Journal of Gerontological Nursing

MARRIAGE, SPOUSAL CAREGIVING, AND A HUSBAND'S MOVE TO A NURSING HOME A Changing Role for the Wife?

Linda Ade-Ridder, PHD; Lori Kaplan, MS

Abstract

Because women tend to marry older men and also live longer, they overwhelmingly tend to play the caregiver role more often than men, and can expect to play this role at some point in their lifetime. For women, caregiving is often an expected duty, while for men, it is an unexpected expression of compassion (Sommers, 1987).

Because life expectancy has increased at every age level, people are more likely to live longer (Centre for Policy, 1989); people living longer are potentially more likely to be married longer as well (Ade-Ridder, 1989). If one spouse becomes ill, it is likely that he or she will be cared for by a primary family caregiver rather than by the family as a unit (Horowitz, 1985; Johnson, 1983b).

As caregiving spouses become older and more disabled themselves, they may be unable to continue caring for a mate at home. Therefore, Cole's (1984) findings - that married persons have longer life expectancies than never-married, divorced, or widowed persons - have important implications. If married people live longer, there may be a greater likelihood for (at least) one spouse to require nursing home care at some point in his or her life. The number of spouses choosing to place a mate in a nursing home will invariably increase, due to the declining health of both spouses. Although there is a greater chance for spouses to care for each other, there is less chance for the marriage to be reconsummated because of the permanency of nursing home placement. This permanence affects the marriage relationship.

This article examines how wives adjust to their husbands residing in nursing homes. The term "community-dwelling wife" is used throughout this article to mean a wife living in the community whose husband resides in a nursing home. Clinical applications are provided for gerontological nurses working with families in this situation. It is hoped that sensitivity to the unique experiences of these women will be gained.

The theoretical framework of symbolic interaction is used to help understand a wife's potentially changing role once her husband moves to a nursing home. An overview of related theoretical concepts is presented. In order to understand the marital relationship of a community-dwelling wife, it is important to examine later-life marriages in a general sense. The relationship of couples married many years is briefly described, including the dynamics of home caregiving by a wife to an ill husband. The decision to institutionalize also is discussed. Lastly, adjusting to nursing home placement of a spouse is presented, including a possible redefinition of marital roles.

REVIEW OF LITERATURE

Current caregiving and later-life literature primarily address either home caregiving to a dependent elder, adult child as primary caregiver, or caregiving upon discharge from a hospital (Cantor, 1983; Crossman, 1981; Fitting, 1986; Johnson, 1983a; Johnson, 1983b; Johnson, 1985; Miller, 1987; Miller, 1990; Stone, 1987; Walker, 1990). There appears to be a gap in the literature because few studies focus on the spousal relationship; among those that do, impact on the marriage upon nursing home placement is not assessed (Brubaker, 1986; George, 1986).

In a decade review of the caregiving and later-life literature, Brubaker (1990) asserted that attention to spousal caregiving is necessary to address both positive and negative effects on the marriage. Perhaps recent literature has not examined the partner living in the community due to the expectation that he or she is no longer alive. Smyer and Frysinger (1985), while evaluating existing interventions, noted that much more work had focused on the older resident than on the family. Interventions aimed at assisting the continued personal growth and development of the spousal caregiver…

Because women tend to marry older men and also live longer, they overwhelmingly tend to play the caregiver role more often than men, and can expect to play this role at some point in their lifetime. For women, caregiving is often an expected duty, while for men, it is an unexpected expression of compassion (Sommers, 1987).

Because life expectancy has increased at every age level, people are more likely to live longer (Centre for Policy, 1989); people living longer are potentially more likely to be married longer as well (Ade-Ridder, 1989). If one spouse becomes ill, it is likely that he or she will be cared for by a primary family caregiver rather than by the family as a unit (Horowitz, 1985; Johnson, 1983b).

As caregiving spouses become older and more disabled themselves, they may be unable to continue caring for a mate at home. Therefore, Cole's (1984) findings - that married persons have longer life expectancies than never-married, divorced, or widowed persons - have important implications. If married people live longer, there may be a greater likelihood for (at least) one spouse to require nursing home care at some point in his or her life. The number of spouses choosing to place a mate in a nursing home will invariably increase, due to the declining health of both spouses. Although there is a greater chance for spouses to care for each other, there is less chance for the marriage to be reconsummated because of the permanency of nursing home placement. This permanence affects the marriage relationship.

This article examines how wives adjust to their husbands residing in nursing homes. The term "community-dwelling wife" is used throughout this article to mean a wife living in the community whose husband resides in a nursing home. Clinical applications are provided for gerontological nurses working with families in this situation. It is hoped that sensitivity to the unique experiences of these women will be gained.

The theoretical framework of symbolic interaction is used to help understand a wife's potentially changing role once her husband moves to a nursing home. An overview of related theoretical concepts is presented. In order to understand the marital relationship of a community-dwelling wife, it is important to examine later-life marriages in a general sense. The relationship of couples married many years is briefly described, including the dynamics of home caregiving by a wife to an ill husband. The decision to institutionalize also is discussed. Lastly, adjusting to nursing home placement of a spouse is presented, including a possible redefinition of marital roles.

REVIEW OF LITERATURE

Current caregiving and later-life literature primarily address either home caregiving to a dependent elder, adult child as primary caregiver, or caregiving upon discharge from a hospital (Cantor, 1983; Crossman, 1981; Fitting, 1986; Johnson, 1983a; Johnson, 1983b; Johnson, 1985; Miller, 1987; Miller, 1990; Stone, 1987; Walker, 1990). There appears to be a gap in the literature because few studies focus on the spousal relationship; among those that do, impact on the marriage upon nursing home placement is not assessed (Brubaker, 1986; George, 1986).

In a decade review of the caregiving and later-life literature, Brubaker (1990) asserted that attention to spousal caregiving is necessary to address both positive and negative effects on the marriage. Perhaps recent literature has not examined the partner living in the community due to the expectation that he or she is no longer alive. Smyer and Frysinger (1985), while evaluating existing interventions, noted that much more work had focused on the older resident than on the family. Interventions aimed at assisting the continued personal growth and development of the spousal caregiver are necessary.

SYMBOLIC INTERACTION

According to the theoretical framework of symbolic interaction, individuals engage in the processes of role selection, role negotiation, and role making when entering into relationships (Burr, 1979). Moreover, they construct a social world or reality through interactions and the processing of symbols. Defining meanings in such a way creates "self" and "others," which enable the individual to better judge where he or she is situated and to make decisions appropriately. If the goal is to understand the reasons why a person makes certain choices, then an understanding of his or her self-concept and definition of the situation becomes important (Burr, 1979).

It is assumed that the wife's perception of her role may not have been a focus of attention by professional caregivers prior to the nursing home placement of her husband. However, after his move, it is possible that the role she played in the past is no longer relevant. Therefore, it is important to understand what role choices a wife has in this situation. More importantly, it is essential for gerontological nurses working with this population to recognize that each community-dwelling wife has her own perception of herself and her situation, and thus her own perception of what role she should play in relation to her husband.

LATER-LIFE MARRIAGE

Marriage in later life undergoes change. Advancing age usually brings increasing interdependence to a marriage. Later life marriages have been characterized by reciprocity, interdependence, and altruism (Kahana, 1990). The shared experiences between the two has been described by Johnson (1985) as leading to a joint commitment and strengthened bond between partners.

According to Kelley (1981), both the number and kinds of social contacts decrease, and the sources of pleasurable leisure activities decrease in importance as couples age. Spouses begin to account for an increasing proportion of one another's social interactions; communication and companionship become important sources of satisfaction. In later life, personal and individual relationships commonly replace formal and group relationships. Couples who experienced much conflict in earlier stages of the life cycle may be drawn closer together by the harsh problems of ill-health. Time may be devoted to concentrating energies, using resources, and caring for each other with greater determination. These relationships can become so intense and interdependent that, in time, the partners can tolerate no separation at all (Silverstone, 1989).

Regarding sexuality and the elderly and /or sexual activity in nursing homes, the focus in the literature appears to be on sexual relations between residents; there is a lack of attention to sexuality between married persons. The literature assumes that frequency and satisfying sexual intimacy is conducive to overall marital satisfaction, and - by implication - to marital stability. However, increased emphasis on emotional intimacy (eg, being close, touching, and holding hands) substitutes for this change (Garza, 1983).

In other words, the nature and role of companionship in older marriages may be instrumental in understanding marital quality (Mancini, 1984). Although physical attraction, passion, and self-disclosure facilitate the formation of a new relationship, it is familiarity, loyalty, and mutual investment in the relationship that sustain it over time (Treas, 1987). The differences in the features comprising a happy marriage over time may reflect a shift in emphasis rather than in kind (Connidis, 1989).

Marital Roles in Later-Life Marriages

Because of the notion that laterlife marriages are characterized by much closeness, it is proposed that spousal caregiving and eventual nursing home placement will affect not only the marital relationship but also the wife's role. The communitydwelling wife may experience the loss of a relationship with the person she has come to share the most. Johnson (1985) noted that irrespective of possible marital problems at earlier stages, "old age is a time when being married provides a significant dyadic relationship for which there are no substitutes." The question that remains is, "What role is the wife to assume when the couple no longer live together and she is not primarily responsible for his care?"

When couples age, it is likely for (at least) one spouse to require the help of the other. For instance, approximately 60% of those over 65 who are not in institutions are functionally limited in some way. About 40% of individuals over 85 require daily assistance to carry out everyday activities (Special Committee, 1988). This assistance often comes from one's spouse. The following section highlights the dynamics of spousal caregiving.

Spousal Caregiving

Loss of functional capacity of one partner has reciprocal emotional effects on both partners; the effects are nonlinear and highly variable (Getzel, 1982). During caregiving, the relationship between caregiver and care-receiver becomes altered. With the persistence of poor health and dependency on others, the impaired person's mood and satisfaction with social supports declines, while the relationship with the caregiver becomes conflictive (Johnson, 1983b). According to Kelley (1981), illness of one spouse leads to inequality of dependence. While the healthy partner may be ready and able to provide care, feelings of resentment for being tied down may arise. The strain may affect their relationship with each other, though the precise nature of the change is less clear (Silverstone, 1989).

Stress Related to Caregiving. For the healthy spouse, declines represent - at least - increased responsibility and drain of psychic and emotional resources. For both individuals, the decline has been noted to challenge the historic patterns of interaction, as well as individual and marital goals. Caregiving then can be said to have an emotional impact on the caregiver.

In addition to the emotional strain, the physical labor of caregiving creates a high level of stress, which is harmful to health. Stress is a prime factor in the development of high blood pressure, stroke, and heart disease (Sommers, 1987). Studies of caregivers noted that spouses more than any other group perceive their own health as fair or poor (Cantor, 1983; George, 1986; Stone, 1987). Therefore, in addition to investigating whether marriage protects against health problems, it is necessary to examine the possibility that in some instances marriage may put a spouse's health at risk (Satarino, 1984).

Moreover, Klein and colleagues (1967) found that the development of illness is attended by role failure, which leads to interpersonal tension and somatic symptoms in both partners. Illness exerts a significant effect upon the healthy family member as well, as both partners experience a change in their ability to perform roles during an illness situation.

There also is a high degree of financial strain incurred through caregiving (Sommers, 1987). A survey conducted by the American Association of Retired Persons (1988) indicated that 42% of the surveyed caregivers incurred additional expenditures as a result of caregiving. Therefore, in addition to the physical and emotional impact on the caregiver, extended home care becomes costly. Home caregiving may eventually involve hiring outside help. People living longer with debilitating illnesses may require aides for long periods, draining the couple's savings. Due to the current system, a wife may live the rest of her life in poverty after playing the caregiving role for many years.

Spouses are more likely to report financial strain than other caregivers, possibly because they must draw from joint and often meager pools and they worry about what will be available for their own futures, and/ or because of feelings of guilt for worrying about money while the spouse is suffering (Horowitz, 1985; Rollins, 1985). According to Sommers and Shields (1987), women are assigned the social role of providing compassion and care without being given any of the resources to do it.

Spouses have therefore been found to be the highest risk group among caregivers, especially regarding finances and health. When spouses take on the caregiving role, they are more likely than other groups of caregivers to experience financial and health related difficulties. Also, spouses provide the most extensive and comprehensive care to the most disabled persons, especially older women caring for disabled husbands (Crossman, 1981; Féngler, 1979; Horowitz, 1985). Spouses also are the least likely caregiver group to turn to formal services for help - because of heightened feelings of mtimacy and privacy, or perhaps because of having fewer resources available to negotiate help (Miller, 1990). It is no wonder then that caregivers experience strain and/ or burden.

Gender Differences in Caregiving. The literature has attempted to distinguish between husbands and wives as caregivers and to examine whether gender differences exist in the outcomes of care (Brubaker, 1986; Connidis, 1989; Fitting, 1986; Johnson, 1985; Miller, 1987; Miller, 1990; Stone, 1987).

Though women tend to become caregivers more often than men (partially due to women living longer), various differences have been noted, although discrepancies exist. Men have been found to experience more difficulty with the completion of household responsibilities, spend less time with friends, rely more on formal supports, experience an increase in depressive symptoms as cognitive functioning of the spouse decreases, and experience more isolation than women, due to the larger number of older women (Brubaker, 1985; Johnson, 1983a; Johnson, 1985; Miller, 1990).

Men tend to continue in prior masculine domains (eg, money management, transportation, and home repairs), while women continue to extend the nurturant component of earlier roles. Women also have been found to offer higher levels of overall assistance, including personal hygiene requirements, household tasks, and meal preparation (Stone, 1987).

Miller (1987) concluded that when caring for a cognitively impaired mate, the dominant pattern appears to be congruence with previous role behavior. However, Crossman and associates (1981) described role ambiguity as occurring when a traditional wife shifts her role to become head of the household, due to the husband's declining health. This shift can cause conflict and confusion to both spouses; the wife must learn new responsibilities in addition to other tasks and caregiving, while the husband must relinquish certain roles.

Connidis (1989) raised the question of whether women experience more burden due to a belief that the caregiver role is supposed to have ended once children are grown. Perhaps resentment from having to continue this role accounts for greater reports of strain for women than for men. Horowitz (1985) contended that wives, who generally have more outside contacts than husbands, may feel more of a loss when they become limited to caregiving and isolated from social supports.

Moreover, the possibility exists that women have an internal model of caregiving based on the parent-infant model. Men might have a different model, derived from the work setting, in which delegation of responsibility and recognition of limitations necessary to do a good job are emphasized (Fitting, 1986). Fitting and colleagues proposed that their unexpected findings (of 25% of the caregiving husbands to dementia wives reporting improved relationships after assuming the caregiver role) were due to the novelty of the role and the chance of repaying the wife with nurturant behavior.

Although the focus here is on the wife as home caregiver to an ill husband, it might be important for professionals to understand possible gender differences. Depending on whether the caregiver is a husband or a wife may determine, in part, what resources may be called on and which interventions may be used.

Home caregiving to a spouse can become a burdensome task. Not only may the couple's relationship change, but the caregiver also may experience emotional, physical, and/or financial strains. While nursing home placement may not have previously been considered, it may eventually be viewed by others as an alternative - perhaps the only one.

NURSING HOME DECISION

The overwhelming theme in the literature regarding how a person or family decides to place another in a nursing home can be summarized in the title of Smallegan's (1985) study, "There Was Nothing Else to Do." The eventual decision appears to be made as a process, beginning when service requirements first become evident. Brody (1977) suggested that newly evaluated decisions should respond to changes in individual and family conditions.

Factors Affecting the Decision

Family members tend to avoid nursing home placement long beyond the time outsiders see it as appropriate. A breaking point generally occurs when the level of care is high, especially when caregiving is necessary 24 hours a day. The home caregiver may feel overwhelmed by the day-today demands and may feel that every alternative has been tried, in addition to exhausting himself or herself (Sommers, 1987). By the time of nursing home placement, available resources and debility of the person admitted tend to be such that almost every decision-maker finds no recourse other than a nursing home (Smallegan, 1985).

According to Dye (1982), however, postponing this decision until there is no other choice may not be in the best interests of the dependent person. Nursing home placement may facilitate better adjustment when it occurs while the dependent person is physically and emotionally able to adjust and cope with separation experiences and the new environment.

The health of the impaired elder at the time of the initial interview for placement, however, has been found not to be a major factor in the decision to institutionalize (Deimling, 1985). Zarit and co-workers (1986) concluded that the subjective responses of the caregiver to the caregiving situation - more than care provision itself - is implicated in the nursing home decision. Further, what is stressful to one caregiver may not be stressful to another. The caregiver's attitude toward nursing home care also is significant (Deimling, 1985). If the healthy spouse has a positive perception toward placement, and feels his or her partner will receive high quality care, then nursing home placement is more likely. Moreover, if the care provided is good, the spouse tends to feel good about nursing home placement; if not, feelings of guilt arise (Brubaker, 1986). Deimling and Poulshock (1985) explained that the single most powerful variable in deciding whether to place a spouse in a nursing home is the caregiver's attitude toward nursing home care; of lesser importance are variables such as the caregiver's health and stress effects. Caregiver attitude, caregiver health, and stress, when combined, can clearly predict which families will institutionalize an elderly relative.

Recommendations for Professionals to Facilitate the Decision Process

The nursing home decision is a difficult one to make; however, professionals can involve the family in a variety of ways. For instance, they can train families (especially spouses) to become good judges of services. This involves actions including articulating expectations of the nursing home and care to be provided, shopping for the appropriate facility based on the particular illness and level of care required, reviewing state reports, and talking with other families/spouses who have placed a mate in a nursing home (Hennon, 1991; Zarit, 1985).

Other important questions include the following: Will therapy be provided? Is privacy available? Do the wives feel free to use it? What are the patient's Bill of Rights? What are the general attitudes of the care providers (including doctors, nurses, aides, social workers, and administrators) toward patients (Fox, 1986)? Are considerations being given to the actual nursing home environment (Brent, 1984)? Given the opportunity to explore various options, a spouse is more likely to place a partner knowing that he or she has done all that is possible (Zarit, 1985).

Although opting for the nursing home may be a difficult decision to make, it may perhaps be even more difficult for later-life wives who have become home caregivers to their ill husbands. Caregiving may have become a meaningful role incurred by the wife, and part of her identity as an individual. Nursing home placement may not only remove the husband from the home, but also may eliminate a way of life to which she has become accustomed. Adjustments and adaptations (or a redefinition of the situation) may be required.

Adjusting to a New Role

Although institutionalization may ease some problems for caregivers, new problems or concerns are often confronted (Pratt, 1987). These persons can be described as "dangling in the grief experience," because grieving still occurs for the way the loved one used to be, as well as for the continued losses that come with a long-term illness (ie, loss of communication, lack of recognition by the ill spouse, physical decline, failing vision and hearing, and loss of the shared family home due to moving to a nursing home) (Rollins, 1985). Upon death of the ill spouse, a common and acceptable reaction tends to be relief as well as mourning. Spousal support groups can help validate the ambiguous feelings experienced.

Emotional Reactions

According to Brubaker (1986), husbands and wives adjust differently to nursing home placement of a spouse. A husband adjusts by acceptance and acknowledgement that he provided care as best as possible and that the wife needs the nursing home. A wife, on the other hand, wonders if home care is still possible and subsequently evaluates her success as a caregiver negatively. Based on this notion, community-dwelling wives may be especially in need of professional assistance in adjusting to their new role.

By use of a case example involving Alzheimer's disease, Farkas (1980) discussed the needs of the healthier partner. A spouse of a chronically ill person may feel significant amounts of guilt, anger, and other emotions. Guilt may be in the form of blaming the illness, being unable to prevent it, having a feeling of not having done enough to help the mate, and even wishing for a quick and painless death for a suffering spouse. Pre-existing guilt (attempting to compensate for past inadequacies, punishing the self, and regarding one's behavior negatively) further complicates the feelings.

Anger is another common experience-toward the sick person for abandoning the spouse, and for no longer being able to care for the healthy spouse or share in decisionmaking; and /or at fate for robbing the couple of good years to share.

Anger toward the patient may be perceived as unacceptable and may instead be directed to the medical staff, or inward, fostering depressive symptoms. The spouse must rediscover his or her needs and differentiate them from the patient's needs (Farkas, 1980).

Upon institutionalization of a mate, the healthy partner's way of life is affected. The community-dwelling wife must adjust to a variety of experiences: not being needed as much, living alone, not having the daily stimulation from support services entering the home, accepting the present situation, and forming relationships with the partners' new caregivers (Brubaker, 1986).

The adaptation and changes for the caregiver are as great as those of the spouse in the nursing home (Brody, 1977). For instance, mourning and grieving may occur due to the loss of the relationship with the spouse, the loss of identity as a functioning couple, and the lost functioning of the person once known (Smyer, 1985). However, this grief is different from grief over loss due to death of a spouse. Loss through death is final; this loss is open-ended - the spouse is not free to resume with his or her life (Sommers, 1987). A woman interviewed by Kaplan and Ade-Ridder (1991b) made the following statement: "It is easier when someone dies than when he is in a nursing home, because that way you are unattached . . . this is elongated."

Role Strain

The experiences of separation for an older person who moves to a longterm care setting have been studied by Dye (1982). Separation for dependent individuals has a greater impact than for more independent persons, both because of the need for help from others to survive, and due to an inability to easily establish other attachments to replace those that are lost. Nursing home elderly persons reflect that the next step after moving to a home is death. In the meantime, they experience the emotions of separation and are keenly aware of impending death. Active attempts to attach more securely to family members, however, lead to increased anxiety and guilt by the family.

According to Smyer and Frysinger (1985), this scenario occurs at the same time the community-dwelling spouse faces the challenge of continuing his or her personal development. Separation experiences occur for both spouses; for the person now residing in the nursing home and for the cornmunity-dwelling spouse adjusting to life alone.

Therefore, while the spouse entering the nursing home clings to family members, the family (especially the community-dwelling spouse) may be involved in grieving, adjusting to the separation, and facing the challenges of life after nursing home placement; he or she may be adapting to the new reality. If the partner in the nursing home gains a new family in the staff and a new home through attachment to the physical setting of the home, what happens to the spouse in the community, as well as to the marriage (Dye, 1982)? What feelings persist for the community-dwelling spouse if the mate does not experience a positive adjustment to the nursing home?

It appears that a spouse's move to an institutional setting does not remove all sources of strain experienced by the community-dwelling wife. Although comfort may be felt in knowing that the ill spouse is receiving quality care, the wife may be unsure of her role. For instance, new roles may be added to her role set (eg, becoming a "visitor" to the nursing home), while other roles may be eliminated (eg, losing the role of primary caregiver in exchange for that of secondary caregiver). Any time roles within a role set are changed, stress can result, both for the individual as well as for the marital unit.

Role strain (the felt difficulty in enacting a role), therefore, becomes an inevitable, normal, and expected consequence of multiple roles (Tiedje, 1990). This strain may be experienced due to conflicting demands on the person to simultaneously play more than one role. A wife with an institutionalized husband may be expected to add new roles to her role set, such as that of provider, in addition to continuing existing roles. Furthermore, other roles may make inconsistent demands on the wife, especially if she is uncertain regarding how they should be enacted. Researchers have noted that specific roles to be enacted once a spouse moves to a nursing home are unclear; role remaking may become necessary (Schwartz, 1990).

Role strain also may result from unclear or conflicting expectations of role performance. For instance, individuals have cultural norms that dictate, to some extent, how to act as a married person. But no such norms exist for married couples who do not live together due to declines in health of one partner.

REDEFINING ROLES

It has been suggested that a neverending negotiation of family roles occurs over the life cycle (Treas, 1987). Transitions of institutionalization create a variety of countertransitions for the family, such as relinquishing the responsibilities of caregiving to others and adjusting to living without the physical presence of the dependent person (Smyer, 1985). With conflicting role expectations, tensions between the healthy spouse and the nursing home staff often arise (Schmidt, 1987). The roles of family members may require redefinition - particularly the roles of elder, community-dwelling wife, and family.

New Roles for Spouses

By analyzing three case studies of elderly individuals providing care to spouses in long-term care facilities, Brubaker (1986) documented that the caregiving role frequently did not end upon placement in a nursing home. Instead, the community-dwelling mate visits and provides services in concert with the facility and the staff. Support offered to a partner may include visiting, advocating for the spouse, purchasing items unavailable in the facility, feeding, taking the spouse out of the facility, and providing other forms of physical, emotional, or social care. The healthy spouse can be said to become a case manager for his or her partner (Hennon, 1991).

Schmidt (1987) concluded that pressures between the spouse and the nursing home staff can be relieved by validation from both of an ongoing spousal role. Professionals can assist community-dwelling spouses in recognizing that expectations of this role may include new ways of caring for a spouse that meet the social /emotional needs of both partners, without interfering with the staff's delivery of essential nursing care. Moreover, acknowledgement of the current situation and recognition that the spouse's actions are limited by the structure of the dependent partners' current home and situation are necessary (Brubaker, 1986).

Continuing Couplehood

Before an ongoing spousal role is maintained, however, it may be important to examine whether a community-dwelling wife feels like part of a couple unit with an institutionalized husband. Kaplan (1991a) coined the term "couplehood" to describe feelings of belonging to a couple unit. Wives can feel they are part of a marital couple and view themselves primarily as part of a "we." In some cases, wives may feel more detached, or like an "I," and not as if they are part of a couple unit. It may be necessary to establish whether the woman wishes to continue in the role of "wife," and the extent to which she feels a sense of couplehood, before the particular role she will assume can be redefined.

A wife who views herself as belonging to a "we" may require a different role than will a woman feeling more like an "I." A woman feeling married may continue in her role as wife, regardless of the fact that her husband resides in a nursing home. In-depth interviews with six women in the qualitative study by Kaplan (1991a) demonstrated that the spousal role was a part of life for some of these individuals.

Examples from Kaplan's (1991a) study demonstrate how some women seemed to continue their role of wife after nursing home placement of the husband, with few, if any, adjustments. These particular women identified themselves primarily as being wives (eg, going by the husband's name: Mrs. John Doe). They spoke of "including" their husbands in certain activities, such as signing his name along with their own on cards and gifts. Some of them maintained contact with his old friends as part of the role responsibilities of wife; others sustained the couple's home and traditions within the home as they were when the husband lived there.

These women also tended to communicate directly with their husbands and his caregivers in the nursing home to see that all his needs were met. Nursing home placement of their husbands may not have particularly altered their overall sense of being wives, although the individual efforts they made to validate themselves may have been different from efforts made before the husband's move.

Married Widowhood

Some of the women investigated by Kaplan (1991a) had different perceptions of their roles after the husband's move. They did not feel a sense of couplehood, but each viewed herself as "I." One woman in particular had resumed with her life, having had few direct ties to her husband. She recognized that she was legally married and wished her husband no suffering, yet expressed the importance of having an identity separate from that as part of a couple. Her new role involved handling his care directly through his doctors because she believed there was no way of communicating with her husband. Her role transition was the most drastically altered of the women interviewed, and can be described as proceeding from housewife before nursing home placement of her husband to provider and mother after his move; she no longer felt married or like a wife.

Literature on widowhood suggests that some transitions may be similar between widows and those having a spouse residing in a nursing home. Rollins and associates (1985) coined the term "married widowhood." One spouse incurring a life-threatening, but not life-taking, physical or emotional problem that leads to nursing home placement of that person can cause the "married but widowed" syndrome. The possibility exists for this arrangement to continue year after year (Sommers, 1987). Individuals in this situation are found to experience many of the psychologic, physiologic, and sociologie guilt reactions to loss, as do those whose spouse dies. However, the responsibilities of the marriage relationship continue.

Perhaps the stages through which a widow progresses are similar to those in which a community-dwelling wife undergoes. A new widow tends to proceed through phases (Bumagin, 1982). Anger toward the deceased for either becoming ill and/ or abandoning the spouse through death is common. Moreover, quarrels, conflict, and disengagement prior to death may be anticipatory mourning (although not possible if death is unexpected).

Husband sanctification or idealization seems to provide a memory support system. Fixation in this stage performs important functions for the surviving wife (eg, because she married this saint, she must not be as unworthy as her depressed state suggests. It also allows the past to be constructed as unusually pleasant) (Lopata, 1986). Sanctification also can alienate those believing that the deceased is not the saint she recalls, while pushing others away due to the widow's belief that no other marriage or man can match her deceased husband (Bumagin, 1982; Lopata, 1986).

Finally, acceptance allows the widow who reaches this phase to go on with her life, to relinquish parts of her past, and to reach out to old and new relationships. However, spouses of nursing home residents may not reach the acceptance stage. Their roles may be less clear; they may be in a type of emotional limbo, due to the unpredictability of the partner's future.

It is not yet clear whether widows and community-dwelling wives experience similar transitions in roles. It can, however, be said that some, but not necessarily all, communitydwelling wives may undergo role transitions when their husbands move to nursing homes. Whether they define themselves as wives may dictate the actions they take in regard to their spouses. For instance, all the wives studied by Kaplan (1991a), as well as by Brubaker (1986), have taken on the role of case manager. Other changes in roles also are evident, whether it is the continuation of the role as spouse, or as an individual with no sense of belonging to a marital unit.

IMPLICATIONS FOR GERONTOLOGICAL NURSES

Some women who were home caregivers to ill husbands may experience easier transitions than others when the husband moves to a nursing home. They may require few, if any, adjustments at all. It is perhaps these women who continue, relatively uninterrupted, in their previous role as wife. Other women may encounter more difficulty in finding their niche. These individuals may experience more tensions between the self and the nursing home staff regarding expectations for their role. One implication is that all professional staff members must recognize that marital relationships can and do continue despite one spouse residing in a nursing home.

Moreover, the staff may be in a position to either take over the kinds of care that the wife no longer can (or wishes to) handle, while acknowledging and respecting her desires to provide spousal kinds of care if she wishes. Some wives may have difficulty letting go of caregiving responsibilities; others may gratefully give up those chores. How the patient's spouse defines her role as wife may determine her ability and willingness to relinquish responsibility to professional caregivers. Letting the community-dwelling wife set the tone for what her continued role will be allows her to define her marriage in a way that serves her needs at this transitory time.

A second implication is that future research to ascertain whether a relationship does exist between community-dwelling wives and widows is necessary. Currently, there is little in the literature that focuses directly on community-dwelling wives; more exists on adjustments made by widows. Perhaps if these two groups have similar emotions, experiences, and role expectations, then the types of efforts developed for widows also may assist wives whose husbands reside in nursing homes.

Many implications also exist for nurses and nurse clinicians. First, it must be accepted that not all wives will wish to continue in the role of wife after their husbands' move. It should not be assumed that continuing the role of wife is preferable to not continuing in this role. Objectivity may be an obvious characteristic of nurses and other clinicians, but it may be even more important with this particular population. For instance, if a woman defines herself as a wife, the nurse or nurse clinician's task may be to aid her in redefining the role's tasks, responsibilities, and limitations imposed by the nursing home setting.

If the spouse does not perceive herself as a wife, nurses must help her accept these feelings as natural, and support her need to establish an identity as an individual and not as part of a couple. Some work on improving her self-identity also may be required if she experiences guilt related to her choice not to continue in the spousal role. Although the focus here is on community-dwelling wives, it also is important for nurses to be aware of potential differences and adjustments between these women and husbands whose wives reside in nursing homes.

The nursing home staff also may see a benefit in developing support groups for community-dwelling spouses; the focus can be on understanding how others adapt to the new role imposed upon them. A husband's move to an institutional setting may reduce or eliminate the wife's stress, especially if she had previously provided his care in the home. With this change in residence, however, also may come other forms of stress. It is important to understand that variability exists among women in terms of how much (if any) role adjustment and what kinds of role adjustments are necessary.

Clearly, additional research is necessary to better understand the range of role adjustments exhibited by women in this situation. In the meantime, gerontological nurses working with elderly couples experiencing similar role transitions must attend to the needs of the healthier spouse, and not only the institutionalized patient.

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