. Specific tests or treatments may be ordered and scheduled. Through most of the morning and into the mid-afternoon these tests will be completed. Late afternoon physician rounds will integrate results into the care plan and perhaps alter treatment to reflect what has been learned. The pastor who plans to visit a hospitalized parishioner will do well to reserve the later afternoon for his visit as well. The likelihood of finding the patient in is increased, as is the possibility of being there during the physician rounds. In one sense, late afternoon represents the end of the patient's “workday.” Tests and procedures are tiring and anxiety-producing. The opportunity to reflect and make a transition into the evening can be a welcome respite which can provide a warm reception to the sensitive pastor.
Almost all hospitals will organize their inpatient areas according to major medical disciplines. This allows nursing staff, in particular, to concentrate skills according to patient needs. An illustrative listing of medical disciplines would include the following, with specialties in each area:
| AnesthesiologyCommunity Health and Family MedicineMedicineAllergy-rheumatologyCardiologyInfectious diseasesNephrologyOncologyPulmonaryNeurologyObstetrics and GynecologyPathologyPediatricsAdolescent medicineCardiologyEndocrinologyGastroenterologyGeneticsHematologyImmunologyInfectious diseases | DermatologyEndocrinologyGastroenterologyHematologyNeonatologyOncologyPulmonaryRenal-urologyPsychiatryAdultAdolescentChildRadiologySurgeryGeneralNeurologicalOrthopaedicOtolaryngologyPediatricPlastic and reconstructiveThoracic and cardiovascularUrology |
Medicine, Neurology, Obstetrics and Gynecology, Pediatrics, Psychiatry, and Surgery will have hospital beds assigned to their service. As mentioned earlier, these beds will usually be grouped together by general area or specialty so that nursing staff and others who have been trained to care for the special needs are also clustered. Anesthesiology, Pathology, and Radiology may serve the hospitalized patient, but do not have assigned beds as such. Generally, Anesthesiology may provide medical supervision in Intensive Care Units. Community Health and Family Medicine extends care through hospital outpatient clinics and satellite clinics located in rural areas. For the visiting pastor, knowledge of which medical service the parishioner is on will provide initial clues to the nature of the health problem.
In addition, special units exist which concentrate services for patients who are critically ill. One grouping of special areas is called “Intensive Care Units.” They may be designated as surgical, medical, pediatric, burn, coronary, or neonatal intensive care. The patients in such units are critically ill and require both regular staff intervention as well as close technical monitoring. Changes in the patient's condition are determined by the minute and hour, which is largely unlike patients in other areas of the hospital. In I.C.U. areas, the nursing staff to patient ratio will usually be 1:1 or 2. For family, visiting hours in these units are generally restricted to short periods of ten to fifteen minutes each visit. Many hospitals will permit the minister to visit at times other than visiting hours. If this is not the case in your area, a meeting between your Ministerial Association and a representative of the hospital can aid in developing a mutually agreeable policy. It is important