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Spousal caregiving in later life: An objective and subjective career Margaret M. Ross BScN, MEd
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Toronto, Ontario, Canada Published online: 14 Aug 2009.
To cite this article: Margaret M. Ross BScN, MEd (1991) Spousal caregiving in later life: An objective and subjective career, Health Care for Women International, 12:1, 123-135, DOI: 10.1080/07399339109515932 To link to this article: http://dx.doi.org/10.1080/07399339109515932
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SPOUSAL CAREGIVING IN LATER LIFE: AN OBJECTIVE AND SUBJECTIVE CAREER Margaret M. Ross, BScN, MEd
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Toronto, Ontario, Canada
During later life, as a consequence of the deteriorating health of husbands, numerous women experience a period of spousal caregiving that can be considered a new phase in their caregiving career. This phase, which often precedes widowhood, is one that has been relatively neglected by researchers. In this article, the concepts of objective and subjective career (Hughes, 1971) are used as orienting concepts to examine the phenomenon of spousal caregiving in later life. Objectively, the caregiving career is seen as an agerelated, gender-specific, and role-contingent phenomenon. The subjective career is seen as the meaning and purposes attributed to complex and extensive responsibilities and activities of caregiving and their potentially serious consequences for health and wellbeing.
During later life, as a consequence of the deteriorating health of husbands, numerous women experience a period of spousal caregiving that can be considered a new phase in their caregiving career. The concepts of objective and subjective career (Hughes, 1971) provide a useful orienting framework within which to examine the phenomenon of spousal caregiving in later life. These concepts draw on the tradition in sociology that "emphasizes the human tendency to construct and share meaning and the human tendency to attempt to control, through symbolic interaction, situations in keeping with biographically meaningful intentions" (Marshall, 1979, p. 355). Within this context, spousal caregiving can be viewed as a sequence of meaningful negotiations with others that
I thank Dr. C. Rosenthal for her comments on an earlier version of this article. Preparation of this article was supported by a Social Sciences and Humanities Research Council of Canada Doctoral Fellowship to Margaret M. Ross. Health Care for Women International, 12:123-135, 1991 Copyright © 1991 by Hemisphere Publishing Corporation
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bridges the interval between the time when wives experience their status of wife in its fullest to the time when they become widows. I begin with an examination of spousal caregiving as an objective career, continue with an exploration of spousal caregiving as a subjective career, and conclude with implications for health care.
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OBJECTIVE CAREER Hughes (1971) referred to objective career as "a series of statuses and clearly defined offices held through the life course in which there are typical sequences of position, achievement, and responsibility" (p. 137). The role of spousal caregiver can be viewed objectively in terms of its age-specific, gender-selective, and role-contingent characteristics. Age Relatedness Women tend to live longer and to marry men who are, on average, 2 3 years older than themselves. This, coupled with the fact that disability increases with age, contributes to a pattern of spousal caregiving in the later life of many elderly women. As elderly husbands become increasingly frail, wives assume new caregiving responsibilities—frequently as they themselves are beginning to experience the health and social consequences of increasing age. These caregiving responsibilities continue, albeit in a different form, after the institutionalization of husbands. There is considerable indirect evidence of the number of aged women involved in caregiving to frail and chronically ill husbands. Chappell, Strain, and Blandford (1986) referred to older couples who maintain variable degrees of independence in the face of infirmities by nursing one another. Horowitz (1985) observed that the usual caregiver for an older man is his elderly wife, typically in her 70s and in fair to poor health herself. Spousal caregivers are thought to be at highest risk because they are themselves elderly and therefore subject to negative health consequences (Fengler & Goodrich, 1979; Shanas, 1979). In a national profile of family caregivers, Stone, Cafferata, and Sangl (1987) reported that wives constitute 23% of informal caregivers, thus providing direct evidence of the significance of spousal caregiving to the informal care system. Gender Selectivity The literature is replete with evidence that caregiving is a genderlinked activity, with women assuming primary responsibility for family care (Aronson, 1985; Brody, 1981; Briggs & Oliver, 1985; Finch &
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Groves, 1983; Horowitz, 1985; Ungerson, 1987). Finch and Groves (1980) reported that "in practice, community care equals care by the family and in practice, care by the family equals care by women" (p. 404). The traditional assumption of nurturing tasks by women and their strong emotional ties to family contribute to the tendency for women to continue with caregiving activities and responsibilities in later life, many of which take a different form in the face of the deteriorating health of husbands. During the period of time before widowhood, elderly women are frequently the primary support of and caregivers to their ailing husbands (Brubaker, 1985; Shanas, 1979). Although there are a few studies that address the experience of elderly husbands who provide care to frail and chronically ill wives (Motenko, 1988; Vinick, 1984), it seems that caregiving continues to be a gender-linked activity that takes on an added significance for women in their later years. Role Contingency Although the major focus of the gerontological literature is on the role of adult daughters as caregivers to elderly parents (Brody, 1985; Matthews & Rosrier, 1988; Morris & Sherwood, 1984; Rosenthal, Matthews, & Marshall, 1989), researchers are beginning to explore the experience of wives who provide care to elderly and impaired husbands (Barusch, 1988; Bowers, 1988; Crossman & Barry, 1981; Fengler & Goodrich, 1979; Fitting, Rabin, Lucas, & Eastham, 1986; Miller, 1987; Pruschno & Resch, 1989; Zarit, Todd, & Zarit, 1986). There is increasing awareness of the importance of spousal caregiving to the health and well-being of people in their later years. Spouses provide the most consistent and dependable care to disabled elderly people and resist institutional placement for longer periods of time than nonspouse caregivers, regardless of the level of disability (Cantor & Little, 1985; Crossman & Barry, 1981; Finch & Groves, 1983; Johnson, 1983). Brody (1981) considered the phrase "alternatives to institutionalization" a euphemism for daughter, Chappell et al. (1986) added that it is a euphemism for wife as well. Horowitz and Dobrof (1982) documented the primary role of spouses in maintaining principal responsibility for caregiving tasks, household responsibilities, and medical supervision of the older person. Motenko (1988) referred to the supplementary role of family members as compared with the primary role of spouses in caregiving during later life. It seems that for some older women, long-term marriages are culminated by a period of caregiving for husbands with debilitating health problems. Other aspects of the objective career of spousal caregiving in later life that influence the needs of caregivers and their ability to "carry on"
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include the nature of the setting where caregiving occurs (Diemling & Poulshock, 1985; Montgomery, 1982; Smith & Bengtson, 1979; York & Calsyn, 1977), the specific tasks associated with caregiving (Bowers, 1987; Clark & Rakowski, 1983; Rubin & Shuttlesworth, 1983; Shuttlesworth, Rubin, & Duffy, 1982), and the duration of caregiving (Pallett, 1990). In a study of family caregiving for impaired elderly persons, Noelker and Poulshock (1982) found that more than half of these elderly people received assistance with at least four personal care tasks and that 38% were completely dependent in the area of personal care. Families in their study had been the major source of assistance and had been providing care for approximately 3 hr per day over a 6-year period. Given the relationship between family care and care by women, it is logical to assume that most of this care was performed by women, and much of it by elderly wives. SUBJECTIVE CAREER Hughes (1971) referred to subjective career as "the moving perspective in which the person sees his life as a whole and interprets the meaning of his various attributes, actions, and the things that happen to him" (p. 137). In other words, the term subjective career refers to the ways in which the objective career of spousal caregiving is experienced (Marshall, 1980). In this section, I explore the experience of spousal caregiving in terms of its meaning, manifestations, and consequences for the personal well-being of elderly wives. Subjective Career: The Meaning of Spousal Caregiving The meaning of spousal caregiving in later life is described as a labor of love, an opportunity for reciprocity, and an expression of duty and obligation. A Labor of Love
Many women use the language of love to describe the roots of their caregiving, thus providing strength to the notion of a loving basis for the caregiving work of elderly spouses (Ungerson, 1987). Love, affection, and commitment serve as the basis of vows and promises made in earlier years to care for each other over time and to avoid institutionalization if at all possible. The promise between wives and husbands to care for each other is powerful and binding for many, and significantly influences the meaning of the care that occurs. Broken promises generate intense feelings of guilt and concern on the part of elderly wives. The
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loving basis of spousal caregiving is also evident in wives' expressions of sadness over their perceived loss of love and companionship brought about by the deteriorating health and, particularly, the admission of husbands to long-term care institutions (McCann, 1988).
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Reciprocity
The decision of wives to devote their later years to the provision of care to elderly and frail husbands is motivated in part by an appreciation of the years of devotion provided to them by their husbands. In this way, spousal caregiving is rooted in spousal relationships over time, with the past infusing meaning into the present and hence into the provision of care. Caregiving means more than the carrying out of tasks and becomes an expression of appreciation, gratitude, and love. Motenko (1988) reported that for men, spousal caregiving provided an opportunity to reciprocate and perpetuate a relationship that continued to hold value. These notions are consistent with Bulmer's (1987) observation of the embeddedness of social relationships over time and emphasis on the importance of a generalized notion of reciprocity for understanding informal care. Corresponding to this analysis are Aronson's (1988) findings that many women raised the notion of reciprocity as the basis for intergenerational caregiving. Hooyman and Lustbader (1986) also viewed reciprocity, or the repaying of what was given, as particularly relevant to spousal caregiving and interpreted the personal sacrifices of spousal caregivers as a meaningful way to express gratitude for years of service and devotion. Hooyman arid Lustbader suggested that a sense of reciprocity provides meaning to the sacrifices of caregiving, makes them more tolerable, and contributes to a sense of the moral obligation to care. Duty and Obligation
The motivation for spousal caregiving in later life derives in part from the norms and values of the North American family system that emphasize the obligation of wives and husbands to fulfill each other's instrumental and socioemotional needs (Fengler & Goodrich, 1979; Johnson, 1985). Ungerson (1987) noted that women frequently express their motivation to care in the language of duty and moral obligation. At the ideological level, marriage is regarded by many as the supreme caring relationship, rivaled perhaps only by the mother-child bond. Marriage vows reinforce the idea that one of the fundamental responsibilities of marriage is to care "in sickness and in health" (Ungerson, 1987). Many couples hold strong and traditional views about the nature of the marriage relationship and the appropriate roles for married men and women. These views, which include the centrality of the nurturant
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relationship for wives in particular (Gilligan, 1982), are firmly grounded in years of living and relating together and continue into later life. These notions are consistent with the findings of Fitting et al. (1986), who studied spousal caregivers, most of who had been married for more than 30 years. The majority of these caregivers expressed a sense of duty and obligation to care for their family members. The wives in this study appeared to feel that if they transgressed this sense of duty, they would experience insupportable feelings of guilt. Subjective Career: The Manifestations of Spousal Caregiving A fuller understanding of elderly wives' caregiving career also includes an exploration of associated activities and responsibilities. Bowers (1987, 1988) provided an approach to this exploration that focuses on the goals rather than the tasks of caregiving. Her typology of caregiving includes preservative or protective care (preserving the care recipient's concept of self and the caregiving relationship), preventative care (preventing physical harm), anticipatory care (anticipating and preparing for what may happen), supervisory care (coordinating and supervising the care providing by others), and instrumental care (performing direct physical care tasks). This approach fits well with the notion of the subjective career of elderly wives. Defining caregiving by the meaning or purpose a caregiver attributes to a behavior rather than by the nature or demands of the behavior itself, Bowers included any process engaged in for the purpose of caregiving. This conceptualization of caregiving activities, distinguished by purpose rather than by task, offers a comprehensive picture of the experience of spousal caregiving by highlighting its invisible nature. Wilson (1989) described a three-stage process of family caregiving for relatives of persons with Alzheimer's disease that further explicates the subjective aspects of the caregiving career. During the "taking it on" stage, caregiving was superimposed on prior responsibilities and enacted within a context of uncertainty and unpredictability. "Going through it," or Stage 2, entailed coping with an ongoing sequence of problems, which resulted in conflicting role demands that were solved on an emergent trial-and-error basis. The "turning it over" stage comprised the gradual process of giving up control over caregiving and preceded the ultimate step of entrusting care to an institution. These approaches to the analysis of caregiving are qualitative in nature and reveal the courage and determination of women who continue to provide care to husbands despite their own advancing years and their husbands' increasing frailty.
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Subjective Career: The Consequences of Spousal Caregiving An understanding of the subjective aspects of spousal caregiving would not be complete without an exploration of its consequences for personal health and well-being. In this section, I explore the daily grind and burden of care and its consequences for personal well-being, including physical and emotional well-being. Some of the reported positive outcomes or rewards associated with spousal caregiving in later life are also noted. The Daily Grind of Care
Researchers are beginning to convey the meaning of the daily grind of caregiving labor for spouses (Bowers, 1988; Zarit et al., 1986). The increasing arduousness and unrelenting nature of tasks associated with the direct provision of care, the constant monitoring and supervision of husbands, and the management of disruptive behavior (categories of caregiving identified by Mohide, 1984) constitute major sources of stresses for elderly wives. Increasingly, studies identify predictable correlates of high stress: inability to converse normally, restrictions on leisure time, poor health of the caregiver, the time and energy associated with visiting, distortions in patterns of living, and difficulties in relating to spouses (Parker, 1985; Robertson & Reisner, 1982; Zarit et al., 1986). To witness the deterioration of a husband's personality as a result of an illness is described as a living death (Mace & Rabins, 1981). The terms caregiver burden (Zarit, Reever, & Bach-Peterson, 1980) and caregiver strain (Cantor, 1983) are often used to refer to the physical, social, and emotional consequences of caregiving. Comparisons are made among the caregiving burdens experienced by wives, husbands, daughters, sons, and children-in-law. Robinson (1983) and Zarit et al. (1980) found no demonstrable differences in caregiver burden between spouses and adult children. Noelker and Townsend (1987), on the other hand, reported that spouses typically experience more burden than adult children. A Canadian study of elderly caregivers conducted by Marcus and Jaeger (1984) and an American study by Fitting et al. (1986) reported that elderly female caregivers experienced their caregiving role as more burdensome and assessed their role more negatively than did elderly male caregivers. Zarit et al. (1986), however, contradicted these findings in a longitudinal study that compared the caregiving experience of elderly husbands and wives. They found that although initially wives reported more burden, there were no significant differences after 2 years. The breadth of issues that are subsumed within the concept of burden of care make its use as a unified concept questionable. Previous research
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and clinical observations, however, suggest that caregiving may have a negative impact on physical and emotional health and on social participation—aspects of personal well-being (Duke Center for the Study of Aging & Human Development, 1978; George & Gwyther, 1986) that are conceptually and empirically distinct from caregiving and should therefore be measured separately.
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Physical Weil-Being
There is increasing evidence that the demands of spousal caregiving in later life have the potential to increase wives' vulnerability to deteriorating physical well-being. In a study of caregiver well-being, George and Gwyther (1986) reported that the spouses in their sample exhibited lower levels of physical well-being as measured by self-rated health and numbers of physician visits. Before the admission of husbands to longterm care institutions, wives typically describe the challenges resulting from the need for around-the-clock caregiving to ailing husbands. Chenoweth and Spencer (1986) referred to the decision to institutionalize as a result of being worn out by 24-hr caregiving. Fatigue, difficulties with sleep, and aches and pains associated with caregiving tasks or concomitant chronic health problems such as arthritis or congestive heart failure may be features of being worn out. Emotional Well-Being
In addition to being at risk physically, there are suggestions that spouses are at greater risk for emotional distress than other caregivers (Fengler & Goodrich, 1979; George & Gwyther, 1986; Rosenthal, Marshall, & Sulman, 1988). Rollins, Waterman, and Esmay (1985) reported a wide range of emotional responses to spousal caregiving, observing that the well spouse often feels uneasy with and ambivalent about the sense of accomplishment and new-found independence that comes with the mastery of new tasks. They also noted feelings of frustration and guilt when spouses began to enjoy the routines of daily living without ill partners. Fengler and Goodrich (1979) also reported that wives in their study experienced worry, frustration, sadness, resignation, and impatience with their husbands' health conditions. There is evidence to suggest that low morale is also a feature of the caregiving experience of elderly women. Fengler and Goodrich (1979) studied the experience of wives who were caring for disabled men. Three fourths of the wives were 50 years of age or older and had significant health problems of their own. Although wives in the sample had originally willingly accepted the caregiving role, at the time of the study 83 % cited isolation, loneliness, economic hardship, and role overload as the most frequent causes of their low morale. Fengler and Goodrich
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referred to these women as "hidden victims." George and Gwyther (1986) also reported lower levels of affect balance and life satisfaction among spousal caregivers. There is also evidence to suggest that depression is commonly experienced by wives who continue to provide care to elderly and impaired husbands. Rosenthal et al. (1988) reported that spouses were twice as likely as other types of family members to be moderately or severely depressed and were much less likely to be free of depression. Although this study focused on families of long-stay geriatric patients in acute care facilities, the findings highlight the unique experience and vulnerability of elderly spouses. Role Accumulation
• Although the majority of researchers who study the consequences of caregiving tend to focus on negative outcomes such as burden and strain, a few researchers convey some of the positive outcomes or rewards associated with spousal caregiving in later life. Spousal caregiving can perpetuate meaningful marital relationships, which are generally a source of self-esteem for couples (Motenko, 1988). Enhanced feelings of self-esteem may result from feelings of being needed and the experience of successfully meeting new challenges (Motenko, 1988). Some wives find gratification in their relationships with their impaired spouses and derive meaning from the caregiving situation. Hirschfeld (1983) referred to this phenomenon as mutuality, which was defined as the sustaining force in long-term family care. The consequences of spousal caregiving for well-being in later life lend support to the notion that the arduousness and enduring nature of spousal caregiving contribute to the vulnerability of elderly wives, and as such constitute an important feature of spousal caregiving in later life that must be addressed by social gerontologists and health care practitioners. Implications for Health Care In later life, the provision of care to elderly and impaired husbands represents a continuation of the caregiving career for numerous women. These women may be particularly vulnerable and at risk for health and social problems as a result of both their own progressing age and the demands of caregiving. Researchers have consistently documented the high level of stress associated with the role of spousal caregiver. Spouses report significantly more physician visits, poorer self-rated health, and lower levels of well-being than do other categories of caregivers (George & Gwyther, 1986). Elderly wives report higher levels of
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burden and psychological distress associated with caregiving (Zarit et al., 1986) and have higher depression scores (Pruschno & Resch, 1989) than do husbands. The significance of these findings for health care practitioners lies partially in the identification of behavioral and affective changes occurring over time that may signal the increasing vulnerability and potential for breakdown on the part of elderly wives who are coping with their husbands' deteriorating health. These findings render it imperative that health care practitioners target health promotion measures and interventions at this group of informal caregivers. CONCLUSION In this article, I have demonstrated how spousal caregiving in later life can be conceptualized as a new phase in the caregiving career of elderly women that has both objective and subjective characteristics. The objective career of spousal caregiving is predominantly an agerelated, gender-selective, and role-contingent phenomenon that has only recently been considered an area of gerontological and social sciences research. Subjective dimensions of the career include its meaning, manifestations, and consequences for well-being. Subjectively, spousal caregiving is described as a labor of love, an opportunity for reciprocity, and the expression of duty and obligation. It is defined as the meaning or purpose attributed to complex and extensive caregiving responsibilities and is associated with a multitude of potentially serious consequences for the health and well-being of caregiving spouses. REFERENCES Aronson, J. (1985). Family care of the elderly: Underlying assumptions and their consequences. Canadian Journal of Aging, 4(3), 115-125. Aronson, J. (1988). Women's experiences in giving and receiving care: Pathways to social change. Unpublished doctoral dissertation, University of Toronto, Toronto, Canada. Barusch, A. (1988). Problems and coping strategies of elderly spouse caregivers. The Gerontologist, 28(5), 677-685. Bowers, B. (1987). Intergenerational caregiving: Adult caregivers and their aging parents. Advances in Nursing Science, 9(2), 20-31. Bowers, B. (1988). Family perceptions of care in a nursing home. The Gerontologist, 28(3), 361-368. Briggs, A., & Oliver, J. (Eds.). (1985). Caring: Experiences of looking after disabled relatives. London: Routledge & Kegan Paul. Brody, E. (1981). Women in the middle and family help to older people. The Gerontologist, 21(5), 471-480.
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Rollins, D., Waterman, D., & Esmay, D. (1985). Married widowhood. Activities, Adaptation and Aging, 7(2), 67-71. Rosenthal, C., Matthews, C., & Marshall, V. (1989). Is parent care normative? The experience of a sample of middle aged women. Research and Aging, 11(2), 244-260. Rosenthal, C., Marshall, V., & Sulman, J. (1988, November 19). Families of long stay patients: The emotional cost of care. Paper presented at the 41st annual meeting of the Gerontological Society of America, San Francisco. Rubin, A., & Shuttlesworth, G. (1983). Engaging families as support resources in nursing home care: Ambiguity in the subdivision of tasks. The Gerontologist, 23(6), 632636. Shanas, E. (1979). The family as a support system in old age. The Gerontologist, 19, 169-174. Shuttlesworth, G., Rubin, A., & Duffy, M. (1982). Families versus institutions: Incongruent role expectations in the nursing home. The Gerontologist, 22(2), 200-208. Smith, K., & Bengtson, V. (1979). Positive consequences of institutionalization: Solidarity between parents and their middle-aged children. The Gerontologist, 19, 438447. Stone, R., Cafferata, G., & Sangl, J., (1987). Caregivers of the frail elderly: A national profile. The Gerontologist, 27, 616-626. Ungerson, C. (1987). Policy is personal: Sex, gender, and informal care. London: Tavistock. Vinick, B. (1984). Elderly men as caretakers of wives. Journal of Geriatric Psychiatry, 17(1), 61-68. Wilson, H. (1989). Family caregiving for a relative with Alzheimer's dementia: Coping with negative choices. Nursing Research, 38(2), 94-98. York, J., & Calsyn, R. (1977). Family involvement in nursing homes. The Gerontologist, 17(6), 500-505. Zarit, S., Reever, K., & Bach-Peterson, J. (1980). Relatives of the impaired elderly: Correlates of feelings of burden. The Gerontologist, 20(6), 649-655. Zarit, S., Todd, P., & Zarit, J. (1986). Subjective burden of husbands and wives as caregivers: A longitudinal study. The Gerontologist, 20(6), 649-655.
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Spousal caregiving in later life: An objective and subjective career Margaret M. Ross BScN, MEd
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Toronto, Ontario, Canada Published online: 14 Aug 2009.
To cite this article: Margaret M. Ross BScN, MEd (1991) Spousal caregiving in later life: An objective and subjective career, Health Care for Women International, 12:1, 123-135, DOI: 10.1080/07399339109515932 To link to this article: http://dx.doi.org/10.1080/07399339109515932
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SPOUSAL CAREGIVING IN LATER LIFE: AN OBJECTIVE AND SUBJECTIVE CAREER Margaret M. Ross, BScN, MEd
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Toronto, Ontario, Canada
During later life, as a consequence of the deteriorating health of husbands, numerous women experience a period of spousal caregiving that can be considered a new phase in their caregiving career. This phase, which often precedes widowhood, is one that has been relatively neglected by researchers. In this article, the concepts of objective and subjective career (Hughes, 1971) are used as orienting concepts to examine the phenomenon of spousal caregiving in later life. Objectively, the caregiving career is seen as an agerelated, gender-specific, and role-contingent phenomenon. The subjective career is seen as the meaning and purposes attributed to complex and extensive responsibilities and activities of caregiving and their potentially serious consequences for health and wellbeing.
During later life, as a consequence of the deteriorating health of husbands, numerous women experience a period of spousal caregiving that can be considered a new phase in their caregiving career. The concepts of objective and subjective career (Hughes, 1971) provide a useful orienting framework within which to examine the phenomenon of spousal caregiving in later life. These concepts draw on the tradition in sociology that "emphasizes the human tendency to construct and share meaning and the human tendency to attempt to control, through symbolic interaction, situations in keeping with biographically meaningful intentions" (Marshall, 1979, p. 355). Within this context, spousal caregiving can be viewed as a sequence of meaningful negotiations with others that
I thank Dr. C. Rosenthal for her comments on an earlier version of this article. Preparation of this article was supported by a Social Sciences and Humanities Research Council of Canada Doctoral Fellowship to Margaret M. Ross. Health Care for Women International, 12:123-135, 1991 Copyright © 1991 by Hemisphere Publishing Corporation
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bridges the interval between the time when wives experience their status of wife in its fullest to the time when they become widows. I begin with an examination of spousal caregiving as an objective career, continue with an exploration of spousal caregiving as a subjective career, and conclude with implications for health care.
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OBJECTIVE CAREER Hughes (1971) referred to objective career as "a series of statuses and clearly defined offices held through the life course in which there are typical sequences of position, achievement, and responsibility" (p. 137). The role of spousal caregiver can be viewed objectively in terms of its age-specific, gender-selective, and role-contingent characteristics. Age Relatedness Women tend to live longer and to marry men who are, on average, 2 3 years older than themselves. This, coupled with the fact that disability increases with age, contributes to a pattern of spousal caregiving in the later life of many elderly women. As elderly husbands become increasingly frail, wives assume new caregiving responsibilities—frequently as they themselves are beginning to experience the health and social consequences of increasing age. These caregiving responsibilities continue, albeit in a different form, after the institutionalization of husbands. There is considerable indirect evidence of the number of aged women involved in caregiving to frail and chronically ill husbands. Chappell, Strain, and Blandford (1986) referred to older couples who maintain variable degrees of independence in the face of infirmities by nursing one another. Horowitz (1985) observed that the usual caregiver for an older man is his elderly wife, typically in her 70s and in fair to poor health herself. Spousal caregivers are thought to be at highest risk because they are themselves elderly and therefore subject to negative health consequences (Fengler & Goodrich, 1979; Shanas, 1979). In a national profile of family caregivers, Stone, Cafferata, and Sangl (1987) reported that wives constitute 23% of informal caregivers, thus providing direct evidence of the significance of spousal caregiving to the informal care system. Gender Selectivity The literature is replete with evidence that caregiving is a genderlinked activity, with women assuming primary responsibility for family care (Aronson, 1985; Brody, 1981; Briggs & Oliver, 1985; Finch &
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Groves, 1983; Horowitz, 1985; Ungerson, 1987). Finch and Groves (1980) reported that "in practice, community care equals care by the family and in practice, care by the family equals care by women" (p. 404). The traditional assumption of nurturing tasks by women and their strong emotional ties to family contribute to the tendency for women to continue with caregiving activities and responsibilities in later life, many of which take a different form in the face of the deteriorating health of husbands. During the period of time before widowhood, elderly women are frequently the primary support of and caregivers to their ailing husbands (Brubaker, 1985; Shanas, 1979). Although there are a few studies that address the experience of elderly husbands who provide care to frail and chronically ill wives (Motenko, 1988; Vinick, 1984), it seems that caregiving continues to be a gender-linked activity that takes on an added significance for women in their later years. Role Contingency Although the major focus of the gerontological literature is on the role of adult daughters as caregivers to elderly parents (Brody, 1985; Matthews & Rosrier, 1988; Morris & Sherwood, 1984; Rosenthal, Matthews, & Marshall, 1989), researchers are beginning to explore the experience of wives who provide care to elderly and impaired husbands (Barusch, 1988; Bowers, 1988; Crossman & Barry, 1981; Fengler & Goodrich, 1979; Fitting, Rabin, Lucas, & Eastham, 1986; Miller, 1987; Pruschno & Resch, 1989; Zarit, Todd, & Zarit, 1986). There is increasing awareness of the importance of spousal caregiving to the health and well-being of people in their later years. Spouses provide the most consistent and dependable care to disabled elderly people and resist institutional placement for longer periods of time than nonspouse caregivers, regardless of the level of disability (Cantor & Little, 1985; Crossman & Barry, 1981; Finch & Groves, 1983; Johnson, 1983). Brody (1981) considered the phrase "alternatives to institutionalization" a euphemism for daughter, Chappell et al. (1986) added that it is a euphemism for wife as well. Horowitz and Dobrof (1982) documented the primary role of spouses in maintaining principal responsibility for caregiving tasks, household responsibilities, and medical supervision of the older person. Motenko (1988) referred to the supplementary role of family members as compared with the primary role of spouses in caregiving during later life. It seems that for some older women, long-term marriages are culminated by a period of caregiving for husbands with debilitating health problems. Other aspects of the objective career of spousal caregiving in later life that influence the needs of caregivers and their ability to "carry on"
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include the nature of the setting where caregiving occurs (Diemling & Poulshock, 1985; Montgomery, 1982; Smith & Bengtson, 1979; York & Calsyn, 1977), the specific tasks associated with caregiving (Bowers, 1987; Clark & Rakowski, 1983; Rubin & Shuttlesworth, 1983; Shuttlesworth, Rubin, & Duffy, 1982), and the duration of caregiving (Pallett, 1990). In a study of family caregiving for impaired elderly persons, Noelker and Poulshock (1982) found that more than half of these elderly people received assistance with at least four personal care tasks and that 38% were completely dependent in the area of personal care. Families in their study had been the major source of assistance and had been providing care for approximately 3 hr per day over a 6-year period. Given the relationship between family care and care by women, it is logical to assume that most of this care was performed by women, and much of it by elderly wives. SUBJECTIVE CAREER Hughes (1971) referred to subjective career as "the moving perspective in which the person sees his life as a whole and interprets the meaning of his various attributes, actions, and the things that happen to him" (p. 137). In other words, the term subjective career refers to the ways in which the objective career of spousal caregiving is experienced (Marshall, 1980). In this section, I explore the experience of spousal caregiving in terms of its meaning, manifestations, and consequences for the personal well-being of elderly wives. Subjective Career: The Meaning of Spousal Caregiving The meaning of spousal caregiving in later life is described as a labor of love, an opportunity for reciprocity, and an expression of duty and obligation. A Labor of Love
Many women use the language of love to describe the roots of their caregiving, thus providing strength to the notion of a loving basis for the caregiving work of elderly spouses (Ungerson, 1987). Love, affection, and commitment serve as the basis of vows and promises made in earlier years to care for each other over time and to avoid institutionalization if at all possible. The promise between wives and husbands to care for each other is powerful and binding for many, and significantly influences the meaning of the care that occurs. Broken promises generate intense feelings of guilt and concern on the part of elderly wives. The
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loving basis of spousal caregiving is also evident in wives' expressions of sadness over their perceived loss of love and companionship brought about by the deteriorating health and, particularly, the admission of husbands to long-term care institutions (McCann, 1988).
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Reciprocity
The decision of wives to devote their later years to the provision of care to elderly and frail husbands is motivated in part by an appreciation of the years of devotion provided to them by their husbands. In this way, spousal caregiving is rooted in spousal relationships over time, with the past infusing meaning into the present and hence into the provision of care. Caregiving means more than the carrying out of tasks and becomes an expression of appreciation, gratitude, and love. Motenko (1988) reported that for men, spousal caregiving provided an opportunity to reciprocate and perpetuate a relationship that continued to hold value. These notions are consistent with Bulmer's (1987) observation of the embeddedness of social relationships over time and emphasis on the importance of a generalized notion of reciprocity for understanding informal care. Corresponding to this analysis are Aronson's (1988) findings that many women raised the notion of reciprocity as the basis for intergenerational caregiving. Hooyman and Lustbader (1986) also viewed reciprocity, or the repaying of what was given, as particularly relevant to spousal caregiving and interpreted the personal sacrifices of spousal caregivers as a meaningful way to express gratitude for years of service and devotion. Hooyman arid Lustbader suggested that a sense of reciprocity provides meaning to the sacrifices of caregiving, makes them more tolerable, and contributes to a sense of the moral obligation to care. Duty and Obligation
The motivation for spousal caregiving in later life derives in part from the norms and values of the North American family system that emphasize the obligation of wives and husbands to fulfill each other's instrumental and socioemotional needs (Fengler & Goodrich, 1979; Johnson, 1985). Ungerson (1987) noted that women frequently express their motivation to care in the language of duty and moral obligation. At the ideological level, marriage is regarded by many as the supreme caring relationship, rivaled perhaps only by the mother-child bond. Marriage vows reinforce the idea that one of the fundamental responsibilities of marriage is to care "in sickness and in health" (Ungerson, 1987). Many couples hold strong and traditional views about the nature of the marriage relationship and the appropriate roles for married men and women. These views, which include the centrality of the nurturant
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relationship for wives in particular (Gilligan, 1982), are firmly grounded in years of living and relating together and continue into later life. These notions are consistent with the findings of Fitting et al. (1986), who studied spousal caregivers, most of who had been married for more than 30 years. The majority of these caregivers expressed a sense of duty and obligation to care for their family members. The wives in this study appeared to feel that if they transgressed this sense of duty, they would experience insupportable feelings of guilt. Subjective Career: The Manifestations of Spousal Caregiving A fuller understanding of elderly wives' caregiving career also includes an exploration of associated activities and responsibilities. Bowers (1987, 1988) provided an approach to this exploration that focuses on the goals rather than the tasks of caregiving. Her typology of caregiving includes preservative or protective care (preserving the care recipient's concept of self and the caregiving relationship), preventative care (preventing physical harm), anticipatory care (anticipating and preparing for what may happen), supervisory care (coordinating and supervising the care providing by others), and instrumental care (performing direct physical care tasks). This approach fits well with the notion of the subjective career of elderly wives. Defining caregiving by the meaning or purpose a caregiver attributes to a behavior rather than by the nature or demands of the behavior itself, Bowers included any process engaged in for the purpose of caregiving. This conceptualization of caregiving activities, distinguished by purpose rather than by task, offers a comprehensive picture of the experience of spousal caregiving by highlighting its invisible nature. Wilson (1989) described a three-stage process of family caregiving for relatives of persons with Alzheimer's disease that further explicates the subjective aspects of the caregiving career. During the "taking it on" stage, caregiving was superimposed on prior responsibilities and enacted within a context of uncertainty and unpredictability. "Going through it," or Stage 2, entailed coping with an ongoing sequence of problems, which resulted in conflicting role demands that were solved on an emergent trial-and-error basis. The "turning it over" stage comprised the gradual process of giving up control over caregiving and preceded the ultimate step of entrusting care to an institution. These approaches to the analysis of caregiving are qualitative in nature and reveal the courage and determination of women who continue to provide care to husbands despite their own advancing years and their husbands' increasing frailty.
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Subjective Career: The Consequences of Spousal Caregiving An understanding of the subjective aspects of spousal caregiving would not be complete without an exploration of its consequences for personal health and well-being. In this section, I explore the daily grind and burden of care and its consequences for personal well-being, including physical and emotional well-being. Some of the reported positive outcomes or rewards associated with spousal caregiving in later life are also noted. The Daily Grind of Care
Researchers are beginning to convey the meaning of the daily grind of caregiving labor for spouses (Bowers, 1988; Zarit et al., 1986). The increasing arduousness and unrelenting nature of tasks associated with the direct provision of care, the constant monitoring and supervision of husbands, and the management of disruptive behavior (categories of caregiving identified by Mohide, 1984) constitute major sources of stresses for elderly wives. Increasingly, studies identify predictable correlates of high stress: inability to converse normally, restrictions on leisure time, poor health of the caregiver, the time and energy associated with visiting, distortions in patterns of living, and difficulties in relating to spouses (Parker, 1985; Robertson & Reisner, 1982; Zarit et al., 1986). To witness the deterioration of a husband's personality as a result of an illness is described as a living death (Mace & Rabins, 1981). The terms caregiver burden (Zarit, Reever, & Bach-Peterson, 1980) and caregiver strain (Cantor, 1983) are often used to refer to the physical, social, and emotional consequences of caregiving. Comparisons are made among the caregiving burdens experienced by wives, husbands, daughters, sons, and children-in-law. Robinson (1983) and Zarit et al. (1980) found no demonstrable differences in caregiver burden between spouses and adult children. Noelker and Townsend (1987), on the other hand, reported that spouses typically experience more burden than adult children. A Canadian study of elderly caregivers conducted by Marcus and Jaeger (1984) and an American study by Fitting et al. (1986) reported that elderly female caregivers experienced their caregiving role as more burdensome and assessed their role more negatively than did elderly male caregivers. Zarit et al. (1986), however, contradicted these findings in a longitudinal study that compared the caregiving experience of elderly husbands and wives. They found that although initially wives reported more burden, there were no significant differences after 2 years. The breadth of issues that are subsumed within the concept of burden of care make its use as a unified concept questionable. Previous research
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and clinical observations, however, suggest that caregiving may have a negative impact on physical and emotional health and on social participation—aspects of personal well-being (Duke Center for the Study of Aging & Human Development, 1978; George & Gwyther, 1986) that are conceptually and empirically distinct from caregiving and should therefore be measured separately.
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Physical Weil-Being
There is increasing evidence that the demands of spousal caregiving in later life have the potential to increase wives' vulnerability to deteriorating physical well-being. In a study of caregiver well-being, George and Gwyther (1986) reported that the spouses in their sample exhibited lower levels of physical well-being as measured by self-rated health and numbers of physician visits. Before the admission of husbands to longterm care institutions, wives typically describe the challenges resulting from the need for around-the-clock caregiving to ailing husbands. Chenoweth and Spencer (1986) referred to the decision to institutionalize as a result of being worn out by 24-hr caregiving. Fatigue, difficulties with sleep, and aches and pains associated with caregiving tasks or concomitant chronic health problems such as arthritis or congestive heart failure may be features of being worn out. Emotional Well-Being
In addition to being at risk physically, there are suggestions that spouses are at greater risk for emotional distress than other caregivers (Fengler & Goodrich, 1979; George & Gwyther, 1986; Rosenthal, Marshall, & Sulman, 1988). Rollins, Waterman, and Esmay (1985) reported a wide range of emotional responses to spousal caregiving, observing that the well spouse often feels uneasy with and ambivalent about the sense of accomplishment and new-found independence that comes with the mastery of new tasks. They also noted feelings of frustration and guilt when spouses began to enjoy the routines of daily living without ill partners. Fengler and Goodrich (1979) also reported that wives in their study experienced worry, frustration, sadness, resignation, and impatience with their husbands' health conditions. There is evidence to suggest that low morale is also a feature of the caregiving experience of elderly women. Fengler and Goodrich (1979) studied the experience of wives who were caring for disabled men. Three fourths of the wives were 50 years of age or older and had significant health problems of their own. Although wives in the sample had originally willingly accepted the caregiving role, at the time of the study 83 % cited isolation, loneliness, economic hardship, and role overload as the most frequent causes of their low morale. Fengler and Goodrich
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referred to these women as "hidden victims." George and Gwyther (1986) also reported lower levels of affect balance and life satisfaction among spousal caregivers. There is also evidence to suggest that depression is commonly experienced by wives who continue to provide care to elderly and impaired husbands. Rosenthal et al. (1988) reported that spouses were twice as likely as other types of family members to be moderately or severely depressed and were much less likely to be free of depression. Although this study focused on families of long-stay geriatric patients in acute care facilities, the findings highlight the unique experience and vulnerability of elderly spouses. Role Accumulation
• Although the majority of researchers who study the consequences of caregiving tend to focus on negative outcomes such as burden and strain, a few researchers convey some of the positive outcomes or rewards associated with spousal caregiving in later life. Spousal caregiving can perpetuate meaningful marital relationships, which are generally a source of self-esteem for couples (Motenko, 1988). Enhanced feelings of self-esteem may result from feelings of being needed and the experience of successfully meeting new challenges (Motenko, 1988). Some wives find gratification in their relationships with their impaired spouses and derive meaning from the caregiving situation. Hirschfeld (1983) referred to this phenomenon as mutuality, which was defined as the sustaining force in long-term family care. The consequences of spousal caregiving for well-being in later life lend support to the notion that the arduousness and enduring nature of spousal caregiving contribute to the vulnerability of elderly wives, and as such constitute an important feature of spousal caregiving in later life that must be addressed by social gerontologists and health care practitioners. Implications for Health Care In later life, the provision of care to elderly and impaired husbands represents a continuation of the caregiving career for numerous women. These women may be particularly vulnerable and at risk for health and social problems as a result of both their own progressing age and the demands of caregiving. Researchers have consistently documented the high level of stress associated with the role of spousal caregiver. Spouses report significantly more physician visits, poorer self-rated health, and lower levels of well-being than do other categories of caregivers (George & Gwyther, 1986). Elderly wives report higher levels of
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burden and psychological distress associated with caregiving (Zarit et al., 1986) and have higher depression scores (Pruschno & Resch, 1989) than do husbands. The significance of these findings for health care practitioners lies partially in the identification of behavioral and affective changes occurring over time that may signal the increasing vulnerability and potential for breakdown on the part of elderly wives who are coping with their husbands' deteriorating health. These findings render it imperative that health care practitioners target health promotion measures and interventions at this group of informal caregivers. CONCLUSION In this article, I have demonstrated how spousal caregiving in later life can be conceptualized as a new phase in the caregiving career of elderly women that has both objective and subjective characteristics. The objective career of spousal caregiving is predominantly an agerelated, gender-selective, and role-contingent phenomenon that has only recently been considered an area of gerontological and social sciences research. Subjective dimensions of the career include its meaning, manifestations, and consequences for well-being. Subjectively, spousal caregiving is described as a labor of love, an opportunity for reciprocity, and the expression of duty and obligation. It is defined as the meaning or purpose attributed to complex and extensive caregiving responsibilities and is associated with a multitude of potentially serious consequences for the health and well-being of caregiving spouses. REFERENCES Aronson, J. (1985). Family care of the elderly: Underlying assumptions and their consequences. Canadian Journal of Aging, 4(3), 115-125. Aronson, J. (1988). Women's experiences in giving and receiving care: Pathways to social change. Unpublished doctoral dissertation, University of Toronto, Toronto, Canada. Barusch, A. (1988). Problems and coping strategies of elderly spouse caregivers. The Gerontologist, 28(5), 677-685. Bowers, B. (1987). Intergenerational caregiving: Adult caregivers and their aging parents. Advances in Nursing Science, 9(2), 20-31. Bowers, B. (1988). Family perceptions of care in a nursing home. The Gerontologist, 28(3), 361-368. Briggs, A., & Oliver, J. (Eds.). (1985). Caring: Experiences of looking after disabled relatives. London: Routledge & Kegan Paul. Brody, E. (1981). Women in the middle and family help to older people. The Gerontologist, 21(5), 471-480.
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