Elder women between
marriage and widowhood:
An abeyance of marriage
By: Dana Pe'er
A THESIS SUBMITTED FOR THE DEGREE OF
"DOCTOR OF PHILOSOPHY"
University of Haifa
Faculty of Health and Welfare Sciences
Department of Gerontology
August, 2014
I
Elder women between
marriage and widowhood:
An abeyance of marriage
By: Dana Pe'er
Supervised by: Prof. Ariela Lowenstein
A THESIS SUBMITTED FOR THE DEGREE OF
"DOCTOR OF PHILOSOPHY"
University of Haifa
Faculty of Health and Welfare Sciences
Department of Gerontology
August, 2014
II
Dedication
This project is dedicated to the many married widows whose husbands I treated
throughout my years working as an occupational therapist in nursing homes. The
inspiration for this project came from them. I can only hope to find the path that is right for
me, as they did.
And to my grandparents; due to the follies of youth I missed out on a relationship
with them, and although they have passed away, I try to make it up to them in my work
with elders.
III
Acknowledgements
I would like to acknowledge first and foremost the lovely women who participated
in this study, and let me into their homes and their lives willingly and openly. I couldn't
have done this without you!
I would like to thank my supervisor, Prof. Ariela Lowenstein, who was willing to
undertake guiding my project, and assisted in directing and pushing it along. Her support
and faith was invaluable.
A special thank you to my peer research group, who were my sounding board for
the various ruminations and numerous drafts in the journey to completing this project:
Hayuta Yinon, Nikki Aharonian and Aya Ben-Eliezer. The hours we spent dissecting and
analyzing our drafts (and griping about the difficulties along the way) not only gave
valuable perspective and feedback, but also encouraged a candid examination of ourselves
as researchers.
Last but not least, my heartfelt gratitude to my wonderful husband and sons, who
encouraged me to start on this journey and supported it throughout, making sacrifices when
needed (sharing the desk).
This project was supported with a grant from the Brookdale Institute of Research. I
thank them for their support and confidence in this undertaking.
IV
Table of contents
1.Literature review ……. ..................................................................................................1
1.1 Introduction ..............................................................................................................1
1.2 Long term marriage ..................................................................................................2
1.3 Spousal caregiving ...................................................................................................7
1.4 Deciding on nursing home placement ..................................................................... 13
1.5 Married Widowhood .............................................................................................. 20
1.6 Phenomenology...................................................................................................... 27
1.7 Research questions ................................................................................................. 31
2. Methodology………… ................................................................................................ 32
2.1 Qualitative research ................................................................................................ 32
2.2 Procedure ............................................................................................................... 33
2.2.1 Purposeful sampling ............................................................................................ 33
2.2.2 Saturation.......................................................................................................... 35
2.2.3 Research tool ...................................................................................................... 36
2.2.4 Bracketing .......................................................................................................... 39
2.3 Characteristics of the participants ........................................................................... 40
2.4 Analysis ................................................................................................................. 43
2.5 Ethical considerations ............................................................................................. 45
2.6 Trustworthiness ...................................................................................................... 46
3.Results………………… ............................................................................................... 48
3.1 Caregiving at home ................................................................................................ 48
3.2 "There was no other option": deciding on nursing home placement………. ............ 50
3.2.1 Influenced by health care professional. .................................................................. 54
1.1.1 Influenced by family, not children……………............................................................. 56
3.2.3 Joint decision making. .......................................................................................... 57
3.2.4 Decision-making by the children ........................................................................... 59
3.3 Introduction to continuing and disengaging processes ............................................ 61
3.3.1 Continuity theory ................................................................................................ 61
3.3.2 Disengagement theory ......................................................................................... 62
3.4 Processes of continuing and disengaging ............................................................... 64
3.4.1 Continuing attachment to the husband – emotional axis ......................................... 66
3.4.2 Interpretation of husbands' behaviors as reinforcing continuing attachment ............. 68
V
3.4.3 Continuing role as main caregiver ......................................................................... 71
3.4.4 Continuing the social role of mother – social axis .................................................... 74
3.4.5 Continuing social ties outside the nuclear family. .................................................... 80
3.4.6 Continuing habits from the past – behavioral axis ................................................... 82
3.5 Process of disengaging from the husband and the past ............................................ 87
3.5.1 Disengaging due to changes associated with the husband - emotional axis ................ 87
3.5.2 From wifely feelings to maternal feelings ............................................................... 89
3.5.3 The disengaging process manifested in the character of visiting ............................... 91
3.5.4 Disengaging from family - social axis...................................................................... 93
3.5.5 Disengaging from family events and gatherings ...................................................... 97
3.5.6 Disengaging from social ties outside the family. ...................................................... 99
3.5.7 Disengaging from past habits - behavioral axis ...................................................... 103
3.5.8 Changes in homemaking and housekeeping tasks ................................................. 104
3.5.9 Changing the home environment ........................................................................ 107
3.5.10 Taking charge of financial matters ..................................................................... 108
4.Discussion……………. .............................................................................................. 112
4.1 An abeyance of marriage ...................................................................................... 115
4.2 "Married? Yes and no" ......................................................................................... 118
4.3 Continuity and disengagement theories................................................................. 124
4.4 Theoretical implications ....................................................................................... 127
4.5 Practice implications ............................................................................................ 129
4.6 Recommendations ................................................................................................ 130
4.7 Study limitations .................................................................................................. 133
4.8 Recommendations for future research ................................................................... 134
5. Bibliography…………. .............................................................................................. 137
6. Appendices…………… ............................................................................................. 157
Appendix 1 – Information about study participants .................................................... 157
Appendix 2 – Interview guide .................................................................................... 162
Appendix 3 – Participant's letter of consent ................................................................ 164
Appendix 4 - Example of data analysis process ......................................................... 165
VI
Elder women between marriage and widowhood: An abeyance of marriage
By: Dana Pe'er
Abstract
Literature review: The purpose of this study is to describe and understand the lived
experience of older women who are married widows. This term refers to elder people
whose spouse of many years has been placed in a nursing home due to functional and
mobility difficulties, while they continue to reside in the community. In light of men's
tendency to marry women who are younger than them, and due to differences in life
expectancy between women and men, the number of women who are married widows is
significantly higher. Therefore, this study focuses on the lived experience of women who
are married widows in Israel.
Traditionally, research on transitions to nursing homes has focused on the feelings
of the older person being transferred, and not on the experiences of the caregivers left at
home (Kellett, 1999). Research on family members of the elders in such a transition has
found that along with the relief they experience, they also feel ambivalence and
depression, guilt about the transfer, and more )Bond et al., 2003(. For the family caregiver
of the elder person, continuing care at home is an important factor in their image of the
"ideal caregiver". The expectation to continue caregiving at home and avoid nursing
home placement causes great stress to the caregiver, especially when more intensive care
is needed for the elder. Hence, the decision on nursing home placement is so emotionally
difficult (Gwyther, 1990). This situation is difficult for family members, but the spouse is
influenced the most.
VII
Elders in long term marriages expect to continue living together until the day they
die, and the new situation that is caused by nursing home placement is usually
accompanied by many and unexpected difficulties.
In this state of destabilization of the usual living arrangement and changes in
roles, the community-dwelling wife may feel guilt, grief, sorrow, relief, etc. After many
years of marriage, her identity as a married woman and what it means to be a married
woman are undermined and need to be re-examined. Additionally, the wife is often
socially lonely and unable to share with others her difficulties, and to receive support.
Her feeling that her marriage is no longer as it was is not necessarily recognized and
shared with others.
Previous research regarding this unique situation has referred to the perceptions
that the couple has of their marriage and accordingly has delineated several typologies
(Gladstone, 1995; Kaplan et al., 1995; Kaplan, 2001), or has described adjustment to this
situation (Rosenthal & Dawson, 1991).
In this study a phenomenological frame of reference was chosen in order to
describe and holistically understand the lived experience of the community-dwelling wife
in this new and unexpected situation: seemingly the marriage continues, but in the classic
sense, that was familiar for many years, it invariably changes.
Method: In light of the relatively few studies on this issue, this study was undertaken as a
qualitative study with a phenomenological framework. Twenty-eight interviews were
conducted with Hebrew-speaking women over 65, who lived in the community while
their husbands of over thirty years lived in nursing homes. The average age of the
participants was 76. They had all been caregivers to their husbands prior to nursing home
VIII
placement for an average time period of four years. Average time since nursing home
placement began was slightly over two years. The participants were from many countries,
and the most common birthplace was Israel (actually Palestine). The average number of
children was three (with a range of 0-10). About half the participants visited their
husband daily at the nursing home, and the others did so 2-3 times a week.
After I gathered the data, each interview was written verbatim, with changes to
identity characteristics in order to protect anonymity and privacy. Then, data analysis in
the tradition of grounded theory was carried out (Strauss & Corbin, 1998). From the data I
found central themes, which were consolidated into a data based model. In order to
increase trustworthiness, the findings were presented to a peer research group, and
feedback was given also from one participant who read the results and discussion
chapters.
Results: First, it is important to know that all the participants emphasized that the nursing
home placement of their husband was made in circumstances in which they felt there
was "no choice". They all described arduous caregiving at home, with much investment of
resources and efforts to give optimal care at home. When this was no longer feasible, the
decision of nursing home placement was made.
Deciding to place the husband in the nursing home was a decision reached in
several ways, which included family members and health care professionals. These
influenced the decision in different ways, and thereby the responsibility the wife ascribes
to herself regarding the decision. These findings, as well as the perception that the
nursing home placement was inevitable, are in line with the gerontological literature
IX
regarding nursing home placement (Abendorth et al., 2012; Buhr et al., 2006; Couture et
al., 2012; Ducharme et al., 2012; McLennon et al., 2010).
The central finding of this study is that community-dwelling wives experience
processes of continuing and disengaging from their husband and their past. These
processes exist simultaneously and are conflictual, thus creating a situation in which the
community-dwelling wife's marriage is in a state of abeyance; a state of in-between. The
processes of continuing and disengaging align on three axes: emotional, social and
behavioral. Along each axis the wife may be experiencing both continuing and
disengaging.
Processes of continuing the attachment to the husband are expressed in the
emotional axis, in that the wife continues to feel attached to her husband. This, despite
there may having been essential changes in his behavior and appearance. The women
tend to attribute the husband's behaviors to their personal relations and specific
intentions of the husband to them, unlike what others around them attribute to the same
behaviors. These attributions strengthen their attachment to him, and their feeling that
they continue to be the main caregiver, despite no longer giving hands-on care. The
caregiver role is now manifested in the role of care monitor, but is no less important.
In the social axis, processes of continuing refer to relations with nuclear and
extended family and friends. The wife usually continues her mothering role towards her
children. Sometimes this entails a personal price of not sharing her difficulties with them,
and pretending to cope beyond her true ability. Continuing social ties with people outside
the family is usually characterized by supportive friends. Women, who were loners
throughout their life, continue this social pattern.
X
In the behavioral axis, wives continue to maintain habits and behavior patterns
from the past despite the changes that have occurred. Thus, it was found that the issue of
what physical space the husband currently occupies in their life is rife with uncertainty.
Many continue to upkeep his lived space in the home, despite his no longer using it and
there is no chance that he will return. Participants that live with their adult children
continue to perform housekeeping tasks as before, and this living arrangement serves as
a protective factor of their roles and functionality.
As mentioned before, the process of continuing exists alongside the process of
disengaging. This process also aligns on three axes. The disengaging process along the
emotional axis is manifested in changes in the feelings the wife has for her husband, often
due to his dementing illness, but not just. There is a tendency of feelings to change from
romantic love feelings to maternal love feelings towards the husband. A close look at the
character of the daily visits at the nursing home, which are perceived as an expression of
deep devotion, reveals another aspect of the disengaging process.
The disengaging process in the social axis is from the family, close and far, and
from friends. Often the nursing home placement objectively limits the opportunities the
community-dwelling wife has for socializing. Sometimes the disengaging happens due to
her feeling that social relations from the past are unsupportive and lack empathy for her
current situation. Family gatherings and holidays are points in time when the wife
particularly feels the change in her life situation, and often the disengaging process is
then more emphasized. Regarding friends, women in this study described a clear process
of disengaging from friendships, sometimes of many years, that were unsupportive of
their current life choices.
XI
Additional to these axes, a behavioral disengaging process was also found. The
nursing home placement usually affects the community-dwelling wife's habits: sleep, food
intake, home keeping and activities. The lived space may undergo changes that express
this process. An unexpected and significant change occurred regarding finances. The
nursing home placement forced the women to cope with financial matters, which were
usually taken care of by their husband in the past. Current money managing was an
expression of disengaging from the husband and from traditional roles in their
couplehood. This change was sometimes accompanied with greater freedom in
expenditures, and sometimes required reducing expenses and more accounting for them,
also a change from the past.
Discussion: This study examined the experience of community-dwelling wives of older
men in nursing homes, and suggests that this experience is embedded with the existence
of two simultaneous and contradictory processes of continuing and disengaging from
their husband and their past. The model in this study shows that women in this life
situation are pulled towards two opposite extremes: continuation and disengagement,
and thus find themselves stuck and unable to forge ahead.
The situation of both these processes co-occurring brings the community-dwelling
wife to a dilemma regarding her marital identity and personal status. Some of the
participants utilized a method of elimination to examine their personal status. However,
this method allowed for concluding opposing conclusions. Some participants concluded
they were still married, whereas others concluded they did not meet criteria for any
acceptable marital status; as one of them said- "living in limbo".
XII
After many years of marriage, and tying their self identity with their being
married, the nursing home placement of their husband affects their whole lived
experience. A consideration of other situations of couples living apart, mostly among
younger aged couples, shows that there is great importance to sharing living space in
order to maintain and keep feelings of sharing and couplehood in marriage.
Theoretical implications: Thus far, continuity and disengagement theories have been
considered to be encompassing theories in the field of gerontology. In light of the results
of this study, it is suggested to re-conceptualize thinking about disengagement as a
unified global process in the life of the elderly. As has been proposed by others (Carp,
1968, Hochschild, 1975), the disengaging process does not happen equally across all life
domains and in all of the elder's social relations. Re-conceptualization of disengagement
theory also allows for including disengagement not only from social relations, but also
from in or from other aspects of life, for example disengaging from objects or past habits.
Similar to other studies (Stadnyk, 2006; Utz et al., 2002), in this study continuity was
found to have an important place in the older women's life. In their experience there is no
contradiction between the process of continuation and the process of disengagement,
and they both exist independently in each life domain.
Practice implications: One of the recommendations of this study is that health care
professionals should familiarize themselves with the term "ambiguous loss" (Boss, 1999).
This refers to situations in which a person is present in the physical sense, while being
absent in the psychological sense. This description is appropriate also for the situation of
abeyance of marriage, in which the marriage is no longer experienced as it was in the
past. People experiencing ambiguous loss are in need of much support, and broadening
XIII
health care professionals' knowledge about this issue will enable them to be more
empathic of women in this life situation. It may assist in developing a more tolerant
attitude among nursing home staff toward these women, unlike today's common attitude
of them being a nuisance to staff. This in turn may find a way to include the women in
the care of their husbands. Further, it is suggested to re-conceptualize the role of the wife
in this situation as a "care partner", a role similar to the role she fulfilled before her
husband needed hands-on direct care, thereby redefining her place in the nursing home
and in her husband's life.
Limitations: This study is not devoid of limitations. First, the study was conducted in the
tradition of qualitative research and therefore the sample is small, and one cannot
generalize onto others who are in this life situation. Also, this study was conducted with
women who continue to be involved in their husband's lives in the nursing home. It is
known that there are women who do not continue the relation with their husband upon
nursing home placement, and some of the participants intimated they knew such women.
However, all efforts to find such women and attain their consent to participate in the
study were unsuccessful. Other than the size of the sample, this study focused on
community-dwelling wives, and purposefully did not include men in such a life situation,
for reasons mentioned earlier. It is reasonable to assume that the inclusion of men in the
study sample would have raised issues pertaining to gender, and were averted in this
study.
Additionally, during the course of the research I continued to update myself in the
relevant literature. In an advanced phase of data analysis, several studies were found that
suggested that the functional state of the spouse in the nursing home may influence
XIV
adaptation of the community-dwelling spouse to this life situation (Gillies, 2011; Mullin,
Simpson & Froggart, 2013; O'Shaughnessy, Lee & Lintern, 2010). Re-examination of the
data regarding this issue showed that there seemed to be no such influence in this study,
but perhaps a more specific treatment of this issue in the data gathering phase would
have yielded other data, and should be addressed in future research.
Recommendations for future research: in addition to addressing said issue, future
research should also address the issue of gender and its influence on "married
widowhood". In this study, I chose to limit the data to experience of women alone for
several reasons mentioned earlier. However, as life expectancy is extended for both
genders, the number of men in this life situation is likely to grow as well. It is feasible to
assume that the experience of men and women in this situation will have similarities and
differences due to gender based factors, and studying these will present a better
understanding of "married widowhood" and its implications. Another avenue of research
recommended in the future pertains to the temporal aspect of this experience. The
women in this study had been "married widows" from a time period ranging from 1
month to 13 years. Although their overall experience did not seem to be influenced by
the temporal aspect, perhaps a study that samples the participants at several temporal
intervals will lend new insight to the experience of "married widowhood".
XV
List of Tables
Table
page no.
Table 1: Characteristics of participants…………………………………………………………...........41
XVI
List of diagrams
Diagram
page no.
Model of abeyance of marriage……………………………………………………………………………..113
XVII
1. Literature review
"For better, for worse,
For richer, for poorer,
In sickness and in health,
…'till death do us part."
(Traditional Christian wedding vows)
1.1 Introduction
The end of couplehood and marriage is generally expected to come about by
widowhood or divorce. Widowhood by definition means the death of one spouse in the
couple. Divorce is a termination of marriage found to be more and more acceptable and
common these days. Both these life altering events are acknowledged and recognized by
the couple and society as signaling the beginning of a new stage in life. But what happens
when the change in couplehood is not a termination of the marriage, but rather one
spouse stays in the conjugal home and the other is placed in a nursing home? When the
experience of sharing everyday life is ruptured at its very core, but the entity of the
marriage seemingly continues?
This study focuses on the lived experience of married widows in Israel. "Married
Widowhood" is a term coined in 1985 by Rollins, Waterman & Esmay. It refers to a
situation in which an elder ill spouse is placed in a nursing home, while the healthy
spouse continues to reside in the community. For many spouses in long term marriages,
placing a partner in long term care is an involuntary marital separation and a major
transition in old age (Tilse, 2000).
Mostly, older people tend to assume that they will die at home taken care by their
spouse or children. Older men and women refer to giving care to the spouse as a part of
the marriage bargain, intertwined with love, duty and commitment (Calasanti, 2006).
1
Spouses are the preferred caregivers in old age and they make up the majority of
caregivers for people who are married.
Due to different life expectancies, women are more likely than men to be the
spousal caregiver (Calasanti, 2006). Accordingly, sick husbands primarily receive care from
their wives, whereas sick wives are more likely to receive assistance from adult children
(LoboPrabhu, Molinari, Arlinghaus, Barr & Lomax, 2005). Added to this, is the propensity
of men to marry women of a younger chronological age and to suffer from more ill health
as they age. Thus, the state of married widowhood is more common among women, and
therefore in this study I focused on the experience of women in this life situation.
This study is unique in conceptualizing the paradoxical pull married widows
experience between a process of continuation, in line with continuity theory, and a
process of disengagement, in line with disengagement theory. It is suggested that the
simultaneous process of continuing and disengaging from the husband and the past is an
inevitable experience of the community-dwelling spouse due to the placement of their
spouse in a nursing home. These contradictory processes bring about a protracted state
of bafflement regarding the community-dwelling spouse's basic tenets and expectations
of conjugal life in old age. In turn, the disruption of these expectations and assumptions
lead to a state of abeyance in marriage.
1.2 Long term marriage
Traditionally, marriages are entered into with the premise that they will last a
lifetime (Cohen, 2004; Leckey, 2002). A marriage is a close emotional and financial union
in which both spouses commit to being each other’s life partner. As they live together,
spouses become deeply intertwined in mutual dependence and care (Leckey, 2002).
2
Traditional Christian marriage vows, which explicate the expectations and
circumstances that one might experience throughout the marriage, express the couple's
emotional commitment and their understanding of the seriousness of their commitment.
These vows describe marital life in idealized and general terms, and commit the couple to
a goal of maintaining a caring, cooperative relationship (Scott & Scott, 1998). In Judaism,
the terms of the marriage are also delineated during the wedding ceremony, and are
presented as contract between the bride and the groom. This contractual relationship is
founded as a beginning of a shared project, which includes the maintenance of a
household, often the raising of children and companionship. Both spouses have an
interest in continuing the relationship (Leckey, 2002).
In the act of marrying, spouses exchange promises to supply each other with
various services throughout their lifetime as a couple. As Atchley (1992) noted, most
marriages serve three functions: affection, interdependence and belonging. Prevalence of
these three components throughout marital life improves the quality of the marriage.
Marital status, as well as marital quality, has been found to be linked to the
physical and emotional health of elders (Wiengarten, 2013). The benefits of being
married have been found regarding chronic disease, impairments, disabilities and
functional problems. Couples in long term marriages generally have lower levels of
disease prevalence and disability compared to couples in short term marriages (Pienta,
Hayward & Jenkins, 2000; Henry, Miller & Giarusso, 2005; Walker & Luszcz, 2009).
Long term marriage in old age has unique characteristics. Couples in long term
marriages have experienced a prolonged period of intimacy, assuming the marriage was a
good one. One of the most pleasant aspects in a long term marriage is that the older
3
person has someone who remembers and reminds them of who they were in the past
(Viorst, 2005). Lopata (1995) also notes that one of the most significant roles of the
spouse in long term marriage is to help maintain the feeling of internal and external
continuity, especially in times of illness, proximity to death or transition to a new living
arrangement, such as a nursing home.
Couples in long term marriages tend to have similar values and goals in life, agree
on division of household labor, relationships with other family members and think that
they are right for each other (Quadagno, 1999). They tend to confide in each other, kiss
their spouse and laugh together daily. Also, most of them love their spouse as a human
being, and a high percentage consider the spouse their best friend (Lauer, Lauer & Kerr,
1995). Supporting this claim, Henry et al. (2005) found that older couples experience less
marital problems than young couples, and do not wish for their spouse to change. They
also found that disagreements about household concerns and health issues differentiate
between happy and unhappy long term married couples. A central issue of discontent
was found to be regarding how to spend leisure time. But, on the whole, long term
married couples experience less conflict and negativity, and more pleasure, affection and
intimacy compared to marriages of shorter duration (Cooney & Dunne, 2001).
Married older couples cope with changing life circumstances that are
characteristic of this phase in their life. Spouses are expected to support each other
through role changes after retirement, cope with declining health of either spouse, and
withstand an ever shrinking social circle (Schmitt et. al., 2007).
Another characteristic of old age is that the stresses of raising children and
working are behind the couple, and they can devote their time to activities of their
4
choosing. Research on long term marriage has found that in the early years of marriage,
high marital satisfaction is reported. Following that is a period of lower satisfaction with
marital quality, usually while engaged in raising young children. In later years, after the
children have left the home, an increase in marital satisfaction is usually reported (AdeRidder, 1984; Cooney & Dunne, 2001; Copeland, Bugaighis & Schumm, 1984; Schmitt et.
al., 2007; Sporakowski & Axelson, 1984). Unfortunately, in old age people are also
vulnerable to losses of relatives and friends and the chances of stress due to health issues
is greater (Cohen, Geron & Farchi, 2010; Schmitt Kliegel & Shapiro, 2007).
Several studies have found commitment to the spouse to be significant to marital
satisfaction and good marriage quality (Swensen et. al., 1984; Clements & Swensen, 2000;
Sharlin et. al., 2000). High commitment is usually accompanied by fewer problems in the
marriage. Commitment serves as a foundation for effective problem-solving, so that it
induces a sense of security and encourages solving problems together. Commitment is
significant as a motive in continuing the marriage in times of crisis, as found by Sharlin,
Kaslow & Hammerschmidt (2000).
Sharlin et al. (2000) conducted an extensive inter-cultural study on long term
marriages. They were interested in the significant components of marriage, that allow for
couples to be satisfied in marriage over many years (over 25 years). The study was
conducted in eight countries around the world, among them Israel, Chile, South Africa
and others. The participants in Israel were married 25 to 40 years, aged 40+ to 74. The
results showed that the most significant components for satisfaction in long term
marriages are trust, loyalty and love. The study also addressed the motives for staying in
the marriage for many years. Amongst the Israeli participants, it was found that in the
5
past the main reason for staying was the perception of the marriage as life-long and for
the children's sake. This study strengthened results from previous studies regarding
factors that constitute a long term marriage. Similar results were found among
participants in this study from other countries.
A more recent study in Israel by Cohen et al. (2010) of Jewish elderly couples in
long term marriages (over 40 years) found three typologies of marriages: vitalized,
satisfactory and conflictual.
Vitalized marriages were characterized by high marital
quality regarding intimate and functional aspects of the marriage. Satisfactory marriages
were characterized by high marital quality in functional aspects and lower marital quality
regarding intimate aspects. Conflictual marriages were characterized by poor marital
quality in all aspects. Additionally, the study found that the components with the most
bearing on marital quality were conflict resolution, communication and liking/accepting
each other's personalities.
In an earlier literature review on the subject of long term marriage, Sporakowski &
Axelson (1984) had found that high marriage quality in long term marriage was related to
various factors: the couple's health, morale, agreement on needs and problems,
commitment, similar values and love. In general, it appears that long term marriages are
influenced by their being continuous and abundant with experiences of tolerance,
pleasure, satisfaction and perseverance between the spouses for many years (Noller et
al., 2001).
A central spousal service is the basic and inherent assumption and expectation of
care in time of need and/or dire circumstances. Each spouse expects that whatever
changes are brought by time and circumstances, whether for good or not, the other
6
spouse will continue to perform their duties in the proper spirit, for the remainder of
their conjugal life (Cohen, 2004; Leckey, 2002). In old age, the nature of the relationship is
often affected by the physical and mental health status of each spouse, and in their
shared household they expect to rely on each other for functional assistance.
1.3 Spousal caregiving
The population in Israel is getting older. At the end of 2012, adults aged 65 and
over comprised 10.4% of the population in Israel. It is predicted that by 2035, this
percentage will reach 14.6% of the entire population (Central Bureau of Statistics - Israel,
2013).
An older person aged 65 and over in need of caregiving by a family member is a
common situation these days (Cherlin, 2010). Statistical data shows that 24% of
community residing elders in Israel are in need of assistance in performing at least one
activity of daily living relating to self care, such as: bathing, dressing, eating or transferring
inside the home (Mashav, 2011). In the U.S.A., similar data was presented already in 1999
(Hillier & Barrow(. In most cases, family members are most likely to be giving care to the
dependent elder (Feld, Dunkle & Schroepfer, 2005; Hillier & Barrow, 1999; Jansson,
Nordberg & Grafstrom, 2001). A more recent report shows that in OECD countries, one in
nine people over the age of fifty reported providing assistance with activities of daily
living to a relative (Special Committee on Aging, 2011). Of these caregivers, most often
the spouse giving the care is the wife (Pinquart & Sorensen, 2011). In Canada, over a
decade and a half ago, already thirty six percent of family caregivers were wives
(Grunfeld, Glosson, Mcdowell & Danbrook, 1997). More recent data from the U.S.A.
shows that 40% of familial caregivers are the spouse of the older person (Keigher, 2008).
7
This is true also for Israel, where most of the care for the older person is done by the
spouse (Kulik, 2001). It is noteworthy that of all the caregivers in Israel, 16% are over the
age of 65, although the percentage caring for spouses or others is unknown (Brodsky et
al., 2010).
Married spouses normally engage in reciprocal behaviors of assistance in the
context of their daily lives (Carpenter & Mak, 2007; Feld et al., 2005). A common view is
that older spouse caregivers are influenced by long-standing behaviors and patterns of
exchange that have developed into relationship continuities. In this context, caring for
and about a partner may be assumed as a normative expectation in marriage and the
development of caring behaviors to respond to the onset of illness is seen as fundamental
to the marriage contract (Ray, 2006).
Due to this state of expected assistance in the sharing of a household, continuous
spousal assistance is perceived as informal care. Formal care is perceived as a service
supplied externally (someone other than family and friends), usually with monetary
compensation. Informal care includes tasks such as basic activities of daily living,
housekeeping, transportation and emotional support to a family member or friend
(Browder, 2002; Price, 2005). Unlike adult children who start to provide informal care to
ageing parents due to an obvious functional deterioration, a spouse will usually undertake
the additional tasks of informal care gradually. More and more of the housekeeping tasks
will be transferred to the healthier spouse. Gradually, instrumental caregiving to the
disabled spouse will happen as an expansion of the support and assistance that are an
inherent part of a shared household (Badr, Acitelli & Taylor, 2007; Seltzer & Wailing Li,
2000).
8
Continuous informal caregiving to the elderly at home has been long known as
having negative consequences for the caregiver, whether it is a spouse, a daughter or any
other family member. These consequences include objective outcomes: decreased leisure
activity, deteriorated physical health, financial strains, and changes in social roles, and
subjective consequences: anger, frustration and resentment, intra-psychic stress, anxiety
and depression (Carpenter & Mak, 2007; Frank, 2008; Keigher, 2008; Lavela & Nazneen,
2010). Older spousal caregivers are unique in the sense that as caregivers they have to
cope with hardships involved both in the care of a spouse and in the treatment of an
elderly person, while they themselves may be suffering from health, social, and financial
problems typical to old age (Lavela & Nazneen, 2010; Navon & Weinblatt, 1996).
Caregiver burden is a term commonly used to delineate emotional, physical, social
and financial problems that family members experience while giving care to the elder
person (Frank, 2008). Studies show that caregivers suffer from a variety of effects due to
their caregiving role (Aneshensel, Pearlin, Mullan, Zarit & Whitlach, 1995; D'Amelio,
Terruso, Palmeri, Di Benedetto, Famoso, Cottone, Aridon, Ragonese & Savettieri, 2009 ;
Sawatsky & Fowler-Kerry, 2003). Musil et al. (2003) conducted a unique study that
showed evidence of emotional and physical changes in caregivers for elders over an
extended period of time. They followed caregivers for elders (spouses comprised 37% of
the sample and the other participants were children or siblings) during two years, using
standard health tests that were administered by a nurse in a health clinic. These tests
were used in conjunction with self estimates of health by the caregivers. The researchers
found deterioration in musculoskeletal and cardiovascular systems. They claim that
though these cannot be attributed only to the fact that these participants were
9
caregivers, there are grounds to surmise that the demands of the caregiver role
contributed to these health changes.
Continuing this, Lavela & Nazneen (2010) conducted a literature review regarding
the psychological health of older caregiving spouses. In their review, they found the
literature indicates that spousal caregivers experience worse cognitive functioning and
poorer mental health compared to non-caregivers. Also, spousal caregivers suffered from
more frequent and significant health problems, resulting in more negative and rapid
health declines. Of particular interest is the finding that wife caregivers report more
depression, anxiety, stress and loneliness than husband caregivers, particularly in cases of
caregiving for a demented husband.
Another aspect affected by prolonged illness and caregiving entailed by a spouse
is the intimate and sexual relationship between them. There is a tendency to ignore this
aspect in the lives of elders, that is expressed also in the small amount of research
regarding sex and sexual intimacy among people aged over sixty (Hinchcliff & Gott, 2004).
Svetlik, Dooley, Weiner, Williamson & Walters (2005) examined in their study a specific
aspect of the influence of a prolonged illness on the intimate relations among couples in
long term marriages. They focused on the relation between a decrease in opportunities to
express love through physical contact and sexual relations due to a prolonged caregiving
situation and between the perceptions of the caregiving spouse regarding the marriage in
general. The study showed that as opportunities for physical love expressions decrease,
so increases the feeling of loss of satisfaction in the marriage.
In exploring the motives for continuous spousal caregiving at home, Navon and
Weinblatt (1996) suggest a unique concept, emphasizing the etic aspects of caregiver
motivation. Their dramaturgical analysis of spousal caregiver motivation led them to the
11
conclusion that prolonged caregiving at home mainly satisfies the caregiver's needs.
Caregiving, though all-encompassing and exhausting, actually provides a coping
mechanism for the spouses in handling fear of the inevitable future for their loved one
and themselves.
As the effects of caregiver burden are gaining recognition as a central issue in the
lives of caregivers, there is also a growing understanding that caregiving is not a wholly
negative experience. Caregiving situations bring coping and enlisting of family and
personal resources and strengths (Brubaker, 1987). In recent years, attention has turned
to the positive aspects of informal caregiving to elders (Raschick & Ingersoll-Dayton,
2004). Keigher (2008) found that many caregivers attest to the positive aspects of
caregiving such as a sense of pride, competence and satisfaction from being able to care
for their relative. Caregiving is perceived as a manifestation of love and affection for the
elder. Many caregivers relate a feeling of returning gratitude for what they have received
in the past. Other benefits include: self growth of the caregiver, positive self esteem,
finding a purpose in life, closer relations with other family members, a deeper
understanding of the difficulties facing handicapped persons, improvement in the
relations with the care receiver, moments of shared intimacy and satisfaction from
knowing that the care given was good (Carpenter & Mak, 2007; Keigher, 2008; Olson,
2003; Raschick & Ingersoll-Dayton, 2004).
One of the many factors affecting the perception of the caregiving situation as
rewarding is the past relationship between the caregiver and the care receiver. In the
case of elders in long term marriages, their past and pre-caregiving relationship is
relevant to the caregiving context. This relationship, which influences coping with illness
11
and dependency, is a continuation of the relationship built throughout years of
couplehood. As a life-long relationship, long term marriage is characterized by long
established roles and responsibilities, and patterns of exchange and reciprocity (Ray,
2006). In this sense, understanding the history of the couple is relevant to understanding
coping with the caregiving situation in old age. Lopez, Lopez-Arrieta & Crespo (2005)
examined various factors tied to caregivers and the caregiving situation, and found that
caregiver burden is lower when the care receiver is a loved one. They suggest that the
positive context from the past enables perceiving the caregiving as an act of gratitude for
what they received in the past, and a feeling of reciprocity with the care receiver.
Continuing this, Raschick & Ingersoll-Dayton (2004) found that a feeling of companionship
with the care receiver is the most significant factor in perceiving caregiving as rewarding.
This issue is particularly relevant for caregivers that are spouses. Ray (2006), in studying
caregiving older couples; found that the nature of stress in caregiving is tied to the nature
of the relationship in which the caregiving takes place.
Functional difficulties that accompany chronic illness interrupt the daily conduct of
the couple by changing their needs. Functional disability of spouse is not limited only to
that person, but rather influences and changes the power relations and the organization
in the life of both spouses (Grand, Grand-Filaire & Pous, 1995). For example, disruption of
coping strategies that had been developed in the past is commonly associated with stress
in the spousal caregiving situation, affecting also how the couple experiences and
perceives themselves as a couple (Ray, 2006). They need to renegotiate the division of
roles and tasks between them (Grand, Grand-Filaire & Pous, 1995).
A change in the functional state of one spouse causes a change in both their lives.
Nursing home placement is a significant life event for the caregiver and the care receiver
12
(Buhr et al., 2006). Most elders transfer to a nursing home after a period of caregiving by
formal and informal caregivers in the home. As mentioned previously, the burden of care
for the elder struggling with activities of daily living falls to close family relations: the
spouse or the children. In Israel there are many community services to assist the elder at
home, yet most of the hands-on care is provided by close family relations. The various
consequences of caregiving have been reviewed in this chapter, and the question that
arises is – what causes caregivers to decide on nursing home placement?
1.4 Deciding on nursing home placement
Several studies (Lowenstein, 1998; McLennon, Habermann & Davis, 2010; Ryan &
Scullion, 2000) have found that the decision of nursing home placement is often made
due to an acute illness or sudden deterioration in the condition of the elder, so as to
warrant more intensive care than previously required. McLennon, Habermann & Davis
(2010) found that most of the caregivers discussed a possible future need for alternative
care solutions for their relative three to four months (on average) prior to actual nursing
home placement. In their study, nursing home placements followed several healthrelated occurrences of the caregiver or the care recipient.
Unlike them, Caron et al. (2006) describe different experiences. They found that
caregivers underwent a process of continued deliberation regarding nursing home
placement. This process was prolonged across two years among their participants. Lundh
et al. (2000) also found a prolonged process of understanding that intensified among
caregivers, when they realized that they would not be able to continue with caregiving.
However, most nursing home placements take place adjacent to an acute illness. The
researchers state that oftentimes the idea of nursing home placement is not discussed
among informal caregivers until it becomes an urgent matter. The main reason attributed
13
to lack of discussion about this issue was due to negative attitudes among caregivers
toward nursing homes.
Different cultural attitudes to caring for elders and nursing homes may indeed be
relevant (Brown & Abdelhafiz, 2011). A study among Hong Kong home residing elders
found that negative attitudes toward nursing homes are common. (Y Tse, 2007). These
elders perceive the nursing home as a place that limits their sense of freedom and
privacy. Some participants refer to aspects of loneliness, dissatisfaction with nursing
home services and feeling of abandonment by the family. Alongside these attitudes, there
are positives perceptions of the nursing home as a solution that keeps the elderly from
becoming a burden to their families. Other positive attitudes relate to the care given at
the nursing home by the interdisciplinary team, the variety of activities and living with
peers. It is interesting to note, that positive attitudes were found among elders that visit
nursing homes.
In Oriental Far East societies, spouses are expected to care for their partner until
their death, and failure to do so is stigmatized as a breach of spousal fidelity. Similarly,
children are traditionally duty-bound to care for their aging parents, and nursing home
placement is perceived as a failure of filial duty (Tew, Tan, Luo, Ng & Yap, 2010).
Supporting this traditional view, a study by Kao & Stuifbergen (1999) found that in
Chinese/Taiwanese culture nursing home placement is considered a violation of
traditional filial expectations. However, a more recent study by Tamiya, Chen & Sugisawa
(2009), found that in Japan there has been a steady rise in institutionalization since the
year 2000. In examining reasons for placing an elder in a nursing home, they found that
caregivers barely express concern with the social stigma following placement. The
14
researchers view this change in attitudes as an indication of a shift occurring in Japanese
attitudes regarding the role of familial caregiving, allowing for nursing home placement to
be considered as an acceptable option.
Similar to Oriental cultures, the Jewish Israeli population is also characterized as a
culture with traditional family roles and expectations (Cohen et al., 2010; Lavee & Katz,
2003; Lavee & Katz, 2005; Levitzki, 2009). A study, conducted in Israel by Letzter-Pouw &
Werner (2003), examined the attitudes and perceptions regarding nursing homes and
their influence on the willingness to move to a nursing home. These researchers
compared willingness to transfer to a nursing home between older Holocaust survivors
and elders who were not Holocaust survivors. To their surprise, the data showed that
among both groups positive attitudes toward nursing homes were the most important
factor influencing their willingness to transfer to one. Contrary to their hypothesis, there
was no difference between these groups regarding willingness to transfer. In the study's
section of open questions, the participants stated that the nursing home gives care to
elders in need, and is a viable future option for them, even if they are not enthusiastic
about it.
Oftentimes, caregivers to elders relate that the decision of nursing home
placement was an extremely difficult decision, accompanied with feelings of guilt, shame
and a sense of failure (Abendorth, Lutz & Young, 2012; Caron, Ducharme & Griffith, 2006;
Dellasga & Mastrian, 1995; Lundh, Sandberg & Nolan, 2000). Kellett (1999) claimed that
nursing home placement is not a rejection of the elder by the family, but rather a last
resort after the failure of many efforts to continue care at home. Abendorth et al. (2012)
support this in their finding that strong emotions, such as those mentioned above,
15
impede the decision making process and delay placement, even when the caregiver's own
well-being was being jeopardized.
More often than not, nursing home placement is perceived as a failure by the
family (for not being able to uphold their commitment) and by the elder (that they can no
longer function as before and are dependent upon others) (Aneshensal et al., 1995). Ryan
& Scullion (2000) state that caregivers tend to think that it is their familial duty to
continue caregiving until the elder's passing away, and feel the need to live up to the
concept of the "ideal caregiver". There are expectations, by family and caregiver, and
much pressure to do all that is possible to live up to this ideal, often despite much
hardship and at a high personal price (Abendorth et al., 2012; Tew, Tan, Luo, Ng & Yap,
2010). When caregivers realize that they are no longer able to provide proper care, they
experience it as a personal failure (Dellasaga & Mastrian, 1995; Dellasaga & Nolan, 1997).
The research literature proposes a variety of factors that influence deciding on
nursing home placement. It is commonly accepted to divide these factors into factors
associated with the older person and factors associated with the caregiver:
a) Factors associated with the older person:
Studies have shown that nursing home placement is associated with a variety of
factors that characterize older persons suffering from a range of illnesses or disabilities.
These include: escalating behavioral problems, need for constant supervision, sleep
disturbances, wandering and getting lost, high dependency in Activities of Daily Living
(especially toileting), communication difficulties, aggression, deteriorating health and
personality changes (Caron et al, 2006; Kesselring, Krulik, Bichsel, Minder, Beck & Stuck,
2001; Lowenstein, 1998; Ryan & Scullion, 2000). Also, Spoelstra, Given, You & Given
16
(2012) found that any elder who has had a fall is at a higher risk for nursing home
placement.
In a recent meta-analysis of the literature, Brown & Abdelhafiz (2011) found the
factors that are most influential toward nursing home placement are physical and
cognitive disabilities due to chronic illnesses. Similarly, Luppa, Luck, Weyerer, Konig,
Brahler & Riedel-Heller (2009) rated the various factors influencing nursing home
placement based on the strength of evidence found in research literature. They found
strong evidence that nursing home placement is basically caused by cognitive and/or
physical impairment. The strongest predictor of nursing home placement was a diagnosis
of dementia.
b) Factors associated with the caregiver:
The main reason for nursing home placement is the need for a higher degree of
care, and even more so, the feeling of the caregiver that they can no longer meet the care
demands (Buhr, Kuchibhatla & Clipp, 2006; Caron et al, 2000; Lowenstein, 1998;
Kesselring et al., 2001; Ryan & Scullion, 2000). Kesselring et al. (2001) found the inability
of the caregiver to meet care demands to be the most contributing cause for nursing
home placement. The illness of another family member or of the caregivers themselves
may figure in as a background factor in caregiver burden )Aneshensel et al., 1995; Buhr et
al., 2006; Ryan & Scullion, 2000). Approximately sixty percent of caregivers experience an
acute health crisis in the eighteen months following the beginning of caregiving (Sawatsky
& Fowler-Kerry, 2003).
More recently, Spillman & Long (2009) conducted a longitudinal study about the
effects of caregiver stress on nursing home placement. They found that physical strain
17
from caregiving is an important predictor of high levels of stress, and this in turn increases
the likelihood of nursing home placement for the care receiver. In their analysis,
frequently disturbed sleep and care-recipient behavior problems were also found to be
important predictors of high levels of stress and its subsequent higher likelihood of
nursing home placement.
Unlike studies that indicate external decision factors, as mentioned above, Caron
et al. (2006) claim that the subjective perception of the caregiver regarding their ability to
continue giving care is the most important factor in the decision regarding nursing home
placement or continuing care at home.
Another decision factor is the perception of the quality of the past relationship
between caregiver and care receiver. Kesselring et al. (2001) and Caron et al. (2006)
found that low intimacy between the caregiver and the older person, usually due to
cognitive and personality changes associated with dementing illnesses is related to lower
willingness to continue caregiving at home. This was also examined by Pot, Deeg &
Knipscheer (2001) in a study regarding the influence of caregiver characteristics on
nursing home placement. Similar to studies mentioned above, they found that the
character of the relations between the caregiver and the care receiver are a significant
influence on the willingness to continue care at home. In addition, this study
strengthened earlier findings, that spouses have a lower tendency to be placed in nursing
homes compared to other family members (Seltzer &Wailing Li, 2000). The shared history
of many years brings about a significant sense of duty among spouse caregivers
(Kesselring et al., 2001).
18
However, some researchers contend that the character of the relations at present
time is more meaningful in the nursing home placement decision. For example,
Hirschfield (2003) found that the most meaningful factor in deciding on nursing home
placement was reciprocity in present relations. In other words, the ability of the caregiver
to find satisfaction in the relationship with the care receiver and meaning in the
caregiving situation. The reciprocity factor was found more significant than demographic,
functional or health factors. A study by Spruytte, Audenhove & Lammertyn (2006) among
caregivers to dementia patients, also found present time relations to be the most
meaningful factor in nursing home placement. In both these studies spouse participants
were well represented (two thirds and forty percent of participants, respectively, were
spouses).
c) Factors associated with context:
Caron et al. (2006) developed a model, which added to the factors associated with
caregivers and care receivers, factors associated with context. These factors influence the
decision making process of the caregiver. They include formal and informal services
available to the caregiver, the physical environment and the existence of an acute crisis
that significantly increases care demands (such as a demented elder getting lost and
needing constant supervision). When community services and social support of the care
giver are inconsistent with needs, the chances of nursing home placement increase.
These researchers claim that incompatibility of these context factors and the caregivers
needs, will eventually lead to nursing home placement.
One of the difficult aspects in caregiving for the elderly is the inherent change in
the marital relationship. Oftentimes, due to the sequela of illness and the changes in the
19
person, the caregiving spouse is left alone in the marriage, and feels alone before they are
widowed in the commonly perceived way (Martin, Baldwin & Bean, 2007).
1.5 Married Widowhood
In every marriage lasting to advanced stages of the life cycle, one spouse ages
before another (Kaplan, 1996). Traditionally, men tend to marry women who are younger
in chronological age. Men also have a shorter life expectancy and are more prone to
illness in old age. These two factors combine to create a common situation in later life, in
which women usually take care of their husbands (Bartlett, 1994; Fengler & Goodrich,
1979). Oftentimes, the long term care needed is beyond the wife's capability. Transferring
the husband to a nursing home, due to the need for intensive caregiving is a crisis in the
marriage, and often the other spouse remains home alone. "Married Widowhood" is a
term first used by Rollins,Waterman & Esmay (1985) to describe the state in which one
spouse lives in a nursing home, while the other spouse continues to reside in the
community. This life situation may happen to both genders. However, due to the two
factors mentioned above regarding marriage patterns and life expectancy, it is more
common to find women in this life situation, and therefore this study will focus on
women as married widows.
Married widowhood, which disrupts the life the couple has had together
throughout many years and the expectation to continue doing so, is characterized by
many difficulties, mostly unexpected ones. Rosenthal & Dawson (1991) posited this life
state on the continuum of family life; positioned between marriage and widowhood. In
their opinion the transition to "quasi-widowhood" is much like widowhood, but has
unique characteristics. For example, research on widowhood shows that feelings of grief,
guilt and anger are common in the early stages. Similarly, women whose spouse has been
21
placed in a nursing home experience a myriad of negative feelings, as well as ambivalence
regarding the transfer.
Relatively few studies have focused on the impacts of nursing home placement on
the spousal relationship (Bond, Clark & Davies, 2003; Sidell, 2000; Walker & Luszcz, 2009).
In general, research on nursing home placement tends to focus on the experiences of the
elder being transferred and not on the experiences of those staying in the community
(Gladstone, 1995; Kellett, 1999; Novak & Guest, 1992). Research that has focused on
caregivers remaining in the community has found that family members experience relief
from intensive instrumental caregiving, but simultaneously have feelings of ambivalence
and guilt, sometimes even depression (Bond et. al, 2003; Dellasaga & Nolan, 1997; Lundh
et al., 2000; Naleppa, 1996; Nolan & Dellasaga, 1999). For example, Novak & Guest (1992)
compared caregivers to living at home elders and caregivers to living in nursing home
elders, and found no difference between them regarding feelings of burden of care in
physical and social aspects.
A more recent study by Bond et al. (2003) focused on spousal caregivers, and
compared between spouses who had become widowed to spouses whose care receiver
was transferred to a nursing home. They found both types of participants to have similar
changes in the period following the yielding of care of the spouse due to nursing home
placement or death.
The transfer of the husband to a nursing home brings many changes in the marital
role of the wife staying at home. Oftentimes, caregiving at home entailed that she fulfill
roles that had previously been her husband's, such as handling finances, driving, house
maintenance and such (Braithwaite, 2002; Rollins et al., 1985). The transfer to the nursing
21
home carries with it a major upheaval in the traditional roles she has had. The most
significant change the wife must undergo is in regards to her role as caregiver to her
husband. In the nursing home, she is no longer the main caregiver responsible for
instrumental caregiving. This aspect of caregiving has been passed on to the staff at the
nursing home (Bartlett, 1994; Kaplan & Ade-Ridder, 1991; Rosenkoetter, 1996; Schmidt,
1987).
Often the staff views the wife as incapable of caring for her husband, based on the
fact that he has been transferred to the nursing home (Bartlett, 1994; Schmidt, 1987).
However, the wife views herself as an expert on her husband and his needs, based on
their many years together and the care she gave at home. Thus, she may attempt to
convey this information to the staff, but is often frustrated and angry, when the staff does
not regard her as an "expert" or her information as useful (Bartlett, 1994; Kaplan & AdeRidder, 1991; Rosenkoetter, 1996; Rollins et al., 1985; Schmidt, 1987).
The transfer to the nursing home demands of both spouses to learn new roles:
that of resident and visitor. The nursing home is an institution and staff tends to have
expectations regarding visitors' behavior, when they may meet and what will be done
during the visit (Rosenkoetter, 1996). The couple now has to cope with a schedule and
strangers, who are supposedly in a helping capacity, but by their very existence disrupt
the couple's intimacy (Sidell, 2000). The couple must also cope with the loss of physical
intimacy, and search for a way to continue being a couple while in the constant presence
of others with staff intruding into the privacy of their relationship (Carpenter & Mak,
2007; Sidell, 2000).
22
In the nursing home, it is expected that the spouse focus on non-instrumental
roles and tasks, unlike the caregiving role the married widow fulfilled at home. These are
emotional, social and personal tasks (Rubin & Shuttlesworth, 1983). For example, giving
emotional support and sensory stimulation, which cannot be expected to be given by the
staff (Bartlett, 1994). Another aspect of non-formal care by the married widow is
monitoring of the quality of care the husband receives (Gladstone, 1995; Novak & Guest,
1992).
The transfer of the husband to the nursing home seemingly frees up a lot of time
for the married widow. She no longer has to give round-the-clock care, constant
supervision or fulfillment of the husband's care needs. However, this may not be the
blessing that it seems. Several studies have found that wives tend to visit the husband in
nursing home frequently (Bartlett, 1994; Novak & Guest, 1992; Ross, Rosenthal &
Dawson, 1997; Rollins et al, 1985). For example, Ross et al. (1997) found that visitation
was particularly frequent shortly after the transfer: twenty percent of their participants
visited every day. Interestingly, in this study the visitation frequency was consistent nine
months after nursing home placement. These visits were two to four hours in duration.
Bartlett (1994) studied the psychological characteristics of frequently visiting wives, and
found that they exhibited fewer coping capabilities compared to wives that visited only
occasionally. This was manifested in the less frequent visitors having developed fields of
interest outside the nursing home and apart from the marriage.
Novak & Guest (1992) conducted another comparison between familial caregivers:
they compared spouse caregivers to offspring caregivers. In a quantative comparison,
they found that spouses visit on average twice as often as off-springs do.
23
Some researchers found a link between visitation frequency and the husband's
condition (Ross et al., 1997). In this study, the researchers found that the more
deteriorated the husband's condition was, so there was greater potential that the wife
would visit less and develop other fields of interest. Unlike this study, Baxter et al. (2002)
did not find such a link. They studied twenty one women whose husband suffered from
severe dementia (some of the husbands did not recognize their wife). They found that
half the participants visited everyday and the other half visited three to four times a
week. Despite the emotional difficulties that arose during visitation, the wives continued
to visit often. This study is limited in that it is unknown how the duration of the husband's
stay at the nursing home influenced the visitation frequency, if at all.
One aspect of the husband transferring to a nursing home is the need to cope with
the social reactions to the placement. Baxter, Braithwaite, Golish & Olson (2002) claim
that normal widowhood has accepted norms of grief and accepting social support.
However, the case of a husband transferring to a nursing home is a situation that lacks
clear social norms of support and expression of grief or "anticipatory bereavement" may
be unacceptable to the social surroundings. Thus, there may be difficulty in preserving
social relations. The uniqueness of the situation may make it difficult for family and
friends to fully understand their issues and concerns, thereby creating a certain alienation
from others (Kaplan & Ade-Ridder, 1991; Sidell, 2000).
Kaplan, Ade-Ridder, Hennon, Brubaker & Brubaker )1995) initially attempted to
present a typology of married widows. The typology was based upon the perception of
the married widow of herself as a part of a couple. Theirs was a very small sample (six
participants) of wives whose husbands' were in nursing homes, and they delineated three
24
types of married widows. The basic premises of the study were that couplehood exists on
a continuum from "we" to "I", and it includes a definition of the self as a part of a dyad
with the husband. The types they delineated were: "unmarried-married", "until do us
part" and "husbandless wives". Braithwaite (2002) conducted a study to examine the
changes in roles and self perception of married widows. She utilized the initial typology
delineated by Kaplan et al. (1995), and found that it was a worthy model for analyzing
attitudes and self perceptions of married widows.
Another attempt to describe the situation of married widowhood and delineate a
typology of elders in this situation was undertaken by Gladstone (1995). This study
included not just spouses who remained at home, but also couples that had moved
together into a nursing home. Some of these couples moved to different wards in the
same nursing home, based on their functional status at the time of the move. The
marriage experiences of spouses remaining in the community were divided across four
themes:
1. Marriage as a memory: approximately half the participants stated that their
marriage was over. They attributed this to lack of companionship or lack of
communication with their spouse due to cognitive disabilities. At the same time,
they all stated that they have feelings of responsibility and duty to their spouses.
2. Pretend marriage: described their situation as an in between state, not married
and not widowed. They tried to cope with the ambiguity of their situation.
3. A changed marriage: emphasized the change that took place in their marriage.
Most of them described a transition to relationship like a parent and child, usually
25
due to cognitive disabilities of the spouse. Some described their relationship now
as more of friends rather than as a couple.
4. Unchanged marriages: approximately a quarter of the participants felt that there
had been no change in their marriage, or that the circumstances were just another
phase in their marriage. They referred to their continuing love for their spouse.
The researcher states that the women tended to describe their marriage as one of
the first three themes mentioned above, whereas men tended to relate the theme of no
change in the marriage. In addition the participants referred to the influence of the
changed living arrangements on their marriage, and most of them stated that lack of
communal living brought about loneliness and loss of companionship with spouse. Some
stated that new areas of interest were found that contributed to further feelings of
distance. On the other hand, several described an improvement in the relationship with
the ill spouse after they had adjusted to the nursing home.
Later, in a larger study, Kaplan (2001) broadened the original typology she and her
colleagues had delineated to five types of marital perceptions held by communitydwelling spouses along the continuum of "we" and "I". These types were found to be:
1. "Till death do us part" - spouses have a strong sense of couplehood. They feel and
will continue to feel as part of a "we" despite their partners' inability to participate
in the marriage.
2. "We, but…" – spouses perceive a continued sense of "we", but also realize that
they are becoming spouses who no longer have partners that participate in the
marriage.
26
3. "Husbandless wives/wifeless husbands" – spouses feel ambiguous about the
boundaries of their marriage. They perceive themselves as married, but not as
having viable partners in the marriage.
4. "Becoming an I" - spouses realize that their marriage no longer includes two
people, but rather just one. Yet, they do not think of themselves as completely
alone.
5. "Unmarried marrieds" –spouses define themselves as still legally married, but do
not perceive themselves as such.
Although this study was limited in that it referred only to cases in which the
husband was diagnosed with dementia, it seems to have found types similar to the
typology presented by Kaplan et al. (1995).
The studies mentioned above focused on the feelings and thoughts of communitydwelling spouses in regards to their marriage. Unlike these typology generating studies,
that were focused on the marital perceptions of the community-dwelling spouse, the
current study was undertaken in order to holistically understand the day to day lived
experience of wives in this life situation based on their subjective understanding of it. To
this end, a framework of phenomenology, which I will now expand upon, was utilized.
1.6 Phenomenology
The phenomenological approach is based on the premise that a person
experiences the world in a unique way. Its foundations are in the philosophy of Husserl,
and it is based on the assumption that people can understand and be aware of their
experiences through consciously relating to their perceptions and intentions (Patton,
2002). Any description of reality inherently integrates the interpretation that the person
27
gives the experience (Creswell, 1998). Phenomenological research is inductive and
descriptive. The researcher aims to understand the subjective perspective of the person
having the experience and the influence of this perspective on their lived experience
(Flood, 2010). Phenomenology is based on several key concepts, which will now be
expanded upon:
Essence: the phenomenological approach assumes that any human experience has a basic
essence that is common to others, influenced by innate mechanisms and socio-cultural
influences, along with unique qualities between different people having the same
experience (Moustakas, 1994; Spinelli, 1989). The same phenomenon may have different
meanings for different people and even for the same person in different contexts or
points in time. This study strives to describe and understand the essence of the
experience of married widows.
Intentionality: The mental process a person undergoes in interpreting an experience is
called intentionality (Spinelli, 1989; Sokolowski, 2000). This process consists of the "what"
of the experience - 'noema', i.e. the content, and the "how" of the experience - 'noesis',
i.e. the way a person finds meaning in the experience ((Moustakas, 1994; Spinelli, 1989).
In this study the 'noema' is focused on the lived experience of the married widow, and
the 'noesis' is the meaning these women give to their marital status, their life situation
and their experiences as married widows.
Life world (Lebenswelt): refers to the world as one experiences it naturally, i.e. a person's
inherent natural ability to construct a reality with meaning (Schwandt, 1997; Streubert
Speziale & Carpenter, 2007; Van Manen, 1990). This means the experience of everyday
life as manifested in the thoughts and actions of a person and the social expression of
28
these thoughts and actions (Schwandt, 1997). The purpose of this study is to understand
the life world of married widows. The life world is constructed through three mechanisms
(Spinelli, 1989). One mechanism, Umwelt, refers to the physical and biological world in
which a person lives. Part of a person's experience of life is through physical space and
their home. In this study the participants continue to live in the same home, in which they
previously lived with their husbands. This situation of continuing to live in the same
physical space that is occupied differently is relevant to their current lived experience.
A second mechanism, Mitwelt, relates to the relationships that a person has with
others (Spinelli, 1989). This refers to the perceptions a person has regarding their society
and its influences on them. In this study it refers to the perceptions of the participants
about how others view them in their current life situation, and what is common to these
perceptions and the perceptions of those who are experiencing married widowhood.
The third mechanism, Eigenwelt, relates to the way people experience themselves
and significant others; the way people perceive themselves, have faith in themselves and
others, self confidence and the like (Becker, 1992). In this study it refers to the way the
participants experience married widowhood in the context of their lives; their marriage,
the life stage of old age and other inter-subjective aspects.
Temporality: phenomenology refers to temporality and experienced time rather than
objectively measured clock time (Becker, 1992). Experiential time is structured based on
experiences and is interpreted by the person experiencing it. Thus, the experience and its
meaning may change over time (Van Manen, 1990). The various dimensions of time (past,
present and future) and intertwined and reciprocally influence each other. The past one
remembers today may be different from the past one remembers tomorrow, based on
29
the reflective process one undergoes (Becker, 1992). In this study time is relevant in that
the experience of being a married widow may change over time.
Morse (1994) suggests that a researcher interested in participants' life world of a
transformative experience should capture the experience after the transformation is
complete, through recall by the study participants. This study is unique in that the
transformative experience of the participants is ongoing while they are participating in
the study.
Space: Phenomenology refers to the lived space of a person: the subjective personal
space that a person perceives and acts in. Lived space is human space and it has dual
qualities: outer and inner space. Human space is demarcated by humans, their actions,
objects and symbols. Bollnow (1967) views the home as the center and essence of a
person's lived space. According to him, 'dwelling' means to be at home in a particular
place that implies special conditions. The home is a reflective referential point from which
other space is constructed (De Silva, 2007). This study is interested in the experiences of
married widows lived space: has it changed, if so – how? How does one feel living in the
home physically with changes in the human aspect of the home?
Language: phenomenology views language as a central mechanism for meaning making.
Language serves as a bridge between the pre-reflective and the reflective, and between
internal and external realities. Language not only reflects reality, but also constructs it,
giving meaning to objects and social situations (Gubrium & Holstein, 1998). Often
metaphors are used to organize and represent peoples' understanding of the world and
their place in it (Lakoff & Johnson, 1980). In this study particular attention will be given to
31
the language and metaphors the participants use to describe themselves as individuals,
their behaviors or their perceptions of their marital status.
1.7 Research questions
In light of the literature review above and the phenomenological orientation of the study,
the research questions in this study are directed to answering these questions:
-
What is the daily lived experience of community-dwelling wives after their
husband has moved to a nursing home?
-
How do community-dwelling wives experience their couplehood, relations with
children and social relations in light of their current life situation?
-
How is their current life situation different or similar to their life before the
nursing home placement of their husband?
-
How do community-dwelling wives feel and think about visiting their husband in a
nursing home?
-
What is the meaning of long term marriage in this life situation?
31
2. Methodology
In light of the research questions and the goal of this study – to provide a holistic
understanding of the phenomenon of married widowhood – I chose to utilize the
naturalistic paradigm and a qualitative research design. The naturalistic paradigm is based
on the assumption that realities are constructed by people, and there is no one objective
truth (Creswell, 1998; Lincoln & Guba, 1985).
2.1 Qualitative research
The qualitative research approach utilized in this study is oriented to the lives of
people, their narratives and behaviors. The central goals of using this approach are to
describe and interpret phenomena, and theorize regarding these phenomena (Strauss &
Corbin, 1990). Research of this type strives to capture meanings and the essence of
human experiences holistically, in relation to various aspects. We learn about the
phenomena through the eyes of persons experiencing it (Creswell, 2007). In addition, this
research approach captures the experience and behavior of people as integrative and
inseparable parts of the same phenomena (Moustakas, 1994).
Qualitative research is not based on statistical data or quantative concepts. This
research approach is common in various fields of social sciences, such as sociology,
psychology and health studies (Creswell, 2007; Kerr, Nixon & Wild, 2010; Streubert
Speziale & Carpenter, 2007). It is acceptably used to study phenomena for which there is
little information, and the goal of the researcher is to understand the essence of the
phenomena (Creswell, 2007; Strauss & Corbin, 1990). To this end, the researcher refrains
from preemptory assumptions, focuses on a specific phenomenon, and constructs
32
research questions to direct the study, and searches for meanings in the data, which
might be used for future research (Moustakas, 1994).
As mentioned earlier, this research project utilized phenomenology as a
conceptual framework to describe and understand the experiences of elder women living
in the community, while their husbands reside in nursing homes. Phenomenology, as was
explicated previously, is a conceptual approach that fits well with the naturalistic
paradigm and qualitative research (Flood, 2010; Sousa, 2014).
2.2 Procedure
2.2.1 Purposeful sampling
Qualitative research usually focuses on a phenomenon using a small sample,
which is purposefully chosen. Unlike quantitative research, which is based on random
large scale samples so as to enable generalization, qualitative research doesn't strive
toward generalization. Rather, sampling in qualitative research is concerned with the
richness of information (O'Reilly & Parker, 2012). The purposeful sampling technique is
based on the principle of finding participants that have rich, firsthand knowledge about
the phenomenon being studied (Patton, 2002: Robinson, 2013; Streubert Speziale &
Carpenter, 2007). Numbers and sample size are not wholly irrelevant in qualitative
research, but the quest for rich data should be the main guideline regarding purposeful
sampling (Robinson, 2013; Sandolowski, 1995). Morse (1994) has suggested that
phenomenological research directed to capturing essences of experiences include at least
six participants. This phenomenological study included twenty eight participants and is
based on rich data of their experiences as married widows.
33
As customary in qualitative studies, the participants in this study were chosen
based on their firsthand knowledge and experience of the phenomenon under scrutiny. In
this study all the participants were older women living in the community, whose husband
of many years was residing in a nursing home.
Initially, I interviewed any woman who was referred and agreed to partake in the
study. After several interviews, initial coding was done and I refined my criteria for
inclusion. The purposeful sampling in this study strived to compile a heterogeneous
sample of women experiencing the studied phenomenon. As Robinson (2014) has pointed
out, commonalities found among a diverse group of people regarding the studied
phenomenon is likely to be more generalisable. As Patton (2002) and Robinson (2014)
suggest, my sampling became of a maximum variation sampling character, in order to
capture themes that cut across variation in cases.
Participants were recruited through nursing homes in northern Israel. After having
obtained agreement from management, social workers or an occupational therapist at
the nursing home approached potential participants and suggested that they participate.
Criteria for participation were: women over sixty five years of age, who live in the
community with a husband of many years residing in a nursing home, and who speak
fluent Hebrew. Women that agreed to participate were referred by the nursing home
agent, and I contacted them by phone to set up a time for an interview. All the interviews,
but one, were conducted at the home of the participant. The exception was conducted in
the nursing home, in the husband's room but not in his presence, due to the participant's
request.
34
Based on the concept of maximum variation sampling 1, I approached thirty two
potential participants, after having received their contact details from the nursing home.
Two women changed their mind about participating during the initial telephone
conversation. Another woman decided not to participate when I came to her home as
prearranged (stating her children had dissuaded her). One interview was conducted with
consent, but due to technical problems of the recording device, it was not recorded and
subsequently not transcribed or analyzed.
2.2.2 Saturation
Saturation is a concept in qualitative research which seems to have become an
important standard for determining diversity of study samples and exhaustion of the data
derived from them (O'Reilly & Parker, 2012). This concept refers to reaching a point in the
collection of data at which there are few surprises and no further patterns emerge from
the data. Simultaneous data gathering and analysis enables the researcher to make realtime assessments whether further data collection is likely to produce additional or novel
contribution to the data set (Robinson, 2014).
Saturation is highly dependent on properly done purposeful sampling, and an
appropriate sample leads to theoretical saturation (Bowen, 2008). Theoretical saturation
is an often used, yet very vague, term for describing a point data gathering and analyzing
at which the categories that have emerged are fully accounted for (Guest, Bunce &
Johnson, 2006). Additionally, at this point the variability between the categories is
explained and the relationships between them explicated and tested (O'Reilly & Parker).
When new data continually converges to the identified categories and no new categories
1
The refined criteria for achieving maximum variation sampling were sent to the contact persons at the
nursing home, and they referred potential participants based on this updated criteria.
35
emerge, the researcher may assume having reached saturation. Guest , Bunce & Johnson
attempted to operationalize the concept and determined that saturation is said to be
reached when new information brings about little or no change in the codebook.
In pursuit of saturation in this study, analysis was done throughout the data
gathering process, and influenced the purposeful sampling criteria. For example, early on
it became clear that family relations, especially with children, were a theme in the data.
Thus, I refined my search for participants to account for variation in the number of
children participants had: I interviewed women with a varying number of children (from
zero to ten) and women who identified children that were their husband's children but
not their own. Other issues such as how long the husband had been in the nursing home,
how often they visited and such were deemed relevant based on the literature review
and also served to guide the sampling of participants. I conducted twenty-eight
interviews, until the data gathered in the interviews converged into the categories that
had been identified and became familiar, redundant and repetitive.
2.2.3 Research tool
As is acceptable in qualitative research and phenomenology, the interviews I
conducted were semi-structured, based on open ended questions, utilizing an interview
guide. The purpose of semi-structured interviews was not to illicit specific answers to
questions from the interviewees or to test predetermined hypothesis. The ultimate goal
of this kind of interview is to understand the experience and the significance people
assign to that experience, emphasizing their point of view (Patton, 2002; Rubin & Rubin,
2005). An important aspect of the interview is to allow the participants to express
themselves in their own words. From a phenomenological position any attempt to
36
understand the experience of the participant must be based on their language, and
language is viewed as a tool for constructing experience (Spradley, 1979). For example, I
avoided using the term married widow or its variations. This term had caused discomfort
among many colleagues, and it was determined that refraining from using it would
encourage a more open discussion about the participant's viewpoint regarding her life.
This decision was warranted and served to create an atmosphere free of labels of any
kind, and encouraged the participants to speak freely and frankly about their lives.
Furthermore, in analyzing the data from the first few interviews, I came to realize that
this phrase contradicts the phenomenological orientation of this study, and most likely
would have hindered the interviews.
It has been suggested that semi-structured interviews are very appropriate for
interviewing elders, because they create an enjoyable experience of being listened to
attentively, favor the development of rapport and trust and invite people to talk at their
own pace and within their own frame of reference (Tilse, 1998).
As is customary in semi-structured interviews, I used an interview guide (Appendix
2). An interview guide is an assistive tool for the researcher, aimed at giving structure to
the interview. It enables the researcher to ensure that all the relevant issues regarding
the phenomenon (based on the literature review) are addressed in the interview (Patton,
2002). The interview guide in this study covered various issues including: caregiving
history to the husband at home, relations with children and family, quality of the
marriage, current hobbies and pastimes, her health, process of deciding to transfer to
nursing home, visiting the nursing home, quality of care at the nursing home, and other
37
issues. Throughout the interviewing process the interview guide continuously evolved,
based on the data that was brought up by the participants.
After the interview, I wrote down pertinent notes regarding my impressions from
the interview. Soon after the interview, I transcribed it per verbatim, also indicating
pertinent facial expressions, laughter, sighs and pauses and other non-verbal expressions
of emotion in order to produce an authentic document to reflect as much as possible
what took place in the interview (Creswell, 1998; Patton, 2002).
The interviews were conducted over a period of two years. This allowed for finetuning the interviews, so that themes and content found relevant in initial analysis were
addressed in later interviews, and the interview questions changed accordingly. Most
interviews lasted one to one and a half hours (the shortest was a half an hour and the
longest was two and a half hours). All the interviews were conducted in a relaxed and
friendly atmosphere. I posed open questions to maintain empathic neutrality, so that the
interviewee would feel comfortable in answering frankly and expansively, with the
trustworthiness of the study in mind (Patton, 2002). The issues raised in the interview
were inevitably emotionally laden. I made sure to give ample time and emotional support
whenever the participant seemed to experience difficulty with the questions. When I
thought the issue was particularly discomforting, I suggested we take a short break or
turn to another issue with which she was more comfortable. Only one participant
objected to recording a certain issue, and therefore we turned to other topics she was
comfortable recording. Most of the participants welcomed the opportunity to discuss
their lives, their husbands and themselves. This could be seen in that many spoke at
length in response to the initial introduction of my research interest.
38
Many participants felt benefitted and expressed gratitude and/or pleasure for
having had the opportunity to discuss relevant issues and their lives. During the interview,
a few participants expressed surprise that they had so much to discuss. Interestingly, the
question that elicited the most surprise from the participants was: in this situation, do
you feel married? Quite a few commented that they had never before been asked that
question nor had they pondered it. These responses were accompanied by the statement
that it is an important question, one that should be asked, and all answered the question
willingly.
2.2.4 Bracketing
An important issue in phenomenology is the bracketing of the researcher's
predispositions and beliefs, so as to be able to "see" the data without bias of any kind
(Schwandt, 2000). Initially, when I started this study I was working in a nursing home and
came in contact with women who lived in the community and came to visit their
husbands at the nursing home. Over time and contact with various women in this
situation, I had developed an opinion regarding them and their behaviors toward the staff
and their husbands. I was aware of this, and made every effort to approach the interviews
and the data analysis after having ridded myself of this attitude. I took measures to
conceptualize to myself the opinions that had been somewhat vague up until then, such
as writing down all my thoughts on the issue and discussions with colleagues (Kvale,
1983, Schwandt, 2000). Also, I wrote personal remarks during the interviews themselves,
and after reading them several times was able to decide whether they were relevant to
the interview and the interviewee, or were a product of my own thoughts and biases.
39
2.3 Characteristics of the participants
In this study, I conducted interviews with twenty-eight women. All names have
been changed in the interest of protecting the anonymity of the participants.
All the women were living at home, while their husbands were living in a nursing
home for a time period ranging from one month to thirteen years, with an average of two
years and three months having passed since the nursing home placement. Most of the
women in this study had experienced a period of caregiving to their husband at home
prior to nursing home placement. Several households had brought in foreign aide workers
during the caregiving period at home. The time periods of caregiving at home time prior
to nursing home placement ranged from one month to sixteen years, with an average of
slightly more than four years.
The women were aged sixty-five to eighty-seven at the time of the interview, with
an average age of seventy six years. Their husbands were aged sixty seven to ninety five
at the time of the interview, with an average age of eighty one years (one husband's age
is missing). The women in this study had been married to their husbands for the past
thirty three to sixty seven years, with an average of fifty three years of marriage. Two
women were in second marriages, which had started over thirty years earlier. The women
in this study all had children, except for one. The number of children ranged from one
child to ten children, with three children the most common (nine participants).
The most common place of birth was Israel (actually Palestine - they were born
before the state of Israel was established) - nine participants. Other participants came
from Europe (eight participants), Northern Africa (seven participants), the United States
of America (one participant), Australia (one participant) and Argentina (one participant).
41
Most of the women had worked outside the home throughout their lifetime (twenty four
participants). They had been employed in various jobs, such as secretaries (nine
participants) and educational positions (six participants). At the time of the interview the
participants were retired, except for three participants: two were working as private
nannies and another worked as a nursing aide. Half of the participants described
themselves as daily visitors to their husband at the nursing home (fourteen participants).
Among them there is a slight variation regarding visiting on the weekend, therefore daily
visitors actually visited five to seven days a week, depending on whether they included
the Sabbath as a day for visiting or not. Participants, who did not visit daily, mostly
indicated that they visited their husband two to three times a week. One participant told
of visiting her husband approximately once a month due to transportation difficulties.
The main characteristics of the participants in the study are summarized in the
Table 1. Additional information about each participant can be found in Appendix 1.
41
Table 1: Characteristics of participants 2
Name
Betti
Cherna
Dina
Dorona
Esther
Fruma
Hava
Haya
Iren
Masudi
Maya
Mazal
Nili
Rachel
Riva
Rivka
Ruth
Sara
Sarina
Shira
Simcha
Sophie
Suzie
Tala
Tova
Yaffa
Yochi
Zari
Age3
70
78
81
76
69
80
65
77
65
80
73
71
77
84
87
80
76
78
65
76
76
69
86
78
77
73
84
73
Years of Care at home
marriage before nursing
home
(in
4
years)
48
0.1
60
1
60
6
56
2
50
6
56
4
46
5
40
2
48
16
60
1
57
5
52
10
60
4
62
8
64
4
5
33(2)
4
60
7
60
-37
5
35(2)
1
60
2
48
2
67
13
34
-60
6
54
4
63
4
52
0.5
Time
in
Nursing
Home
(in years)
0.5
0.5
2
4
0.75
1.2
3
0.5
6
2
0.5
7
0.5
2.2
3
1 month
4
0.25
1
4
2
1
1 month
1.5
1.5
13
0.5
4.5
2
Visiting
Age of No.
of
frequency
husband children
(days
per
week)
2-3
77
4
7
82
3
7
81
5
2
81
2
6
73
6
6
81
3
3-4
76
3
2-3
77
2
2
78
3
2
84
4
3
76
3
6
78
3
7
87
3
2-3
84
3
2-3
95
1
2-3
80
1
6
84
2
6
80
6
5
67
4
2
unknown
2
6
83
4
4
71
2
6
93
2
1
83
0
6-7
84
3
7
83
2
7
87
2
1 a month
75
10
Presented in alphabetical order of pseudonyms
Ages of participant and her husband refer to the point in time when the interview was conducted
4
All temporal data refer to the point in time when the interview was conducted.
5
Parentheses indicate second marriage
3
42
2.4 Analysis
The analysis process in qualitative research is one of reduction and reconstruction
in order to discover meanings and the holistic nature of a phenomenon (Creswell, 1998;
Strass & Corbin, 1990). In this study, data analysis began after transcribing the first few
interviews, thus enabling me to refine my interview questions so as to include all issues
deemed relevant. As the sole interviewer and transcriber, I became intimately familiar
with the data and engaged in analysis during the prolonged data gathering procedure
(Kemp, 2012).
The qualitative research analytic program Atlas.ti (version 6) was used to help
store, manage, code and analyze data. This program is designed to assist in qualitative
data analysis. All twenty eight interview protocols were entered into the program. The
program assisted in coding the interviews, especially during the initial open coding phase.
Later phases of analysis were done manually, and the program assisted in easily referring
to the relevant passages of text.
The analysis process was an inductive one, initiating with repeated readings of the
interview transcriptions and immersion in the texts (Kvale, 1983). Through this immersion
in each text by itself and then reading between cases, evolved initial ideas and beginnings
of units of meaning were revealed. Campbell, Quincy, Osserman & Pederson (2013) state
that there is sparse guidance in qualitative research literature for establishing a reliable
coding of semi-structured interviews. Therefore, I initiated the process by utilizing the
technique of open coding (Strauss & Corbin, 1990), which relatively well-documented, by
making notes of initial categories that represented ideas and issues that came up from
the texts. These initial categories were temporary and not in a hierarchical order.
43
Using the technique of constant comparison between the texts, the categories
were then examined to discover the relations between them, also called axial coding
(Strauss & Corbin, 1990). Axial coding entails discovering relations between the categories
and attributing sub-categories to them based on their dimensions. These sub-categories
relate to the category by describing and detailing conditions, strategies and consequences
of the categories (Strauss & Corbin, 1990). Through axial coding, the researcher sorts
through the various ideas into 'units of meaning' (Patton, 1990), that later construct a
theoretical model. Thus, the analysis was an inductive process of organizing central
themes and describing the relations between them, in line with the framework of the
study (Padgett, 1998).
After discovering the relations between the categories, it was possible to
construct themes and corroborate them through cross-case analysis (Patton, 1990).
Through the use of the selective coding technique (Strauss & Corbin, 1990) I organized
the data along a central storyline that reflected the relations between the categories.
The analysis concluded with constructing a theoretical model of the experience of
married widow, based on interpretation of the data. Thus, the 'grounded theory' method
was utilized in this analysis (Strauss & Corbin, 1990). This stage of analysis was carried out
alongside writing (and much rewriting) of the results chapter. The process of organizing
the storyline was a continuous one, which involved changing, reconsidering, reframing,
and reconstructing the categories. This was done while referring back to the data, the
open coding and theoretical literature, and also while re-interpreting, refining and
arriving at new insights until it was found that the storyline was cohesive.
44
2.5 Ethical considerations
The use of interviews in which people reveal their inner thoughts and emotions,
especially regarding sensitive issues, brings up various ethical issues that deserve
consideration (Kvale, 1996). Prior to the beginning of the research project, it was
reviewed and approved by the internal faculty review board of the Faculty of Health and
Well-being Studies at the University of Haifa. All the participants in this study read and
signed informed consent papers prior to the beginning of the interview (Appendix 3). The
names of the participants have been changed to protect their anonymity. Unusual
personal details have also been masked towards this goal.
As mentioned earlier, the participants in this study were pleased to have an
opportunity to discuss their lives. Several mentioned that we were discussing issues they
had never spoken of before; in particular they mentioned that they do not speak of these
things to their children. Several participants became emotional and cried during the
interview. I was empathic and supportive, allowing them to choose the degree of
elaboration regarding sensitive issues.
Interestingly, several participants brought up relevant and related issues as I was
at the door preparing to leave. Seeing as these statements were said while the tape
recorder was off, and this may have contributed to the timing of these things being said, I
did not include this information as data for that participant. Rather, I made note and
addressed these issues while interviewing the following participants on record.
45
2.6 Trustworthiness
It should be noted that all the interviews for this study were conducted in the
Hebrew language, except for two that were conducted in English 6. The dissertation is
written in English and data analysis was conducted simultaneously in both languages. This
is due to my being bi-lingual, and alternating between these languages in my thinking
processes. The decision to analyze and write the thesis in English (due to my own
technical considerations) came about after the interviews had been finished. Therefore
the translation of the quoted interview texts is uninfluenced by the various translational
issues discussed by Temple & Young (2004), who refer to translational problems during
the data gathering phase.
The qualitative researcher strives to describe an appropriate and encompassing
representation of the phenomenon being studied. The type of qualitative research
presented in this dissertation does not hold generalization as a central aim (Williams,
2004), rather it zooms in and explores the specific, the local, and the situated. Qualitative
research, unlike quantitative research, is uninterested in the ability to generalize the
findings of the study (Sousa, 2014). Therefore, quantitative criteria for measuring
reliability and validity of findings are exchanged for measures of trustworthiness of the
researchers' findings. These include the researcher's ability to demonstrate the inductive
nature of the findings and that they are based on the experiences and perceptions of the
study participants (Poortman & Schildkamp, 2012; Streubert Speziale & Carpenter, 2007).
Lincoln & Guba (1985) proposed criteria to establish trustworthiness in qualitative
research studies. These are ascertained by implementing various techniques. For
6
These two interviews started in Hebrew, but the women were English speakers and naturally slipped into
English during the course of their talking. Seeing as I also am an English speaker, I saw no reason to insist on
speaking Hebrew and the interview was conducted in English, with occasional interspersing of Hebrew.
46
example, credibility may be accomplished through triangulation or peer debriefing
(Sousa, 2014). Thick description and member checking also apply as techniques to this
end (Poortman & Schildkamp, 2012).
Interestingly, Poortman & Schildkamp (2012)
propose that traditional quantitative criteria for assessing validity and reliability of
research should be used, through adapted techniques, for assessing the quality of
qualitative research. They claim that there is no need for different terms or new criteria
for such an assessment, but rather the focus should be on developing corresponding
evaluative operations for qualitative research.
Although the position Poortman & Schildkamp (2012) propose is of interest, being
a novice researcher, I chose to follow in the footsteps of experienced qualitative
researchers, and base the trustworthiness of this study on traditionally used techniques.
The interviews were tape-recorded and their transcriptions enabled verification and
ensuring referential adequacy (Lincoln & Guba, 1985). I also utilized peer debriefing: the
findings were presented to a group of colleagues familiar with qualitative methods, which
raised thought-provoking questions and gave feedback regarding the clarity and
plausibility of the findings (Lincoln & Guba, 1985). Throughout the research period I
presented and received feedback on various aspects of my findings on six occasions to my
peer group, which was made up of colleagues with a varied professional background (two
gerontologists and two educators). Finally, I utilized member validation (Seale, 1999,
Poortman & Schildkamp, 2012): after the findings were conceptualized in an orderly
fashion, one of the participants in the study read the full chapter and gave feedback as to
whether the findings did indeed reflect her experience. This particular participant was
chosen because English is her native language; she expressed interest in reading the
47
findings and had experience in research projects. Her feedback was then used to finetune the findings.
In the next chapter, I present the findings arrived at by using the analysis process
described above. As is customary in the presentation of research findings, the quotations
and examples presented were selected out of an array of possibilities on the basis of their
representativeness and relevance to the findings (Talbott, 1990).
3. Results
To properly understand the lived experience of wives in this life situation, one
needs to understand the context in which this situation came about. Hence, this chapter
presenting the results of the study will begin by addressing the caregiving period at home
and making the decision of nursing home placement for the husband. Afterwards, the
results of the study pertaining to processes of continuing and disengaging in reference to
the past will be presented.
3.1 Caregiving at home
Many of the women in this study were familiar with the role of caregiver, having
first cared for their own children, and later on being involved in the care of their
grandchildren. They relate a traditional role division between husband and wife
throughout their lives regarding the upkeep of their household. Women who worked
outside the home held part time jobs so that they might be available to care for their
children and home. After retiring from work, several husbands took up some household
48
chores, under the direction of the wife. As the husbands became ill or had difficulties
functioning, the wives naturally took up again all the household tasks and easily slipped
into the caregiver role.
Caregiving to the husband was due to cognitive disability in cases of dementia and
physical disabilities in cases of stroke, Parkinson's or a muscular disorder. Most of the
wives in this study were in the role of caregivers to their husbands for an average period
of four years prior to nursing home placement.
Many women in this study relate the toll caregiving took on their physical health,
some having suffered serious health consequences that cannot be remedied. In fact in
several cases, health issues were a central factor in bringing about the need for nursing
home placement. Dorona was unable to continue providing care for her husband at home
due to a continuous deterioration of her back problems, which were exacerbated in her
efforts to transfer him from room to room in their home:"Physically it was difficult for me
to lift him…my back. I didn't care for myself medically. I didn't go to the doctor…it wasn't
important. He was in first place". At the expense of her own health and functional
abilities, caregiving for her husband was Dorona's first priority. Similarly, Iren also
suffered an acute back injury while caregiving for her husband, who suffers from
Parkinson's disease, which caused him to fall often: "with all my lifting him…I made a few
wrong movements…so one of my discs was dislocated and I spent two months in the
hospital". After her hospitalization, Iren continued caregiving at home to her husband,
despite continuing to suffer pain from her back injury. Like Dorona, caregiving at home
was the first priority, even in face of potentially debilitating herself.
49
As the husband's condition deteriorated, the women found themselves unable to
provide the amount of care needed on their own, and several brought foreign aides into
their home to assist them. Ultimately, with or without foreign aides, the wife was not able
to provide the necessary care at home, and the husband was transferred to a nursing
home.
3.2
"There was no other option": deciding on nursing home placement
The living situation of participants in this study is perceived of as distressing, one
that occurs in situations in which there are no other feasible options. This may seem
obvious and be taken for granted, but it should not be. Several of the women indicated
that they heard rumors that the nursing home placement was perceived by people
around them as a way to make their own life easier. But the participants in this study
paint a different picture –they did not want this situation, and most tell of the great
lengths that they went to in order to avoid it.
The decision of nursing home placement is brought about by the occurrence of an
acute event (such as a fall and inability to walk), or by a continuous deterioration in the
resources and capabilities of the wife. Either way, the wife and the children take action to
allow for the husband to stay at home as long as possible by using financial or health
resources, remodeling the house, moving or bringing a foreign aide into the home. After
all available resources have been exhausted or the situation is irrevocably altered, then
the nursing home placement is considered and executed.
Many of the wives used the expression "no option" to describe the nursing home
placement decision. They tend to relate a narrative of what happened before the nursing
51
home placement, whether sudden or gradual deterioration, and end the narrative with
the expression "no option".
For example, Esther relates that her husband refused to take medication and
gradually deteriorated until she and her six children decided on nursing home placement.
After the nursing home placement she tells: "I saw that they were sad and sorry about
it…I told them we had no option. We tried and he refused (medications). It is not our fault.
We had no other option". Esther feels that she and her children made a great effort to
keep her husband at home, despite various behavioral disturbances and noncompliance
with medical treatment that was prescribed for him. From her point of view, nursing
home placement was done after all other resources were depleted and this mitigates guilt
feelings that may accompany nursing home placement.
Similarly, after two years of caregiving, Simcha concluded that she had no option
other than nursing home placement in order to continue providing the best care for her
husband:
"I am very sorry that he is in a nursing home, but I had no option…I did everything. I
redid the bathroom, everything. Just so that it would be good for him, just good for him.
In the end there was no other option".
Simcha took measures such as remodeling their home and bringing in a foreign
aide, in order to accommodate her husband's care needs. And yet, as his dementing
condition deteriorated, the measures she undertook were insufficient and she found that
she had no option other than nursing home placement in order to continue providing the
best care for him.
Another wife, Iren, also relates that she made various changes in an attempt to
adapt to her husband's needs and avoid nursing home placement:
51
"I brought a whole hospital in here. There was a bed, everything he needed…I took my
house apart. I changed my life from A to Z. And still we came to a situation that there
was no option but to take him to an organized place. It's just that the situation brought
it upon us".
Not only did Iren modify her house, but her whole life changed in order to
accommodate the husband's needs. Due to the continuous deterioration in his functional
capabilities caused by the Parkinson's illness he suffered from, these efforts were not
sufficient to continue caregiving at home.
Similarly, Dorona, who was mentioned earlier, describes her attempts to provide
care for her husband at home. Firstly, as she realized he needed hands-on care, she left
her job as a nurse, and stayed home with him. They remodeled their small apartment:
"we took out the bathtub and put in a shower stall. I made the best accommodations that
I could, hand railings, no carpet…he started sleeping in the living room because the
bedroom door was narrow". Later on, a foreign aide was brought into their home to assist
in the caregiving of her husband. For a while this was sufficient, until the aide left, and
Dorona could not continue with the physical caregiving on her own. She says: "if there
was any option not to have him leave the house, he would not have left. There was no
option but for him to leave". During the caregiving period at home, along with the aide,
Dorona had hurt her back and was suffering from mobility problems. The departure of the
aide coupled with her limited capability in caregiving brought them both to the conclusion
that she could no longer care for her husband: "so I sat my husband down and I asked him
if he thought I could care for him at home by myself. He said he thought it would be too
hard for me". Thus, they made the decision about the nursing home placement after they
felt they had exhausted other possibilities of home caregiving.
52
Like Dorona, Nili made modifications to her home in order to accommodate her
husband's care needs:
"We changed the bathroom...took out the bathtub. When I saw it was hard for him to
lift his leg over the edge and I was afraid he would fall…and we put in a wider door. And
the same with the toilet".
All these modifications were made based on the assumption that she would
continue to provide care for their husband in their home. The financial cost and hassle of
remodeling to meet the care needs of the husband were not done lightly. Nili was aware
that these modifications should have been done before for the benefit of both of them,
but: "as long as it was possible we kept the bathtub. Simply because we did not want the
mess, and ruining the house and all". These accommodations made caring for her
husband possible at home until an acute event occurred: he fell and broke his hip. When
this happened, all the modifications that had been made were insufficient to enable
caregiving at home, and he was placed in a nursing home.
Sometimes the physical aspects of the home environment are not modifiable to
accommodate the care needs of the husband, and thus are the reason that there is no
option other than nursing home placement. For instance, Riva and her husband lived in
an apartment on the second floor in an old building without an elevator. She relates: "He
could no longer stay at home because he could not stand or take a shower…couldn't go
out because of the stairs…it hurts, but there was no option". In this case, the physical
environment was an obstacle to continuing caregiving at home: her husband was not able
to leave the house due to the two flights of stairs needed to leave the building.
Functionally, this meant that he could not go to the doctor, and also she could not leave
him home alone in order to run errands or socialize outside the home.
53
Making the decision of nursing home placement is a difficult one by all accounts.
None of the wives make this decision lightly. Several of them made this decision
independently, later on involving significant others. Usually their children were involved
at an early stage, and sometimes other family members. For some, the children are
perceived as having made the decision or pressed the wife into the decision on nursing
home placement. For others, professional figures in the health care system are perceived
as having steered them into nursing home placement for their husbands.
3.2.1 Influenced by health care professional.
Several of the wives in this study were encouraged by health care professionals to
place their husband in a nursing home. Usually the health care professional intervened
after an acute medical incident and hospitalization of the husband. Health care
professionals that intervened were social workers, doctors or nurses. Interestingly, the
narrative told by the wives is that they were preparing to bring the husband home, and
the health care professional sat them down and explained that it was not possible or that
it would be mistaken on their part to do so.
Such are the events described by Betti. Her husband had become increasingly
violent and confused for a month, which ended in a hospitalization in an acute psychiatric
ward due to his attacking her and their son. During the hospitalization he was diagnosed
with dementia, which had caused delusions, agitated behavior and the violence. When he
was due to be dismissed, Betti had been considering bringing in a foreign aide into their
home, in order to continue caregiving in the home. She recalls:
"The social worker sat me down, with the children. She said the final decision is yours. If
you want to take a foreign aide into your home, you can do that. Our recommendation
is more in line with nursing home placement".
54
Following this discussion, Betti accepted the recommendation of the social worker
and changed her mind and her goal, to finding an appropriate nursing home for her
husband.
Similarly, Shira was influenced by a social worker. Her husband suffered from a
series of repeated falls, and was hospitalized in a geriatric rehabilitation hospital. When it
was time to be released, Shira went to the social worker to discuss the procedures for
taking him home. She recalls: "she said to me- Mrs. Shira, you cannot take care of your
husband. I said- but what should I do? I really had not thought about a nursing home. She
said, sit here. I will take care of everything". For Shira the initial idea of nursing home
placement was brought up by the social worker: she had not even considered it before
this discussion. The social worker then proceeded to connect her with a professional firm
that assists in nursing home placement. They took Shira on a tour of possible nursing
homes, and finally she chose the one her husband moved to directly from the hospital.
Another wife to be persuaded by a social worker of the need for nursing home
placement is Tova. She had been caregiving for her husband for over five years as his
dementia progressed. Due to fall at home, he was hospitalized. Tova also had not
remotely considered nursing home placement, though the burden of caregiving was
heavy on her. The issue was brought up initially at the hospital:
"I had not thought of it when they started talking to me. The social worker started
talking to me at the hospital that I need to find a place for him. I said stop talking; I am
not removing him from the house…the head nurse and everyone said that I could not
take him home".
Tova was told by health care professionals at the hospital that she would need
nursing home placement, but although her profession is nursing, she resisted this idea.
55
Ultimately, she had no option but to accept the advice of the health care professionals
because her husband was no longer able to walk.
A variation from the examples mentioned above is Ruth's case: the doctor treating
her husband recommended nursing home placement for her husband: "at the hospital
the doctor said: don't even think of taking your husband home. It is already impossible. He
needs to be in a nursing home". Ruth's husband suffered from mini strokes, and had been
at home with a foreign aide for the past four years. The current hospitalization signaled a
change is his condition, which now required constant medical monitoring. Due to the
doctor's order, Ruth had no option but to place her husband in a nursing home.
Similarly, Sara had no option regarding her husband being moved to a nursing
home. This was due to the fact that her husband was dependent on a breathing respirator
and needed constant medical supervision. In fact, unlike the other wives, Sara had no
option regarding in which nursing home to place her husband. In this case, the medical
state of Sara's husband dictated the necessity of nursing home placement and the
appropriate facility.
1.1.1
Influenced by family, not children.
Many of the wives in this study were the ones to initiate the process of nursing
home placement of their husbands. In cases where they were not the initiators, most
commonly influences in the family stemmed from the children of the couple, but in some
cases another member of the family initiated the process. For example, Masudi tells that
her sister-in-law helped her come to a decision: "it was difficult at home. He has one
sister. She used to come and visit. She said no, no, you can't. You need to find a place for
him. Even his sister". From Masudi's perspective, her husband's sister is a blood relative of
56
her husband, which implies that she has his well-being in mind as a first priority.
Therefore, if her sister-in-law acknowledges the need for nursing home placement, she
thereby legitimizes Masudi's hardships in caregiving and the complexity of the situation.
Another case in which the sister-in-law was of particular influence is Sarina's. Her
husband suffers from dementia, and she took care of him at home for five years before
the nursing home placement. Caregiving was difficult for her, and she was assisted by her
own sister. Once, her sister-in-law came to visit them and she was the one who brought
up the issue of nursing home placement:
"She (his sister) said to me- this is impossible, you are not normal…she came and
decided to place him in a nursing home. If it was up to me, I don't know if I could have.
But she did it, and to this day I thank her."
Even though her own sister assisted in caregiving, it took the active decision
making of the sister-in-law to start the process of nursing home placement. Sarina places
the responsibility for the nursing home placement on her sister-in-law, thereby relieving
herself from it. For Sarina, as for Masudi, having a member of the husband's nuclear
family legitimize the difficulty of continuing caregiving at home, and initiate the process
of nursing home placement, was a crucial point.
As mentioned earlier, when the nursing home placement was initiated by
someone other than the wife, most often it was by the children of the couple. The
incidents in which the children influenced the decision of nursing home placement fall
into two categories: a) shared responsibility and b) initiative of the children and sole
responsibility for the decision.
3.2.3 Joint decision making.
These participants describe sharing the decision making process and responsibility
with their children. In general, the women recall that the children became distressed
57
about the situation in the parents' home, seeing their mother overburdened by the
caregiving for their father. Then, the children discussed the idea with their mother and
pressured her into agreeing to nursing home placement. Fruma, when asked why her
husband was placed in the nursing home, tells that her children pressed her into this
situation: "it was pressure from them…to place him. When they saw that things were
deteriorating, then they pressured me". Fruma knew that caregiving for her husband was
difficult for her, even with the assistance of a live-in foreign aide, and she described
various aspects of the caregiving burden that she felt. After being pressured by her
children thus, they accompanied her in the search for an appropriate nursing home.
Similar to Fruma, Hava relates that her youngest daughter pressed her into placing
her husband in a nursing home. Hava recalls: "it was very difficult for us…and she says to
me, my daughter: Mother, do you want to bury yourself and me? He needs skilled nursing.
It is not for our capabilities". Unlike Fruma's children, Hava's daughter was living with her
parents and sharing the burden of caregiving. Her initiative to place her father in a
nursing home was based on the physical difficulties she shared in taking care of him.
Like the wives mentioned above, Cherna also tells that it was her children that
pressed her into the decision: "they wanted it. I didn't want to. They said – Mother, you
are killing yourself. I said but it is a lot of money". Interestingly, Cherna's opposition to
nursing home placement was her reluctance to spend money that she and her husband
had set aside for their children. She suffers from a heart condition, and was told by her
doctor that continued caregiving of her husband would kill her. Therefore, there was no
denying the need to place her husband in a nursing home, and she tells that her
reluctance to do so was related to financial aspects of the process. She felt she needed
permission from her children to utilize savings money to this end and she recalls: "I went
58
to the bank, and I said open up all the accounts, the children said their father comes first".
She justifies using the money in their savings accounts even to the bank teller. It seems
that although Cherna realized the objective need for nursing home placement, she places
the responsibility for the decision on the children's insistence on it.
Unlike these women who felt pressure from their children, Sophie tells of a
different process: joint decision-making with her children and her husband. As the
caregiving burden became greater, the issue of nursing home placement was brought up
with the whole family:
"Somewhere along the line, it got to be too much. So we spoke with Larry (the
husband), the whole family, my son, my daughter and I…and we said maybe a nursing
home would be a better place…everything is out in the open in our family".
In this case, Sophie and her children openly discussed the possibility amongst
themselves and included her husband in the decision making process. Following the
husband's agreement to nursing home placement, she and her son jointly searched for a
suitable nursing home. They then brought her husband to the proposed nursing home,
and after it was approved by him, the decision was final.
3.2.4 Decision-making by the children
The wives who experienced this type of decision-making relate a chain of events
that transfers the final decision and responsibility to one of their children. Usually
following an acute event, one of the children steps up and takes an active part in the
process of nursing home placement.
For Mazal, it was her daughter. After several years of caregiving at home with
Alzheimer's disease, Mazal's husband was hospitalized due to a heart attack. At the same
time, she was suffering from a broken arm, and both her sons were on vacation abroad.
She recalls what happened while her husband was in the hospital:
59
"My daughter said: now I am making the decisions. I am taking matters into my hands.
You (Mazal) can't say anything to me….I said whatever you decide is fine with me. I was
so very tired. She said I checked out a nice nursing home, and we will take him there. So
we did".
Mazal conceded to her daughter taking the lead in the making the decision on
transferring her husband to a nursing home. She remembers being overtired from the
continued caregiving at home, which had recently been complicated by her broken arm.
This caregiving tiredness, both physically and mentally, is presented as the background
for accepting her daughter's authority and handing over the responsibility for deciding
what would happen after her husband's discharge from the hospital.
Nili's recounting of the events that led to her husband's nursing home placement
is similar to Mazal. Her husband was hospitalized due to a broken hip after a fall. In this
case, it was her eldest son that took the responsibility and steered the process: "My son
said – you are absolutely not taking him home. You cannot take care of him. He can't walk
and he is incontinent…and that hurt me a lot, because I didn't want to take him out of the
house". She places the responsibility for the nursing home placement on her son, and
even recounts that her initial reaction of being insulted by even bringing up the
possibility. She accepts her son's authority when she realizes that her husband's condition
is such that she cannot take care of him at home any longer. Later on, Nili acknowledges
her son's correct assessment of the situation and says: "you could say that he saw what
was to come", and she is grateful for his insistence on a nursing home for her husband.
One manifestation of the responsibility for nursing home placement resting upon
the shoulders of the children is their searching for a nursing home on their own. Nili
recalls: "he (her son) went and searched for a nursing home, first by himself, and then he
took me to see also". As mentioned above, Mazal's daughter had also been surveying
61
nursing homes on her own before she insisted on transferring her father there after
discharge from the hospital. Unlike these cases, wives that felt shared responsibility with
the children relate that the nursing home search was conducted jointly.
This life situation in which one spouse continues to live at home and the other
spouse has moved to a nursing home is a process with a set point in time when the life
changing event occurred. Until now, I have addressed the context in which this event
occurred, and now I will address the lived experience of the wife living at home, while her
husband is in a nursing home.
3.3 Introduction to continuing and disengaging processes
The central finding of this thesis is that the wives of elder men in nursing homes
that participated in this study are undergoing simultaneous and opposing processes of
continuing and disengaging from attachment to their husbands and to their past lives
with the husband, in an attempt to adjust to their current life situation.
Before expanding on this and presenting the findings, I will briefly present two
theories that are relevant to the conception of the results.
3.3.1 Continuity theory
Continuity theory (Atchley, 1989) is a general theory aimed at explaining
continuity as a common coping strategy regarding changes in late life. General continuity
in one's life is constructed of internal and external continuity. Internal continuity refers to
a perseverance of personal structures based on past memories. External continuity refers
to living in familiar surroundings and familiar social interactions and roles (Atchley, 1987).
Continuity in this context is conceptualized "as the persistence of general patterns rather
than the sameness in the details contained within those patterns" (Atchley, 1999, p. 2).
61
Thus, continuity and change in a person's life are processes that may exist simultaneously
in varying degrees.
In the process of becoming an adult, a person develops habits, commitments,
preferences and such that become a part of their personality. Continuity theory holds
that, if possible, peoples' lifelong experiences will make them predisposed to maintaining
their habits and dispositions (Covey, 1981). The theory of continuity is concerned with
and centered on the adaptive process to aging throughout the lifetime. It deals with the
development and maintenance of adaptive capacity, assuming that in the face of
adversity most people will try continuity as their first adaptive strategy (Atchley, 1999).
Each person determines the degree of continuity in their life based on an
assessment of their current life compared to their remembered past. It should be
stressed that people classify themselves with regard to the degree of continuity in their
lives based on their own interpretations (Atchley, 1989). Degree of continuity can be
generally classified into three categories: too little, optimum and too much continuity.
Lack of continuity that is experienced as severe may also be called discontinuity.
Discontinuity refers to a change in patterns that is a dramatic shift, for example ceasing or
beginning an activity - "discontinuity focuses on significant departures from the past and
not on minor fluctuations within past patterns" (Atchley, 1999, p. 4). Optimum continuity
enables the person to view changes as manageable and cope with them. Excess
continuity means that the person feels caught in a rut.
3.3.2 Disengagement theory
Disengagement theory, formally delineated by Cumming and Henry (1961),
maintains that aging is a process of "mutual withdrawal or disengagement, resulting in
62
decreased interaction between the aging person and others in the social systems he
belongs to" (Cumming & Henry, 1961, p. 14). This process of disengagement is of
quantitative and qualitative nature. The number of people with whom one habitually
interacts is reduced, as well as the amount of interaction with each person. Additionally,
there are qualitative changes in the style or pattern of interaction with others, which
reflect decreased involvement.
Disengagement occurs in all areas of life, not just interpersonal ties. In addition to
social relations, people invest throughout their lives in possessions, activities, ideas and
other pursuits. Thus, the disengagement process may affect other various components of
a person's life (Carp, 1968, Hochschild, 1975).
Disengagement process may be initiated by the person or by their social
environment. A person initiates disengagement when they experience changes that alter
their motivation in maintaining bonds with others. Society may initiate disengagement
when a person's chronological age is delegated to a cohort deemed obsolete in its
capability to adapt to modern conditions (Cumming & Henry, 1961).
Sill (1980) has suggested that awareness of finitude may be a central factor to
disengagement theory, but is largely ignored. Awareness of finitude refers to the amount
of time a person perceives he has before his death. In his study of mostly elder women,
Sill (1980) found that chronological age alone was not a predictor of engagement in
activities. Instead, awareness of finitude and physical incapacity were more relevant to
activity level.
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3.4 Processes of continuing and disengaging
The state of being married to a spouse living in a nursing home is an intermediate
state – one is not fully married in the classic and conventional sense (i.e. conjugal
residence), nor is one widowed in the conventional sense, seeing as the spouse lives on
elsewhere. A state of being unable to continue marital life as before, while
simultaneously being unable to disengage from the husband, who now resides in a
nursing home. Unlike the status of widowhood, this situation is riddled with ambiguity
because the separation from the husband is not finite due to death. Neither is it a
desirable and voluntary separation, but rather has occurred due to circumstances. Thus,
the women participating in this study find themselves undergoing two simultaneous,
parallel and contradictory processes: continuing the past while disengaging from the past.
These processes exist simultaneously, even though they are contradictory,
because while the women may disengage in one life area from their past, for examplebehaviorally, at the same time they may continue their past in another area, for example,
emotionally. This state of simultaneous contradictory processes is precisely what makes
this life situation so difficult. The women are constantly propelled between opposing
feelings, thoughts and behaviors. Often the women do not recognize the processes
themselves, or they may do so only in hindsight.
In the following chapters I will demonstrate the processes of continuing and
disengaging that the women in this study are experiencing.
Processes of continuing and disengaging are individualistic and are expressed
uniquely in each participant. These processes of continuity and disengagement in the
wives' lives exist on three axes:
64
a. Emotional – processes of continuing and disengaging the emotional attachment to
the husband. These processes are intra-psychic, and refer to feelings towards and
thoughts about the husband. These in turn may be expressed through the other
two axes.
b. Social - processes of continuing and disengaging from the husband and from the
past in regards to the women's relationships with their nuclear families, extended
families and friends.
c. Behavioral – processes of continuing and disengaging in regards to behaviors,
habits and relations to lived space from the past. Some of these behaviors are
directly linked to the husband, and others are independent of him, but all are
currently influenced by the continuing and disengaging processes that the woman
is experiencing.
These axes are independent of each other and one does not reflect the other.
Some women undergo acknowledged processes in one axis, while others may experience
processes in all three axes simultaneously. Thus, a woman may be emotionally
disengaged from her husband in a way that is not reflected in her behavior towards him.
For example, Mazal who has been visiting her husband daily for the past seven years may
seem to be devotedly continuing her emotional attachment to her husband based upon
her behavior. However, she does not feel particularly attached to him anymore and does
not consider herself married. Conversely, a woman may continue to feel attached to her
husband more than her behavior would seem to indicate. For example, Dorona visits her
husband perhaps once a week, yet she feels as close to him now as ever before, saying he
is her whole world and the only thing that interests her in life.
65
The process of continuing emotional, behavioral and social attachment to the past
will be presented first along these axes. Then, the same will be done regarding the
process of disengaging. Some of the manifestations of the two processes are parallel, i.e.
for some women the home environment is an area of continuing life habits and
attachment to the husband, and thereby this arena has remained unchanged since the
nursing home placement. Whereas, other women are disengaging from their husband
and past habits in this same area, and have changed them since the nursing home
placement. These parallel manifestations of contradictory processes in identical life
domains accentuate the conflicting nature of the simultaneous continuing and
disengaging processes.
In the next section, I will first present the process of continuing attachment to the
husband and to the life the wife experienced prior to the nursing home placement along
the three axes mentioned above. Then I will present the process of disengaging that the
wife is undergoing regarding these same axes.
3.4.1 Continuing attachment to the husband – emotional axis
Many of the women feel continuing feelings of love and affection for their
husband. Some of them continue to perceive him as he was throughout most of their
lives, ignoring the physical aspects of his present appearance. Several of the women
participating in this study continue to be as highly attached to their husbands as they
were throughout their marriage. These couples are mostly characterized by marriages
that were filled with love and positive emotions between the spouses.
Two women particularly stand out in relation to the depth of attachment to their
husband in the past and in the present. Yaffa and Yochi have had long marriages (54 and
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63 years, respectively), which were experienced as highly satisfying and with a very close
connection between the spouses. This attachment to their husband continues in their
current life situation. This can be seen in the language that they use to describe their
husband's condition: the illness and its sequela are described in the plural first tense of
"we". Yaffa recalls treatments that her husband needed: "for a year we went to the
hospital every week… we7 took half a milligram (of medication) for six months, and it
made him feel bad". Though her husband was the one taking the medicine and feeling
the side effects, Yaffa describes the process of taking the medicine as a joint action.
Similar to Yaffa, Yochi also describes her husband's difficulties in plural first form.
Regarding the time when he started having trouble walking she says: "at home he was
with the walker…but we fell a few times…there was a stationary bicycle for training, so we
tried that as well". Yochi herself walks without difficulty; therefore she is clearly referring
to her husband's walking difficulties, and by using the first tense she indicates a very
personal experience.
These women's self concept is unequivocally connected to their husband. Their
deep attachment of many years to the husband continues in their current life situation. In
their minds, the husband is the same as he used to be, despite evidence to the contrary.
Yaffa's husband sits in a geriatric armchair with support cushions on either side, has an
amputated leg and a feeding tube directly to his stomach, and she says: "if it weren't for
his mouth hanging open, he would still look like my Isidore". Unlike others, her deep
emotional attachment enables her to continue seeing him as the man he once was.
7
Underlined text is my emphasis
67
Yochi and Yaffa describe an extremely close relationship at home while caregiving.
This close attachment continues when the husband is in the nursing home. As can be seen
next, the women in this study find encouragement in interpretations of various behaviors
of their husbands' regarding their continuing attachment to him.
3.4.2 Interpretation of husbands' behaviors as reinforcing continuing attachment
Many of the husbands of the participants are in a very deteriorated functional
state. Most are in advanced stages of dementing illnesses, i.e. they are no longer able to
perform self care activities, have significant difficulty in communicating and partaking in
meaningful interactions or activities. At this stage, many do not recognize their family
members, or may forget the family members' names. As demonstrated forthwith, some
women interpret certain behaviors and minimalistic reactions of their husband to the
outer environment as a sign of continuing attachment, directed especially at them.
Whether it is imagined or real, they feel that only they elicit this reaction or behavior
from him, and it is a sort of feedback for them, that motivates them to visit often, usually
on a daily basis. Some have been doing so for many years, and though the condition of
their husband has deteriorated much and perhaps such behaviors and reactions from the
past have dissipated, the attachment has not.
One such behavior interpreted as an indication of continuing attachment of the
husband to the woman, is being told by the staff that their husband constantly calls out
their name. A common symptom in advanced dementia is agitation, which may manifest
in shouting, yelling, and general psychomotor disquiet. The staff reports to Cherna that
her husband shouts often while she is not there, mostly calling her name. She interprets
this behavior as a sign of continuing attachment and of yearning by her husband: "There
is a nurse who tells me he is making a ruckus. He is shouting my name all the time. I said 68
what do you want him to shout? Your name? Of course he is shouting my name". For the
staff, the husband calling her name constantly is a nuisance and a common manifestation
of agitation and behavioral disturbances. From Cherna's point of view, it is a confirmation
that he needs her, misses her and is aware of her absence. This, in turn, reinforces her
feelings of continuing attachment and daily visits.
Yaffa has been visiting her husband in the nursing home daily for the past thirteen
years. He is currently in advanced stage dementia: not speaking or functioning at all and
sits in a geriatric armchair with his eyes closed all day. She describes her morning ritual: "I
go to him and I say good morning…and he licks me like a baby, as if he is kissing me". She
is the only one to elicit such a response from him: her son expresses jealousy of her
because he does not get any response from his father. This reaction is interpreted as
indication of his continuing unique attachment to her, and reinforces her feeling that her
husband is aware of her and that he needs/wants her particular presence. The nursing
home psychiatrist supports this interpretation and is of the opinion that: "he feels me. The
psychiatrist, who comes once a month, told me that he feels me". Confirmation by an
objective medical persona of her interpretation of his reaction to her reinforces her basic
assumption that their past emotional attachment is continuing, despite the change in
external circumstances and conditions.
Behaviors indicating continuing attachment in the woman's view may be less clear
cut than those interpreted by Yaffa and Cherna. For example, for Fruma a slight
difference in her husband's capabilities seems to take on meaning: "The children, he is
very happy to see them. He sometimes says their names…Me, he always calls by name".
She views her husband's ability to recognize her consistently as an indication of his
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continuous significant emotional attachment to her. The small nuance, that he recognizes
her by her name all the time and their children only part of the time, reinforces her
feeling that she is important to him, more than anyone else. Unlike Yaffa and Cherna,
who interpret an observable behavior of the husband, Fruma has difficulty pointing to any
certain behavior or reaction of her husband that may be seen as a unique sign of love for
her. She finds reinforcement of continuing attachment in the differences of recognition of
other close family members.
Tova visits every day, though she is not certain that her husband is aware of who
she is: "he is happy when he sees me. I don't know if he even knows who I am…When he
sees me from afar, he's happy." Unlike the other women mentioned, she does not
attribute this happiness to herself specifically, and even expresses doubt that he is aware
of her as his wife per se. But this positive active reaction is enough to maintain her
continuing attachment. She feels that her daily visits are significant for him and bring him
joy. Her continuing attachment to her husband is manifested in her daily visits for the
past four years: "I could not take that away from him, the little happiness that he has".
Though Tova says she feels emotionally frustrated by her daily visits, she simultaneously
feels compelled to continue visiting due to his reaction upon her arrival in the ward. Her
interpretation of his reaction to her as being unique and directed at her specifically are
the driving force for continuing to visit daily.
A different approach to behavioral interpretations of continuing attachment is
presented by Mazal, whose husband has been in the nursing home for the past seven
years. She has witnessed his slow deterioration, and currently he no longer speaks, but
for a few random utterances, and minimal interactions with the environment. She tells
that in the past, he recognized her and used to laugh when she came, but these behaviors
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have disappeared: "sometimes I say to him, Eddie, who am I? He just stares. Maybe it has
been erased. He used to laugh when I came. Today he doesn't". Nowadays, she refrains
from "testing" their emotional attachment, rationalizing that it might embarrass him: "I
don't know if he really recognizes me, but I don't ask. I don't want to, like, embarrass
him." Mazal positions herself as preserving his dignity by not posing questions that might
embarrass him, because he may not know the answer. She then compares herself to staff
members that occasionally prod him with questions in her presence: "Who is that? Who is
visiting you?...what kind of questions are these?". These questions put to her husband by
the staff upset Mazal, and she views them as demeaning to her husband – that they
relate to him in an infantile manner by asking "simpleton" questions. She prefers to rely
on past indications of his continuing attachment to her.
As presented above, the women in this study view various objective behaviors of
their husbands as carrying subjective, personalized meanings for them. The interpretation
of these behaviors is a part of the process of up-keeping internal continuity. In the
relatively recent past, due to the deterioration in the husband's state, assuming the role
of main caregiver was another manifestation of the women attachment to their husband.
The sudden upset of nursing home placement has not necessarily disrupted their
continuous perceptions of this role.
3.4.3 Continuing role as main caregiver
Upon nursing home placement, several women recall a sense of relief and
freedom from constant anxiety about their husband, his whereabouts and actions.
Others, such as Maya, expected to feel relief with his nursing home placement and were
surprisingly disappointed: "(life) was not better. I thought it would be…I thought there
would be a sense of relief". For Maya and others, the sense of relief they expected did not
71
appear. Instead, they realized that though their husband was now in the care of the
nursing home, their role as caregiver was not over, but rather, it was undergoing
modifications. Freedom from minute worries and hands-on care did not relieve them of
overall concern for his well-being. As Maya later states: "I have not been released from
the role of main caregiver. Who else will notice what is going on? Only me". Though she is
not giving direct care to her husband, Maya feels responsible to assure that he is receiving
proper care. Her role as main caregiver has changed from direct-care tasks to supervision
over the quality of care given in the nursing home.
Many of the women continue their attachment and commitment to their husband
by positioning themselves as his advocate and care monitor in the nursing home
environment. Due to the lack of control over the minute details of the husband's life, they
feel responsible for assuring the best possible quality of life for him in his present state. In
fact, quite a few view this as their main interest/cause in life. One example of this stance
is Dina's:
"I want to live longer than him, because I don't trust anyone else to care for him. And
immediately after that, I am ready (to die)…Actually I am ready (to die) right now, but I
need to watch over him".
Clearly, Dina continues to feel that she is in charge of the care her husband
receives, though she is no longer directly performing the care tasks. This sense of
responsibility as main caregiver has become very central, so that she has constructed her
life around it, and sees this role as giving meaning to her life.
The woman's visit to the nursing home usually lasts two to three hours. All the
women plan their visit in accordance with the schedule of the ward, timing their visit to
coincide with meals. In the morning most nursing homes serve a snack of fruit and a
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beverage at approximately ten o'clock. Later on, lunch is served approximately at noon.
The women who visit in the morning are present for both of these meal services. Most of
the daily visiting women reported doing so in the morning. One of the reasons for the
timing of these visits is in order to actually feed their husband, or to oversee that he eats
the meal properly. This also supports their perception of continuing to be a caregiver, by
allowing them to perform a necessary direct care task8.
In line with the view of continuing to be the main caregiver, many women
subscribe to the assumption that their constant vigilance and actual physical presence is
needed to assure that their husband receives quality care. The women in this study
visited their husbands in various frequencies, but the most common frequency was daily
visiting (fifteen participants). These women construct their daily routine around when
they visit and for how long. They are certain that frequent visitation contributes to the
quality of care that the husband receives.
Mazal states out-rightly that she does not trust the staff to give her husband
proper care. Responding to the question as to what has motivated her to visit daily for
the past seven years she says: "I don't believe them, I just don't believe them". Her
attitude is not lost upon the staff, and they have suggested numerous times that she
decrease her visiting schedule. But Mazal has seen the way they care for others, and does
not want that for her husband, and continues to visit and feed him daily. Her daily visiting
is a continuation of the role of main caregiver in its latest form.
8
Assistance in feeding is the only direct care task family members may partake in the nursing home. All
other tasks are done by the staff. Grooming is also done by some family members, but is generally not
perceived as a direct care task.
73
Sarina is another participant that feels that her daily visits positively influence the
care her husband receives: "It is better if you come daily…Even for an hour. I think it is
very very important. I surprise them...". Sarina not only visits daily, but she also changes
her visiting hours so that she may get an impression of the care her husband receives at
various hours. In truth, she attempts to keep the staff on their toes by changing her
visitation times, thinking that if they don't know exactly when she will appear, they will
give better care throughout the whole day.
The process of continuing from the past presented thus far has referred to the
first axis of continuing emotional attachment to the husband. The women in this study
focus much energy on this emotional aspect of continuing their past, but the process of
continuing the past is manifested in other aspects of life as well. Now I will present the
process of continuing in regards to the other axes mentioned earlier. First, I will address
the social axis. This refers to processes of continuing relationships from the past that are
not the husband: family and friends.
3.4.4 Continuing the social role of mother – social axis
Similar to continuing the role of caregiver to the husband in the nursing home, the
participants in this study attempt to continue their past role in another caregiving
capacity: as a mother. This can be seen first and foremost in regards to the protective
aspects of mothering. Although their children are all adults, mostly living in other
households, the women assume that it is still their duty to protect their children. While
caregiving at home, they attempted to shield them from difficult situations that were a
part of caregiving for the husband at home. They try to hide from their children their own
feelings of loneliness and frustration. Although they may partially share with their
children their feelings about the nursing home placement, they attempt to "be strong"
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when they are with the children so as not to be the cause of a sour mood/atmosphere.
They repress their own feelings in order to provide comfort to the children.
The women in this study are reluctant to share their feelings and emotions with
their children. They say that they don't want to be a burden to them, rationalizing that
the children are now busy with their own lives and concerns. For example, Tova says: "I
never tell them that I am frustrated. I don't tell them. They don't need that. They have
their own lives. They are still young. They don't need my frustrations". Tova's children are
unaware that she often comes away from her daily visit with her husband feeling
frustrated that there is "no one to talk to". She does not share these emotions with them.
On the contrary – relating a typical conversation with her children: "(they ask) how is
Dad? Dad is fine…did he know you? Yes, he knew me. It is fine, everything is fine. They
don't need to be bothered…". Although her children show a genuine interest in her wellbeing, she dismisses them with perfunctory answers, which are partially true, and avoids
sharing with them. She does this in order to put their mind at ease, rationalizing from the
standpoint of her mothering role that they have their own lives to lead and she should
not unnecessarily burden them with her own worries and feelings.
Tova later elaborates that this attitude is not new, and she has always avoided
sharing issues she thinks might be distressing with her children. In the past, she avoided
telling her children about her husband's health problems, hospitalizations, doctors'
appointments and such. And now, she continues with this behavior pattern, and does not
mention her own current health problems to them:
"I try not to disturb them. Tomorrow I have an appointment for a stomach endoscopy,
but I haven't told them...I was feeling very bad, with fainting spells and all that. I didn't
tell them at all…and you are home alone, and you don't know what to do…I don't want
to disturb anyone".
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Though she is in distress and has a disturbing health problem, which is intensified
by her living alone, she avoids sharing with her children so as not to burden them. Thus,
in her mind she continues the role of mother, by putting up a front of being able to cope
and being resilient.
Similar to Tova, Mazal admits that she avoids sharing her troubles with her
children, and that all her life she has coped independently. As an example, she recalls
when she had been ill with breast cancer - she refused psychological assistance, against
her doctor's recommendation. When her husband was first moved to the nursing home
she had a difficult time about it, but kept her emotions to herself: "at first it was very
difficult. Very, very difficult. Difficult for me. But I did not let the children see it. I did not let
them feel that it was difficult for me". Her husband's nursing home placement was set in
motion by her daughter after he had a heart attack and was hospitalized. The repetitive
nature of her statement reveals that she underwent a particularly upsetting time after
the nursing home placement, and she made a conscious effort to conceal her emotions
from her children.
In continuing the line of thought of her role as a mother, Mazal feels that she
needs to avoid burdening her children, but rather her role is to help them: "my daughter
lives close by. I don't go to her (house) at all, except on Friday. They are very busy
people…I need to help her. So should I sit and bother her?". In her mind, visiting with her
daughter more than a weekly visit would impose on the already busy life of the daughter,
and that is not something which a mother, who fulfills the role of helper in their child's
life, should do. She emphasizes that although they live close, she doesn't make a habit of
dropping by at their homes during the week for idle chitchat.
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Similar to Mazal and Tova, Iren, actively strives to conceal from her children her
distress with her husband's condition and her current life situation. She tells about an
incident when she was visiting her husband at the nursing home along with her youngest
daughter and he didn't recognize her daughter:
"We looked at one another, didn't speak. She cried a lot. I didn't want to cry. Because
when she cries; I want to be the strong one and not cry. Even though I cry often, but
when no one can see me. At night I cry a lot. I didn't cry…she cried and cried, I calmed
her down…never mind that I cried all the way home".
Iren puts up a front of strength for her daughter's benefit in a situation that was
difficult for both of them – being confronted with the deteriorated condition of her
husband. However, remembering her role as a mother and the need to be a source of
comfort to her child, she represses her own emotions and reactions in order to comfort
her daughter. Alone in her car, on her way home, she allows herself to express her own
emotions and cry. As she mentions, this is not a single incident: often she represses her
emotions and reactions until she is alone, for instance at night, and then she cries freely.
For Iren, like Tova and Mazal, concealing her emotions in this situation is a
continuation of the concealing she did while giving care to her husband at home. Her
husband has had Parkinson's disease for over fifteen years, and for most of that time
caregiving was done by her at home with the assistance of various aides. But as time
passed, his condition deteriorated and Iren tried to put up a front, and minimize her
difficulties in caregiving:
"I tried very hard that they should not see the terrible suffering that I went through.
When they came over…he would be sitting in the armchair, clean and organized, so they
would feed him a bit. That picture looks different from all the other caregiving (tasks)
that is unpleasant."
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In the context of caregiving at home, Iren had tried to protect her children from
realizing the difficulties she had in caregiving to her husband, and to prevent them from
understanding the whole of her suffering due to his deteriorated state and what it
demanded of her. Now that her husband is in the nursing home, she continues in this
vein, and though she cannot prevent them from understanding her husband's
deteriorated condition, she continues her attempts to hide her true feelings from them.
Another aspect of continuing the mothering role is that of providing resources for
their children; babysitting for grandchildren, giving gifts and financial assistance. A unique
manifestation of providing services while also refraining from becoming a burden to their
children is related in several participants' attitudes to the participation of their children in
financing the husband's stay at the nursing home.
As mandated by law, the Ministry of Health pays for entitled residents' upkeep in
full nursing care wards (known as a "code"). Applying for a "code" entails presenting
financial statements of the couple and their children. Based on these financial
statements, the Ministry of Health may decide whether the couple and their children
must partake in the monthly payment to the nursing home and what amount each party
will pay. Mazal personally pays a large sum of money every month to the nursing home
and does not apply for financial assistance in these payments, because she does not want
the Ministry of Health to require her children to partake in the monthly payment:
"Not a chance. They want the children to partake. That I should take from my children?
Children these days, they all need money. Have you seen a child that doesn’t need
money?...They each have their problems. So I should go and tell them my problems?...So
they should help me?"
By refraining from approaching the Ministry of Health for a code, Mazal continues
to pay over 10,000NIS every month, and has been doing so for over seven years. As
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mentioned above, Mazal views her mothering role in the context of being of
assistance/help to her children. In this case, refraining from applying for a "code", while
incurring all the costs of the nursing home, is a form of assistance to her children in line
with her being their mother.
Similarly, Fruma has been paying out of her own pocket to the nursing home her
husband has been residing at for the past four years. She too refrains from applying for a
"code" in order to avoid having her children partake in the monthly payment:
"I was told that the Ministry of Health starts to ask about the children's income…two
engineers I have, but you can't get rich from that…my eldest son now has two students.
So how can I request as well?…If I don't have to take from the children…the least
possible".
Both of these participants may be eligible for financial assistance for the nursing
home, but they do not exploit this option in order to avoid what they consider as being a
burden to their children.
Other participants have applied for the financial aid of a "code", and received it
with their children officially required to partake in the payment. In reality, they are the
ones to pay their children's part, as well as their own. Tala has no biological children, and
her husband has two sons from a previous marriage. One of his sons has been required to
partake in the monthly payment to the nursing home in a sum of 400NIS, but Tala relates
that: "the truth is that he doesn't have it and I pay for his share". Another participant
paying her children's share is Zari, who has ten children and several of them have been
required to partake in the monthly payment. Like Tala, in reality she pays out of her own
pocket some of their shares: "the Ministry of Health wanted financial statements from all
the children. I said I will pay…they wanted Amir to pay 400 and Ahuva to pay 800. I said
write yourselves down, and I will pay. You won't pay". It is relevant to note that Zari lives
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in near poverty, and yet she deprives herself in order to avoid her husband or herself
becoming a burden to their children, thus continuing the mothering role which has been a
central role in her life.
The role of mother and relations with children are central to the lives of the
women in this study. Additional social relationships from the past, other than children,
are also continued after the husband has been placed in the nursing home.
3.4.5 Continuing social ties outside the nuclear family.
Social connections continue to play a significant part in the lives of the women in
this study. Many of the participants continue to keep up social connections from their
past, albeit most of them experience a change in the character of these relations. Social
contacts currently tend to focus on relationships with other women, some of them
married and some widowed9.
The overall experience of the participants is of support from their social contacts.
Friends understand their reluctance to place their husband in a nursing home and support
the necessity of the placement. For example, Sophie was uncertain about the decision of
nursing home placement, though it had been made jointly with her husband and children.
She recalls support from a close friend, Hilda, who had also had a similar experience with
her own husband. Hilda told Sophie that she: "used to go over and over what had
happened. It was a stroke. So she said I should just shut away those thoughts that go
nowhere and move on". Sophie remembers Hilda's comforting words and tries to shut
away her thoughts that she feels lead her nowhere. She continues to receive support
9
Interestingly, no participant was acquainted with another woman outside the nursing home who was at the
time of the study in the same life situation.
81
from Hilda and other friends. They continue to meet frequently as before at different
coffee shops.
Friends continue to be a source of support and comfort to the women throughout
the time the husband is in the nursing home. Close friends understand their difficulties
and urge them to participate in events and activities. For example, Sarina says: "my
friends were very supportive and took me out to a lot of things…whether at work or at
home, they took me out". Sarina needed her friends' encouragement and incentive to go
out and participate in various activities, the most recent one being joining a weekly
singing club.
Sometimes friends rally around the woman and encourage her to do things she
would not consider doing on her own. For example, Iren took a trip to Morocco with her
friend. At first, Iren completely rejected the idea of going abroad while her husband is in
the nursing home. But her friend pressed her, and enlisted Iren's children in persuading
her and the funding of the trip, until Iren was convinced and they travelled there: "it was
a trip, which to this day I can't forget. Amazing…I came back a different person". Iren's
friend continues to encourage her to go abroad, and now Iren says the only limitation is
the financial one.
For Nili continuing close social ties is a priority. She has a standing coffee shop
meeting every morning at 11:00 a.m. with two other friends. She continued this routine
while caregiving to her husband at home, and she currently continues these daily
meetings and close relations. For this reason she visits her husband daily in the afternoon,
keeping her mornings free for meeting up with her friends.
Some women continue a social pattern of aloneness which was characteristic of
them for their whole lives. Tala and Dorona indicate that they are loners, have few friends
81
(if any) and prefer their own company. They have been so all their lives, and thus
continue now. Dorona seems to have a skeptical view about friends, and she says that
this has been true for most of her life: "In principle, I don't like girlfriends. Because the
best girlfriend will sell you out for a man. Not from personal experience, but from general
experience". With this view of friends, Dorona is in touch mostly with close family
members. She has difficulty walking and lives on the fourth floor in a building with no
elevator. Therefore, she now waits for others to come and visit and spends her holidays
alone.
Similar to Dorona, Tala has been a loner her whole life: "I have no friends. I never
had a social life. I am a loner…I am truly different from most people because I have been
alone since I was born". Interestingly, Tala was born and raised on a kibbutz, which is
considered a close knit society. She feels that her current social situation is a direct
continuation of what she has experienced throughout her whole life. Tala is an artist, who
spends her days with painting and writing mythical fables. Perhaps this accounts in part
for her tendency to be alone.
In summary, these sections have referred to the social aspects of the process of
continuing with the past in the life of the study's participants. The women continue the
relationship with their children similar to the past, emphasizing the protective aspects of
mothering and shielding their children from the burden of care for their husband;
emotional or financial. Other relationships also continue in the same vein as in the past,
providing support and motivation to continue engaging in social activities.
3.4.6 Continuing habits from the past – behavioral axis
The third axis on which we can find the process of continuing the past is a
behavioral axis. This refers to habits, behaviors and actions that the women continue
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with, which are ingrained in their past, and might not be exactly attuned to their current
life situation.
One of the issues that the participants in this study grapple with is the space, in
the physical sense, which their husband now occupies in their lives. Some of the women
in this study have changed their home environment since their husband was moved to
the nursing home, and some have not. As mentioned in the overview at the beginning of
the results chapter, the home environment is an arena in which the two contradictory
processes of continuing and disengaging are expressed in opposing behaviors. Here I refer
to those women continuing their habits and their lived space; keeping the home the same
as before the nursing home placement
Suzie is an extreme case of keeping the environment the same as before the
nursing home placement. Her husband was transferred just a month ago, and she has
kept the house exactly the same as it was: "the bed is made, the towel in its place, the
chair in front of the computer…nothing (has changed). He could come back tomorrow and
everything is the way it was". Suzie insists on maintaining the order of things as they
were; seemingly frozen in time, at least in outer appearance. This may be tied to a hope
that she harbors for his returning home. One might argue that Suzie's husband
transferred to the nursing home recently, and she is still adjusting, and therefore she has
kept the home environment the same. However, Suzie's adherence to continuing the
home environment as before can be seen also among women whose husband has been in
the nursing home for longer periods of time.
Sarina's husband has been in the nursing home for four years, and she has not
changed her home: "I haven't changed anything. He made this kitchen cabinet that I don't
83
want to throw out. There are things that you can't let go". In keeping the home
environment as it was before the nursing home placement, she is continuing the
attachment to her husband. For Sarina, continuing to hold on to objects that have special
meaning attached to her husband is a means of continuing to hold on to him. Her
reluctance to let go of these objects seems to reflect her reluctance to let go of her
husband. The environment shapes habits and lifestyle, by keeping it the same; she
continues past behaviors and habits, and by proxy feels that she is continuing her
attachment to him.
Some women, when their husband moves to the nursing home, continue the
spatial living arrangements that were relevant to the period of caregiving at home. Sophie
had an in-home caregiver living with her and her husband for several years. During that
time, she started sleeping in her study, so that the caregiver could be closer to her
husband's room. In the study, she sleeps on a day bed, and since he moved to the nursing
home, she has not returned to sleeping in the master bedroom:
"When the aide came, I moved to my study, a different bed and everything…I can't go
back to that room (master bedroom). I can't. I go in there, but no one sleeps there. I
won't sleep there. Because I am in my bed in the study by myself".
Though this habit was actually a necessity due to the circumstances of caregiving,
Sophie has continued with these sleeping arrangements. She feels she cannot go back to
the bed that she shared with her husband and sleep there alone; her lived space has
changed. It is not the room itself that makes her uncomfortable, but rather the change in
the space that is left empty in the bed that they used to share. By continuing the sleeping
arrangement from the caregiving period, Sophie also preserves their communal bed as it
was in their shared past.
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As for Sophie, also for other participants their current lived space expresses their
continuing attachment to their husband. For example, Nili continues to sit in her living
room in front of the television in the same chair, keeping her husband's armchair vacant:
"Interviewer: I see that you do not sit in his armchair.
Nili: Yes, I am used to sitting here. Permanently.
Interviewer: and you continue to sit in your chair.
Nili: yes, and Avi sits here (indicates chair next to hers). So when I want to show
something (to him), my hand automatically goes over there".
Her husband, Avi, has been in the nursing home for the past six months, and Nili's
lived space inside her home continues to be as before he was transferred; his seat affords
a better view of the television, but Nili does not even consider occupying it. In keeping
their seating arrangement as before the nursing home placement, Nili is continuing the
experience of her lived space as it was in the past. This, and Nili's referring to her
husband's presence in the present tense (see quote above) seem to indicate for Nili
preserving his "spot" is actually a way of preserving her husband's "place" in her life.
Similarly, Yochi continues to sleep on her side of the bed, and doesn't sleep on her
husband's side: "it is not easy…I sleep exactly the same. I dare not go to his side". She
continues to maintain his lived space in their bed, thereby defining her own lived space.
Interestingly, Yochi uses the word "dare" to describe the possibility of occupying her
husband's lived space. This verb is usually associated with taking risks regarding the
consequences that might transpire from certain actions. Seeing as Yochi and her husband
had a very close, even symbiotic marriage, it would seem to indicate that such an act is
not associated with fear of her husband, but rather that she perceives occupying his lived
space in their home as an action with consequences which she wishes to avoid. She too
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continues to adhere to her lived space from the past, and the left space in the bed seems
to symbolize the "place" her husband has in her life.
The participants in this study continue behaviors from the past not only in the
context of keeping the physical environment the same, but also in regards to general
upkeep and caretaking of their home. Continuing habits from the past, specifically
housekeeping and homemaking, are strongly influenced by the presence of adult children
living at home. In these circumstances, the presence of live-in children serves as an
incentive to continue the upkeep of the house as was before the nursing home
placement. For example, Esther's sons live at home with her: "I live with my two sons. One
just finished studying. The other lived abroad and now came back and hasn't found a
job…so they live here. Good thing that they do (laughs)". As evidenced by her last
comment, Esther is well aware that having her sons continue to live at home with her
serves as a protective factor from the implications of living alone.
Living alone after nursing home placement is accompanied by a decrease in
housekeeping tasks and chores, freeing up much time for leisure, which might only serve
to emphasize the situation of being alone. Continuing to provide in-home services for
grown children prevents the decrease in the amount of household tasks and the woman
continues to attend to the household similarly to before the nursing home placement.
This in turn enables to maintain homemaking tasks at a level she is familiar with. As will
be demonstrated later on, absence of grown children at home after nursing home
placement of the husband usually brings about a decrease in the quantity and quality of
home making tasks.
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Thus far I have presented the various aspects of the process of continuing that the
women in this study are undergoing in relation to their husband and their past. As
mentioned, this process can be delineated along the emotional, social and behavioral
axes, which have been demonstrated. The premise of this thesis is that while these
women are undergoing this process of continuing, they are simultaneously undergoing an
independent and parallel process of disengaging from their husband and their past.
The next section will present the process of disengaging that these women are
experiencing, also along the three axes of emotional, social and behavioral
disengagement.
3.5 Process of disengaging from the husband and the past
Disengaging in this context refers to the process of disconnecting the emotional
attachment from the husband. It may be that the disengaging process is subconscious,
but the manifestations of the process indicate undergoing a prolonged separation.
3.5.1 Disengaging due to changes associated with the husband - emotional axis
Sometimes changes the wife associates with the husband are due to a dementing
illness that he suffers from, but not only. By their prolonged and cognitively debilitating
nature, these illnesses gradually chip away at the husband's ability to be a viable partner
in the marriage. Limitations in functional capabilities and communication may undermine
the perception of the husband as a spouse and life partner, such as he was until now.
Disengaging is stated often in seemingly subtle statements, which may seem
lacking in emotional overtones. Disengaging can be found in little things, such as Betti
stating that she and her husband recently "celebrated" – her indication of quotes by hand
motions – their anniversary. This is stated in irony, as there was no real celebration and
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her husband wasn't aware of the significance of the date. Later Betti recalls that her
husband used to bring her gifts for their anniversary, and then breaks down and cries: "no
more gifts…there are no more gifts from him (crying)". The comparison between his
actions in the past and in the present to significant marital events enables Betti to
differentiate between her past and present attachment to her husband. Separating
between past and present in a defined manner is a way of discontinuing the past, and
redefining the present situation as inherently different. This in turn enables her process of
disengaging from her husband.
Betti is in the process of emotionally disengaging from her husband, similar
perhaps to the process of separating from a spouse after their death. But, for Betti this
process is drawn out over time and ambiguous because her husband is alive. She feels
conflict regarding her feelings for him. On one hand, she is attached to her husband in
light of the long relationship they have had: "we were together for almost fifty years. That
is a whole lifetime…we were together for so many years. Not one or two days. Forty seven
years, that's….that's…a whole world". Yet, later on, she expresses feeling that he is no
longer a partner in her life and does not share in daily burdens. Betti's attachment to her
husband is different from the past, because his moving to a nursing home has displaced
him from her life. Thus, she feels that he has become a stranger to her: "he is no longer
with me. He doesn't live with me. He doesn't sleep with me…he doesn't partake in
anything with me. I feel a kind of strangeness, that he is a stranger". This feeling of the
husband being a stranger and no longer partaking in her life is also linked to changes that
he has undergone due to his disease.
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Other women tell of discontinuity in the husband's behavior or personality that
affects their degree of attachment to him. For example, Rachel's husband has Alzheimer's
dementia and she has seen his personality change from the beginning of the disease: "he
went to the day center and sat all day and played dominoes. And he became, he changed
his skin, became a convenient, submissive person…does what he is told. Just the opposite
from what I knew all my life". The change in her husband's behavior due to the dementia
started a process of separating from him. Rachel feels that she has already undergone a
bereavement process regarding her husband and her marriage. When her husband fell ill
fifteen years ago she cried endlessly, which was unlike her. This brought her to seek
professional counseling, and a social worker told her: "she explained to me that I was
grieving. I was grieving for the person I lost…you lose a person while they are still alive…
and when she told me that I immediately realized that this was the situation". Thus,
Rachel disengaged her emotional attachment to her husband by grieving for her loss,
while her husband was still alive, but significantly changed from the person she had
known him to be.
3.5.2 From wifely feelings to maternal feelings
A specific change some women feel is that the husband has become childlike, and
their feelings for him are now of a maternal nature. Usually, these feelings and
perceptions have evolved throughout the period of caregiving, and are often linked to the
character of the caregiving tasks that they performed. Currently, they perceive their
husband as a helpless child, which they need to protect and fret over his wellbeing. This
perception and the accompanying feelings are fundamentally different from past feelings
that characterized their marriage. For example, Suzie has been married for 67 years,
during which her husband was very dominant in the marriage and she bowed to his
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wishes. Since he had a stroke, she has had to take charge of running the household and
giving him assistance in activities of daily living. This significant shift in marital roles and
the vulnerability of her husband in his deteriorated state, has wrought a major change in
the way Suzie perceives him:
"He is my baby, but not my husband…since that stroke…he was no longer a husband, he
became a baby…that doesn't mean that I am less attached to him. It is just
different…now when I leave him there, I leave a baby for others to care for".
Suzie continues to be attached to her husband as she states, but this attachment
is of a different kind from the attachment throughout most of her marriage. The change
from perceiving her husband as a life partner to perceiving him as a child has left Suzie
feeling alone and desolate. She is still attached to him, but as he is perceived as a child, he
is not a source of support and solace, as he used to be in the past.
Similarly, Ruth also feels that there has been a shift in the way she perceives her
husband. For her, the change from a person that was many things to her has narrowed
down to him being dependent on her and has affected her perception of him:
"You see a person that was a man, loving, a friend, a companion, a father, a husband
and suddenly you see a small child... suddenly your husband that was "the" one for
you...You see a child that needs to be helped".
For Ruth, the dependency of her husband due to his condition caused a shift in her
perception of him, from partner to needy child. Like Ruth and Suzie, Tova also currently
views her husband as a child: "suddenly he is like a little boy. He is not an adult at all…with
those drawings that he draws…". Tova perceives her husband as a little boy, and his
current favorite pastime of drawing seems to reinforce this perception. Her husband
started drawing only after he became ill, and she bought coloring books to keep him busy.
In the nursing home he continues to draw, and there has been a change in the quality of
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his drawing. Tova seems to react to this change in a maternal fashion, concerned with the
quality of the results: "Now he doesn't keep to the lines or the colors. I ask him why he
colors everything green now…today he used brown… he colored the whole tree brown. I
don't understand it". She later says that the occupational therapist explained to her that
the quality of the drawing is not very important, but this does not seem to ease her mind.
His drawings serve as a sign of the change that her husband and her perception of him
have undergone.
3.5.3 The disengaging process manifested in the character of visiting
Parallel to their process of emotional disengaging from their husband, as
mentioned earlier, these women continue their role as main caregiver to him. In the
nursing home environment, this role has been transformed to advocate and care monitor.
These roles they fulfill faithfully. Perhaps these roles are a throwback to time of caring for
children attending an organization outside the home (i.e., school). Seeing as the feelings
many of these women currently have toward their husbands are of a maternal nature, it
seems likely that they are comfortable fulfilling roles of maternal nature that they had
fulfilled in the past. When their children went to school, they had no control over the
minute details of activities in the school, but were involved in the general monitoring of
their children's school experience. Similarly, currently they monitor the husband's life in
the nursing home.
Women who visit daily may be devoted to their husband in their visitation
schedule, but this does not contradict their emotional disengaging process from him.
Several of the women mentioned above as undergoing a disengaging process from their
husband and changing their perception of their feelings for him visit daily. A minute
scrutiny of the character of their visit may show indications of the disengaging process.
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Tova visits daily and after the initial affectionate greeting to her husband, spends
her time on the ward assisting in the care of other residents and interacting with the staff.
Although, she comes with the purpose of visiting her husband, his deteriorated state and
limited capabilities for social interaction leave her feeling frustrated, and she turns to
other ways of passing the time:
"(you) sit there for two hours and you can't have a conversation or words or ask something
(with him). So I help them out there. I help everyone, so that sometimes people think I work
there. But I can't sit all the time. He sits there and scribbles on paper and you can't talk to
him."
While Tova seems to visit for her husband's sake and in order to be with him, in
practical terms she invests relatively little time and energy in her husband while visiting in
the nursing home, preferring to assist in the care of other residents in the ward. So much
so, that she feels that outsiders may accidentally assume she is part of the regular staff.
Thus, the emotional disengaging process she is undergoing is manifested in the character
of the visit.
Similarly, some of the daily visiting women, such as Mazal and Fruma, always go
and sit in the public areas with their husbands. In these areas, it is customary for other
visitors to gather with other residents, and there is much socializing among everyone in
the public area. Thus, they are accompanying their husbands and they are able to interact
and converse with many other people during the visiting hours. While sitting by their
husbands, and feeding them the midmorning snack, these women's attention and
interest is mostly directed to the other people in the public area. For example, Mazal
describes what she does during a visit to her husband: "I take him outside. I sit, I converse
with other people. He listens. Wherever I go - people come there and sit and
chat…sometimes he falls asleep, I sit beside him. I give him food…some food I bring from
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home…until lunchtime". Her interaction with her husband focuses on feeding him, while
she is interacting socially with other people in the public areas.
These daily meetings in the nursing home with other visitors may develop and
become more than cursory acquaintances. Some of these connections with others have
developed into relationships outside the nursing home. Nili recalls, once when she went
away to her daughter's house for the weekend, an acquaintance from the nursing home
(a visitor to a different resident on the ward) called and inquired where she was.
These women demonstrate that though they visit daily, their focus during the visit
may not be their husband. Thus, although they seem to be continuing their attachment to
him, the daily visits may actually serve other purposes, for example socializing. The
women may visit daily while disengaging emotionally.
Thus far, I have presented the emotional axis of the disengaging process. This axis
is centered on the process of disengaging from the attachment to the husband of many
years. The women are mostly aware of the changes their emotions have undergone
regarding their husband, although some manifestations of disengaging may seem to be
less clear-cut.
The next section will reflect the social axis of the disengaging process from the
past: in relation to family and friends.
3.5.4 Disengaging from family - social axis
The women in this study find themselves disengaging from their family in relation
to the ties and relationships they had with these same family members in the past. The
reasons and circumstances for the disengaging process may be various, but the process
itself is the common experience.
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One of the consequences of their husbands' illness for many of the women is that
they are limited in their transportation options. Many women never got a driving license,
and relied on their husband as their mode of transportation. Since his deterioration and
nursing home placement, they have been more limited in the travel options. This affects
their opportunities and ability to visit with family and friends. Several participants
mentioned this limitation as a general reason for the tapering off of contact with their
children who live far away from their home. For example, Fruma has not visited her
children and grandchildren for several months because they live in a remote area with
limited public transportation access: "They live far. No one lives in this city...they come to
visit me, to visit their father, sometimes the grandchildren come alone, sometimes I visit
them, but rarely, because it is difficult for me". She feels that her limited ability to visit her
children, and other family members such as close cousin, affect their relationship, and
they are not as close as she would like them to be. Recently Fruma was hit by a car and
she suffers from pain in her hip, which limits her ability to walk and she finds visiting her
children even more complicated and difficult than in the past.
Another participant that finds herself disengaging from her children in light of
transportation limitations is Dina. Though she does drive, she limits her driving to short
inner city distances and in daylight. Visiting her children, all of whom live outside of her
town was dependent on her husband driving them. Since his nursing home placement,
she has not visited her children outside the city, and feels that her connection with them
is weaker than before. She attributes this weakening of ties to her limited driving: "I keep
thinking that if he were here now…I would go visit with him more than I do now. I invite
them over all the time, but they are busy…and I miss that". Though Dina would love to
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have her family visit at her home, they do so infrequently. This, combined with her driving
limitations, has limited her contact with her children and grandchildren.
Several women have experienced disengaging from their children and
grandchildren as a direct result of the nursing home placement. Yaffa and Yochi have
both become estranged from their sons.
Yaffa's son cut off his family's ties with her when he was requested to participate
in the governmental payment to the nursing home for his father. This happened after
Yaffa applied for a "code". As mentioned earlier, a "code" is the financial support that a
family may receive for the nursing home occupancy. This financial help is given after
scrutiny of the couple's finances, as well as that of their children's. The spouse and the
children of the patient are required to participate in monetary monthly payments
determined by the Ministry of Health based on their financial capabilities. Yaffa's son
blamed her when faced with this financial requirement:
"(the Ministry) demanded my son Ricki and his wife should produce three months' salary
accounts. He calls me up at 10:30 p.m. and I hear my daughter-in-law shouting: where
will we get 426 NIS every month…let her pay and when it is gone then we will
participate. I said to him, you know what Ricki, you don't have money? You don't have
to pay. For four years my son and his family didn't show any interest in me. He would go
visit his father, but never me. He didn't even call".
Nowadays they are back on speaking terms, but their relationship is strained, and
Yaffa does not feel that they are a source of support for her. This disengaging process was
instigated by her son and the quarrel lasted for four years, during which there was no
contact between them. However, even after reconciliation, Yaffa remains disengaged
from her son and his family, keeping up only perfunctory ties with him and his children.
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Similar to Yaffa's case, the disengaging process with Yochi's sons seems to have
been instigated by them. They stopped speaking with her, and though they live in the
same town, she depends on other people's generosity for transportation to visit her
husband. From Yochi's story, the background for the estrangement is unclear, but it
started when her husband transferred to the nursing home (before that they had assisted
her at home with his care) and she alludes to financial disputes as the basic reasons for
this situation. Her sons independently visit their father: "He (the elder son) doesn't speak
to me. Nothing…Not on the holiday…he goes to the nursing home twice a day, but he
doesn't give me a ride".
Though the disengaging process may have been initiated by the sons in the cases
of Yaffa and Yochi, it has become a reciprocal process and the women have significantly
decreased any attempts to revive the relationship to its past character.
In a more subtle way and for different reasons Shira is disengaging from her two
daughters. She feels that they view her as an old invalid and diminish the value of her
opinions:
"They treat me as if I were already 90 and without a clear mind. That's how it feels. So I
don't tell them anything like I am telling you…they decide for me. They give me advice. I
hear them. I don't say anything, but I don't get a good feeling at all. What can I do?
There is nothing to do".
In Shira's case, she feels that her daughters discount her opinions and her real
needs, arranging assistance for her that they deem necessary without consulting her. For
instance, one of her grandson's has recently moved into her apartment, supposedly to
help her out in the home. But, Shira says dismissively of him that he is out at all hours and
is of no real help, perhaps even a hindrance, to her. Outwardly, she seems to accept her
daughters' decisions, such as having her grandson come and live with her. Yet,
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emotionally she is disengaging from them, as she mentions above: not sharing her
feelings with them, keeping her opinions to herself, hearing their advice but not accepting
it. It seems Shira is reciprocating her daughters' attitude by disregarding their advice and
what she feels is feigned interest in her. In this case, as well as with Yaffa and Yochi, the
disengagement between the participant and children appears to be mutual.
3.5.5 Disengaging from family events and gatherings
One of the instances that turns a spotlight on the difference between the past and
the current life situation for the women in this study are occasions of Jewish holidays. All
the women in this study recall celebrating the holidays at home with large family
gatherings, which they hosted. Nowadays, most of them refrain from hosting the holidays
at home, and prefer to go to one of their children's homes. Though they are continuing
the connection with their family, there is a feeling of disengaging from the past and from
the way things were due to the change in the locale and the absence of the husband.
Their enjoyment of the holiday is not as it used to be. As Betti says:
"The holidays are difficult…every time there is a new holiday I wish that it will pass
quickly, quickly. I don't enjoy the holiday. It is not the same. Each one is sitting with
their partner and I am alone. I am with my children, my grandchildren, but it is not the
same".
For Betti, the holiday is currently something to get through, unlike the
celebrations that she enjoyed in the past. Masudi also has changed her view about
holidays, disengaging from the past: "we used to do the holiday properly. The children
came, the grandchildren came, everybody came to our house, and friends came. The
house was full. Now we are done with that". In Masudi's case the spotlight on the
difference between past holidays and current holidays is focused on the locale. She
continues to prepare the holiday feast (claiming her daughter-in-law doesn't cook well),
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but rather than entertaining in her home with her husband, she takes all the dishes to her
son's house. This change of locale reinforces her sense of disengaging from her past.
Another sphere in which the participants are disengaging from their social past is
regarding attending family events and gatherings, which often occur on holidays and lifecycle events, such as weddings. Since their husband is no longer able to attend with them,
after the nursing home placement many of the women recall having avoided going to
extended family events, for example Sarina: "at first I couldn't go to weddings, and I didn't
go out. He was the type (of person) that we went out all the time…so it was really difficult
for me". For Sarina, as for others, the contrast of having attended family events as a
couple was in stark contrast to the possibility of attending these events on her own. It
was easier for her to avoid family events in the initial period after the nursing home
placement. As time went by, most of the women were pressured by family members to
attend extended family events. They then adopted a habit of being escorted to these
events by their children. For example, upon returning from a family event Simcha insists
that her son escort her to her door: "if there is a wedding, I attend with my sister and my
son, and I tell my son to take me all the way home". Though insistence on her son
escorting her to the door may be due to anxiety about being out at night, Simcha refuses
to attend extended family events on her own. She attends with a nuclear family
entourage of her son and her widowed sister, which is regarded as an acceptable
alternative to attending as part of a couple.
Even with an acceptable alternative entourage and escort of children, many of the
women prefer to avoid going out to family events if they can. When they do attend, it
may be for a short period of time, putting on a perfunctory appearance. Cherna recently
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attended a Bris 10 for a new great-grandson: "I have a grandson whose wife just gave birth,
so they had a party at my daughter's house. They took me there for lunch. I said take me
home quickly. If your father isn't here, neither am I". Though the event was held at her
daughter's house, Cherna felt uncomfortable attending an event without her husband
and after a quick luncheon insisted on her son taking her back home.
3.5.6 Disengaging from social ties outside the family.
The disengaging process in the social axis has thus far related to the nuclear and
extended family of the participants. Social networks accumulated throughout the lifetime
include also friends, neighbors and casual acquaintances. The disengaging process occurs
in regards to these figures as well, though perhaps it is not experienced in the same
intensity as with family members.
The participants in this study are elderly women with an average age of seventysix years. At this stage of life, if only due to their chronological age, they have experienced
loss of friends and acquaintances. This issue was the main reason cited by the participants
as an explanation for a decrease in their social relations outside the family. Meeting with
friends is limited because of difficulties in mobility or transportation. Many of their
friends have passed away. As Fruma says: "my social circle is gradually shrinking…age
does its part for some of us, and the rest that are still here have a difficult time. Rarely do
we meet". Not only has their social circle from days past shrunk, but also debilitating
conditions of those that are still living restrict opportunities to continue the social
relations as they were. Therefore, the process of disengaging from social ties with peers is
often not a choice, but rather occurs due to circumstances – their own life circumstances
and the life circumstances of their social contacts.
10
An event celebrating the circumcision of a new-born Jewish male.
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As mentioned earlier, most of the women in this study relied on their husband to
drive them. Since he is no longer capable of doing so, they need to use public
transportation, and that coupled with even slight mobility difficulties makes getting
together with friends complicated. Also, some participants mentioned that their friends,
who used to live close by, have moved away. For example, Shira has a long time friend
who moved: "she used to live in this city and we were very very close…we were together
all the time. Her husband passed away and she moved to a far city, where her daughters
live. Now we just talk on the phone". This geographical move away of her friend has
affected Shira's social connection with her, and the geographical distance limits the
character of their friendship to phone calls alone.
Whether the friends moved to be closer to their children or to residential facilities
for the elderly, these changes in location increase the difficulty of continuing social ties.
For all these reasons, most of the disengaging process of social ties is presented as a
naturally occurring and unintentional drifting apart in relationships.
Some of the women in this study recall having met with hostile responses to the
nursing home placement from social acquaintances. These responses expressed the
assumption that they had transferred their husband to the nursing home in order to
make their own lives easier and more convenient. In some cases, these responses were
passed on by other closer social contacts, and in other cases these words were flung
directly at them. Sophie recalls: "people said to me, not friends, but acquaintances in the
neighborhood – you put him in the nursing home so now your life is easier. That hurt me.
That really hurt me". Like Sophie says, insinuations such as these are not made by close
friends, who are familiar with woman's difficulties in caregiving at home, but rather by
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casual acquaintances and neighbors. Nonetheless, these insinuations seem to hit a nerve
in the women who are the brunt of them. This may be because seemingly there is a hint
of truth to them. Most of the participants experienced a certain kind of relief, usually
physical, when their husband was transferred to the nursing home. This is the obvious
result to onlookers, but they are unaware of the emotional hardships involved with the
nursing home placement, and the loneliness these women now experience.
Sometimes social ties become strained or are severed due to a conscious choice
by the woman, and are related to her current life situation. Zari has chosen to stop going
to her social club and prefers to stay at home alone and suffer loneliness, because she
doesn't want to discuss her husband's condition with other people. Similarly, Dorona
explains her reasons for decreased socializing:
"I don't want anyone. What would I talk about? So that they should pity me?…They
already said why do they let him live for so long and all that…I don't want to hear
that…people listen to other people's troubles so that they can gossip later on".
Despite having earlier presented herself as a loner by character, and one who
tended to have few social ties throughout her life, Dorona is disengaging from the few
ties she has. There are several reasons for this current disengaging process as explicated
in this quote. First, she is highly sensitive to being pitied by others, and mentioned her
distaste for such pity several times in the interview. Repetition such as this may indicate
that in her mind there is a reason for pity of her current life situation. Second, she seems
to feel that her social contacts' interest in her life is not focused on empathizing with her
and her difficulties, but rather they regard her as a gossip item. And third, from the above
passage clearly the issue of her husband's condition has been discussed in the past, and
the general stance was that he would be better off passing away. For Dorona, who
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continues to be very emotionally attached to her husband, such sayings are unacceptable
and she would rather avoid the company of those who prescribe to this view.
Similar to Dorona's attitude, Yaffa has taken disengaging a step further. Whereas
Dorona avoids social contacts that she feels are currently unsupportive of her, Yaffa
actively severed social ties that do not support her current life choices:
"I cut off from people that said to me: why do you visit him daily, he doesn't see or hear.
He doesn't know whether you visit or not. I said we are through… I don't want to see
you or hear from you, and don't call me on the phone. I am erasing you. And I did."
Yaffa takes the disengaging process to an extreme and severs social ties with
anyone who is unsupportive of her current life choices. She is unwilling to accept any
criticism of her continuing devotion and dedication to her husband. Thus, Yaffa finds
herself isolated and alone, saying: "Friends? There are no friends". Although she laments
her loneliness and social isolation, Yaffa refuses to maintain contact with anyone (family
or friend) who is less than wholly supportive of her current conduct.
Whereas Yaffa's conduct in severing ties is extreme, other participants have
weakened their social contacts simply because they devote all their time to their
husband. Yochi outlines her priorities: "I have detached myself. I cannot go to exercise
class. I use my time to come to the nursing home". Yochi and Dina have stopped going to
their social clubs, not for lack of support from other members there, but rather because
they choose to spend most of their waking hours at the nursing home by their husband.
Another participant that is disengaging from her former social ties is Cherna. She
has not severed ties intentionally due to perceived lack of support or for lack of time for
socializing. Rather, this seems to be because she has mixed feelings of loyalty and guilt
about her husband that affects her social life. Cherna participates shortly, if at all, at
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social outings because she feels disloyal to her husband if she enjoys herself, while he lays
in the nursing home: "I have friends but I don't have any patience for them…how can I get
dressed up and go out when my husband is sitting there and suffering all the time?".
Cherna limits herself to visiting the nursing home and activities that are functional and
necessary for living. Her loyalty to her husband does not allow for frivolous activities, such
as socializing, so long as he is not a part of them.
In summary, disengaging in the social axis can be in regards to children and other
nuclear family members, and in regards to friends and acquaintances. The process of the
participants' disengagement is generally propelled based on real exchanges or presumed
attitudes that the participants feel that others may hold. However, mostly it is related to
their own perceptions and/or feelings about what they have now compared to the past,
and their feeling that they cannot continue as before which leads to disengaging.
3.5.7 Disengaging from past habits - behavioral axis
The absence of the husband is felt not only subjectively, but rather can be
measured in an objective manner – by tallying daily and weekly household chores.
Caregiving is by its nature a time of increased household chores for the caregiver, since
they need to assist in the personal care of the care receiver, attend to their own personal
care, and are responsible for the instrumental tasks of daily living for the household unit.
Nursing home placement dramatically decreases the number of tasks necessary in the
household. Even more so if the husband suffered from behavioral problems that impeded
the woman's ability to attend to the various household tasks. The woman now attends
only to her own activities of daily living and the volume of daily chores decreases
significantly.
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In this next section I will demonstrate various behaviors, habits and activities
manifested by the women participating in the study as part of their disengaging process
from their husband and from their past. Some of the behaviors are directly linked to the
husband, and other behaviors are not. Behaviors not directly linked to the husband are
included in this process because they are influenced by the current life situation and
occur in the context of the nursing home placement of the husband. These behaviors
appeared after the nursing home placement, and are qualitatively different from
behaviors during the caregiving at home period, or any other period of conjugal life in
their married past.
3.5.8 Changes in homemaking and housekeeping tasks
Many daily habits change after the husband moves to a nursing home. The woman
suddenly needs to adjust to preparing and caring only for herself. One area in which the
participant women perceive a difference in their daily lives is housekeeping chores,
especially compared to the period of caregiving at home. These chores of cleaning,
laundry, even dishwashing, taper off significantly once the husband is transferred to the
nursing home.
Interestingly, the issue of nutrition and food preparation becomes a central
concern and eating habits change. Many of the women related changing their eating
habits after the husband left the home as something that happened to them, unplanned
and unintentional. Most of them have ceased cooking throughout the week, and cook on
the weekends with the expectation that their children will visit them.
Attitudes towards food preparation also reflect the division of household
responsibilities throughout the marriage. In all the participants' households, the women
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were responsible for preparing meals and food. In fact, the women in this study have
never before been in a situation in which they are responsible only for themselves. They
went from their parent's home to their marital home, never having lived on their own,
without significant others to care for. The sudden change from preparing and caring for
others to preparing and caring only for themselves is a difficult adjustment, emotionally
and functionally. They need to adapt their food preparation habits from cooking for
several people to preparing for a single person.
Grabbing a light snack, a sandwich, cold food or buying prepared food are some of
the ways the women in this study currently get their nutritional sustenance. Food has
become functional, something that needs to be done in response to a biological need.
Participants who enjoyed food in the past in different ways: cooking, baking, and eating;
have changed their relation to this issue. Yochi states that she simply does not feel like
cooking, relating that she has tried to: "I come home and I don't feel like eating. I don't
feel like cooking…Once I cooked…I thought I would come home and I would have soup. It
was left over, I forgot about it. I grab something here and there". She has been in a
depressive mood since her husband moved to the nursing home. This has affected her
appetite, and her efforts and attempts to continue eating well as before are minimal.
Another woman that has stopped cooking is Maya. She has taken to eating only
sandwiches, but her habits regarding food have only partially changed:
"I don't think I have cooked a full meal since (he left). And once I used to cook large
meals. I throw out a lot. I don't know how to buy well yet. So I buy and it sits and sits
and sits until I throw it out".
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Though Maya has changed her nutrition and food preparation habits, this
necessary functional change has not seeped through to her mind in regards to purchasing
food products. Therefore she finds herself throwing out many food items.
Maya gives insight as to one of the reasons for cessation of cooking among the
study participants. When asked why she no longer cooks, she responds with a rhetorical
question: "for whom would I cook?". The nursing home placement has usually left the
women living alone, and they may often feel that they are not worth the bother of doing
things such as preparing food or setting a table. Tova echoes this sentiment. She has
stopped cooking since the nursing home placement, unless she knows that her children
are coming to visit. When asked why, she responds: "There is no one to prepare for…only
when the children visit I cook. Then I freeze food for myself. I don't think to prepare food
for myself, cooking and such". The lack of significant others to prepare for brings about
avoiding food preparation, and reflects the disengagement process in her present life, as
compared to before when her husband was at home.
A broader explanation of the influence of lack of significant others on preparing
food for is supplied by Betti. Initially, after her husband was transferred to the nursing
home, she was home alone, and avoided other people. Her food intake was limited to
snacking on available food items that didn't need lengthy preparation. Lately, that has
changed: "I started cooking again. And every time I cook something that they like, it does
me good, because I get compliments from the children. My grandson says I make the best
chicken soup in the world". Betti's food preparation continues only in the context of
preparing for significant others, as she did in the past with her husband at home. For her,
receiving feedback from the people consuming the food she prepares is important. When
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her husband was home, she received such feedback from him. Currently, in the absence
of such feedback - living on her own, she does not make the effort involved in preparing
food as in the past.
3.5.9 Changing the home environment
As mentioned earlier, some participants continue to keep their home environment
the same as before their husband transferred to the nursing home as a part of their
process of continuing attachment. In accordance with the central premise of this thesis,
that women in this life situation undergo simultaneous and opposing processes, some of
the participants reported changing their home environment when the husband
transferred to the nursing home as a part of their disengaging process.
For example, Riva recalls that when her husband was moved to the nursing home:
"I immediately threw out the bed and bought a new bed. Now I am like a queen (laughs)".
Riva revels in the change she made to her home, something she had wanted to do for a
long time, but refrained from doing so as long as her husband was at home. Seeing as her
husband suffered from urinary incontinence, it is understandable that she happily
exchanged the old bed for a new one.
Some environmental items, in particular the husband's possessions, are easier to
change as time passes and the husband is in the nursing home longer. Masudi tells that
there are no more of his clothes at her home. She has transferred all of them to the
nursing home, for him to use. This seems a sensible thing to do, and thereby is not
perceived by Masudi as a significant change in the home environment. Sarina also relates
that she recently gave away some of her husband's many clothes, and by the way also
cleared closet space for her coats.
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Sophie was mentioned earlier as an example of a woman who no longer sleeps in
the master bedroom. Yaffa's current sleeping habit is similar, for she too has moved taken
to sleeping in a different room. However, unlike Sophie who made this change while her
husband was still at home, Yaffa only moved to a different bedroom when her husband
moved to the nursing home:
"I would wake up, looking for him. I left that room, like the doctor told me to. I moved
the television to a different room and I sleep there. I have three bedrooms…so I went to
sleep in the room that belonged to my son. And in that bedroom I put a small table, two
chairs and the television".
Yaffa was unable to sleep well in the bedroom she used to share with her
husband, and therefore moved her sleeping arrangements to a different room. She also
transferred her cosmetics and makeup to the dining table by the living room. Sleeping in a
bedroom she had never slept in before is a significant divergence from her past habits.
Although Yaffa is still very attached emotionally to her husband, her change in habits is a
manifestation of disengaging from the past and from her life with her husband.
3.5.10 Taking charge of financial matters
All the participants in this study have experienced some change in regards to their
financial status and expenditures. Most of them were uninvolved in fluent monetary
transactions throughout their lives, leaving the handling of finances to their husbands,
and signing bank papers when told to. With the nursing home placement, they are left to
fend for themselves in this area. Though many of the participants were handling finances
during the caregiving period at home, the nursing home placement is new and
unexpected stressor on their finances, whether they are paying the full or subsidized
price of the nursing home.
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Perhaps the most noticeable example of this disengaging process is Shira. Since
her husband was transferred to the nursing home, she is in charge of her finances, and
feels that she can prioritize her expenditures as she likes. This is unlike the financial
arrangement when her husband was at home: he was always interested in saving money,
whereas she was interested in spending it to enjoy life:
"Today I am my own boss. Jacob was…tightfisted with money, and I am not. Today I
don't save money. As long as I have some, I spend it…I don't squander it away, but I like
an easy life. Comfort. Someone to clean my house, someone to carry for me, to do
things for me. I don't even carry milk from the store."
Shira is exploiting her current life situation to spend her money as she sees fit,
without having to account for her decisions to her husband, who (based on past
experience) would most likely disagree with her. She seems to be enjoying the situation in
which she can ensure herself comforts that make her life easier, while avoiding past
arguments about such expenditures.
Unlike Shira's take-charge attitude, Betti was suddenly thrust into taking care of
financial matters when her husband was transferred to the nursing home
"I was left alone. I knew nothing. Other than getting money from the ATM, I knew
nothing. He did everything. I had never been to the bank: what to do, where the
accounts are, where to pay…suddenly you are alone with a huge responsibility".
She had depended on her husband throughout their married life and was clueless
regarding their financial situation. With the nursing home placement, Betti not only had
to familiarize herself with the details of her financial situation, but also to take on a role
that she had never had before. It seems Betti is deterred not just by the technical details
of taking on this role, but rather mostly concerned with the enormity of the responsibility
attached to it. Also, taking on a role that was clearly her husband's signals to her in an
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unequivocal manner that she is disengaging from her past life and from her husband as
she has known him to be.
Hava is another example of a woman who suffered a crisis due to the need of
taking charge of financial matters, which had previously been taken care of by her
husband. Unlike Betti, Hava was able to lean on her youngest daughter, who assisted her
in learning to deal with these matters. Having had her daughter to assist her has eased
the role transition for Hava, and she focused on mastering the technical aspects of
managing their finances. "At first it was very difficult for me, the things that he had done. I
used to really lean on him, so I leaned on her. Until she taught me how the bank works,
taking out money, all those things". Hava went from relying on her husband to take care
of financial matters to relying on her daughter. However, unlike her husband, Hava's
daughter insists on ultimately transferring these matters to Hava: "Slowly I am releasing
her, because she says – Mother, I will not live with you forever and you need to cope with
these things by yourself". Thus, Hava finds herself disengaging from her past role of being
financially supported and taken care of, and must adjust to taking charge of her own
finances.
Some of the women are experiencing a more subtle process of disengaging from
past financial habits. These are mostly women who are privately paying the full price of
the nursing home. At the time this study was conducted in the participating nursing
homes, the prices ranged from 10,000 to 15,500 NIS per month. Whether they are
financially well off or rely on various insurance policies to pay for the nursing home, all
these women find themselves calculating and rethinking their expenditures, unlike prior
to the nursing home placement. For example, Sophie says: "I don't spend without a
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reason. Things I didn't think about (financially) before, I think about them now. Even
twice". Having to finance her husband's stay in the nursing home, has forced Sophie to
reconsider her spending habits and re-evaluate purchases as necessary or not. These
considerations are new, and a direct result of the nursing home placement and impose
constraints on her finances.
Like Sophie, Cherna also finds herself rethinking her spending, and she now
forgoes beauty treatments that were a routine part of her life. One of the reasons she
presents for having stopped investing in her appearance is their expense: "where can you
find 400 NIS? All the money is counted". The new stressor of nursing home payment takes
a significant toll on Cherna's financial situation, and she can no longer afford frivolous
expenditures such as beauty treatments.
In summary, one can see that the nursing home placement has not only usually
had a negative impact on the women's finances, but also has required an adjustment and
change from past roles and habits, often unexpectedly and requiring disengagement from
the past.
Thus far I have presented the processes of continuing and disengaging from the
husband and the past that community-dwelling wives undergo. Having delineated these
simultaneous and sometimes contradictory processes, the next section I will discuss the
state of abeyance of marriage that characterizes the lived experience of these women
and its effects on their lives.
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Yesterday upon the stair
I met a man who wasn’t there
He wasn’t there again today
Oh, how I wish he’d go away
(Antigonish, William Hughes Mearn)
4. Discussion
This study focused on the lived experience of community-dwelling wives whose
husbands have been placed in a nursing home, also known as married widows. The
naturalistic qualitative paradigm was used as the framework for this study (Patton, 2002).
Upon analyzing transcripts of twenty eight semi-structured interviews conducted in a
phenomenological orientation, it was found that these women are in a state of abeyance
in their marriage. This is due to their undergoing simultaneous and contradictory
processes of continuing and disengaging from their husband and their past. It has been
found that positive and negative psychological states can co-occur in caregiving (Quinn,
Clare & Woods, 2012).
The participants in this study describe the period of caregiving at home and
making the decision of nursing home placement in terms well covered in gerontological
literature (Abendorth et al., 2012; Buhr et al., 2006; Couture, Ducharme & Lamontagne,
2012; Ducharme, Couture & Lamontagne, 2012; McLennon et al., 2010). As in this study,
nursing home placement has been found to be a difficult decision for family caregivers.
Many do not consider the option until a health care professional recommends the
placement, usually a doctor or social worker. In times of crisis, such as hospitalization,
health care professionals evaluate the home situation and the option of placement is
brought up. Also, as was described in this study, sharing the decision-making
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responsibility between members of the family serves to reduce the caregiver's distress
about decision to place in a nursing home. The decision to place the husband in the
nursing home usually occurs when the wife and her family feel that it is beyond their
capability to give adequate care at home.
The central contention presented in this dissertation is that the situation of
"married widowhood" is difficult and unique in the context of long term marriages. For
women in long term marriages identity in most areas of life is tied to their husband and a
major change in the marriage significantly impacts their experience of continuity in their
lives. Unlike divorce or a mutually agreed upon separation, this significant shift in the
marriage was forced upon them, a contradiction to their expectation to share their lives
until the end. In response to this unexpected and significant shift they continue and
disengage from the past, each in her own unique way. Gwyther (1990) suggests that
couples expect to care for each other in old age and illness, but they usually do not
anticipate the need to separate-individuate psychologically and physically from the
spouse during the caregiving period. The process of separation begins at home during
caregiving and is accelerated if and when the ill spouse moves to a nursing home.
Unlike prior research that has dwelt on the subject of "married widowhood", this
study strived to holistically capture the lived experiences of women in this life situation of
"married widowhood". Previous research regarding this phenomenon has focused on
communication styles between the spouses (Baxter et al., 2002), alteration of tasks (Ross
et al., 1997), feelings of perceived couplehood (Kaplan et al., 1995; Kaplan, 2001), and
effects on the sexual aspect of marriage (Kaplan, 1996). Some of these studies have
formulated typologies, portraying community dwelling spouses along a continuum based
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on their feelings in the marriage after the nursing home placement. In this study, I have
found that the experience of "married widowhood" pertains to various dimensions in the
community dwelling spouse's life, and the essence of the experience is characterized by
prolonged conflicting processes.
The model presented in this study posits "married widowhood" as a state of
abeyance in marriage, between two conflicting processes: continuity and disengagement.
This state of abeyance in the marriage is oftentimes prolonged and may be extended over
months and years.
Model of abeyance of marriage
Life dimensions
social /
familial
emotional
Continuity
process
behavioral
abeyance of marriage
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Disengagement
process
This study would like to propose that continuing and disengaging are two
extremes of a continuum. The state of abeyance in marriage positions the communitydwelling wife in the center of this continuum. She is constantly pulled to one extreme or
the other with regard to each dimension of her life. These pulls are independent of each,
but each dimension has a tendency to one extreme. Thus, a wife may tend to disengage
emotionally from her husband –closer to the disengagement extreme; while continuing to
behave in the lived space of her home as though he stilled lived there – closer to the
continuity extreme.
4.1 An abeyance of marriage
The women in a state of "married widowhood" experience ongoing processes of
continuing and disengaging from their husbands and their past in various aspects of their
lives: emotional, social and behavioral. Unlike the occasion of the death of a spouse and
the beginning of widowhood, the placement of a spouse in a nursing home signifies the
beginning of an undefined and abeyant state in marriage. On one hand, the spouse is not
deceased and therefore the marriage continues. On the other hand, the state of living in
two separate locations, and conducting separate daily lives, is a significant shift and
discontinuity in the basic definition and experience of marriage and couplehood.
Essentially being in a state of abeyance in this context refers to being in a life
situation which is no longer continuing that which was in the past and simultaneously not
being able to move on to a new life situation. In this study, the women are no longer
wives in the conventional sense as they understand the institution of marriage, yet
neither are they widows in the conventional sense. This in-between state prevents them
from disconnecting from their past as a wife while restricting their ability to forge ahead.
They may even be ambivalent in whether their situation is a unique experience. Some feel
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that their situation is different from other women, married or widowed, in that their
status in life is unclear. For them, the experience of living alone while their husband lives
elsewhere leaves them out of sorts, in uncharted emotional and behavioral territory, or
as Maya eloquently describes it - "living in limbo".
Earlier references in gerontological literature to feeling in "limbo" have related to
time construction among older people participating or residing in formal frameworks.
Hazan (1980) has referred to the limbo state in his research on old people attending a day
center. His findings indicated such a limbo state should be conceived not only in temporal
terms, but also in social terms. Old people were found to be in an ambiguous undefined
social position by the very nature of being old. On one hand, old people seem to be at a
social standstill, and on the other hand, there are constant changes occurring in their lives
(Hazan, 1994). One might juxtapose this idea to the state of abeyance in marriage;
seemingly to society community-dwelling wives are still in the role and status of being
married, while simultaneously they may feel and perceive that their life is constantly
fluctuating between this role and status and other undefined ones.
Golander (2010) also referred to the idea of being in limbo in her study of nursing
home residents in Israel, and found that they conceive their lives as merely existing in a
time and place between life and death. The nursing home residents no longer perceived
themselves as belonging to the mainstream of life, while they were obviously not dead,
and thereby in a transient state, between two clear extremes and in an indeterminate
middle. Similarly, the "married widows" in this study, no longer perceive themselves as a
part of the mainstream of married life, while they are also clearly not conventionally
widowed.
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This state of in-between or being in "limbo" may be related to what has been
termed the "post-caregiving transition". Ume & Evans (2011) state that there has been
little research on the post- caregiving transition, referring to what happens to caregivers
after caregiving has ceased. Although they refer to the cessation of caregiving due to the
death of the care receiver, it would be feasible to state that nursing home placement of
the care receiver is also an initiator of transition. Transitions, such as the post-caregiving
transition, are processes that occur over time and that have a sense of flow and
movement (Meleis & Trangenstein, 1994).
Transition is generally conceived as a passage between two relatively stable
periods of time, in which a person moves from one life situation or status to another
(Schumacher, Jones & Meleis, 1999). Abeyance of marriage is a prolonged transition from
the position, role and status of being married and a part of a couple to the position, role
and status of being a widow.
Transitions start with a significant turning point, which precipitates the transition;
in this study – nursing home placement of the husband. The initial phase is characterized
by disengagement from the past relationships or behaviors, as well as change in the
person's sense of self (Schumacher et. al, 1999). The second phase of transition is an inbetween period, in which the person experiences disorientation caused by the losses in
the first phase. The final phase of transition, and reconciliation of it, is characterized by
new beginnings and finding meaning. These phases are all necessary parts of transition,
and may occur in a sequential, parallel or overlapping manner (Ume & Evans, 2011).
During transition the person experiences profound changes in the external world and in
the manner that the world is perceived (Schumacher et. al, 1999).
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Most people in transition have the experience of not being quite sure who they
are any more (Bridges, 1980). Separated from the old identity and the old situation or the
important aspects of it, the person feels in a kind of limbo between two worlds.
In the past, Rosenthal & Dawson (1991) proposed a four stage model of the
transition to "married widowhood". In this model of linear stages, the communitydwelling spouse moves from feelings of ambivalence and uncertainty about the future, to
a shift in interpersonal concerns, to relinquishing roles and negotiating definitions of
responsibility, and finally to resolution and adaptation. In the end stage, approximately
eighteen months after nursing home placement of the husband, the wife achieves a
balance between her own needs and her husband's needs. In this study, it became clear
that the achievement of such a balance is a challenge, if at all feasible; regardless of the
time the husband has been in the nursing home.
Rather, it would seem that the post-caregiving transition initiated by nursing
home placement is a process throwing the community-dwelling wife into a chaotic and
unclear situation. For women of this age and life stage, marital status is an integral
component in their personal identity. Any change that destabilizes their marriage; also
destabilizes their own identity, and the nursing home placement sheds a new light on
their identity.
4.2 "Married? Yes and no"
Most clearly this state of abeyance can be seen in regards to self perception of the
married widows' current marital status; for many of the women in this study the current
separation from their husband brings up questions regarding their marital identity. Some
continue to consider themselves married as before, claiming everything is the same as
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before the husband's transfer to the nursing home. Others embark on a search for a
status that will reflect how they feel in their marriage, often unsuccessfully.
One way of defining one's marital status is through a process of elimination. The
process of elimination and sifting through possible personal statuses may be used by
some women to conclude that they are in fact still married. Others try to come to figure
out what their marital status is by going over the standard possibilities: single, married,
separated, divorced or widowed. Oftentimes they discard all these possibilities, unable to
identify with any of these socially accepted statuses.
In utilizing the process of elimination, the women adhere to objective definitions
of marital status and the cues that these offer. There is no clear definition for the state of
marital abeyance they are currently in. For some women, the standard definitions offer
security: until a formal change based upon these definitions occurs - they remain in the
same married status. For others, these definitions are binding and restrictive, so that if
the wife does not fit a certain definition, she feels herself to be reduced to a position of
nothingness. Thus, the elimination process can be used with indeterminate conclusions,
allowing for each woman to construct her own preferred view of her current marital
status.
Some of the women base their feeling of continuing to be married on their shared
past with their spouse. The shared past and many years together carry a sense of
commitment and emotional investment. However, these exact points may complicate
deciding what marital status the woman is in now and how she identifies herself.
Commitment to the marriage and their shared past are the reasons for continuing to feel
attached to their husband. However, similar to the process of elimination, these
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components can lead to contradictory conclusions regarding marital status. Continuing
emotional attachment to the husband seems to be independent of continuing to feel
married to him; illuminating the simultaneous processes of continuing and disengaging
from the husband and the past. Gwyther (1990) suggests that couples expect to care for
each other in old age and illness, but they usually do not anticipate the need to separate
psychologically and physically from the spouse during the caregiving period. The process
of separation begins at home during caregiving and is accelerated if and when the ill
spouse moves to a nursing home.
It is unclear what the reasons or instigators for processes of continuing or
disengaging from the husband and the past may be for the participants in this study. For
some wives, who felt they had had an idyllic marriage, continuing to be attached to their
husband and clinging to him seems to be a natural process. However, such continuing
processes were found also among women who described a less than ideal marriage, one
that was often fraught with tension. Older married couples tend to conduct themselves
on the basis of well established values of commitment and family solidarity (Gwyther,
1990). In order to respect themselves, wives strive to live up to their values, and the
losses associated with not being able to do so generate uncomfortable feelings. Processes
of continuing and disengaging from the husband and the past reflect their attempts to
live up to their values, while accommodating for the unexpected state of a fundamental
change in their marriage and its being in a state of abeyance.
In recent years it has been proposed that situations similar to the state of
abeyance in marriage incorporate a character of ambiguous loss. Ambiguous loss refers to
situations in which a person is both present and not present (Boss, 1999). There are two
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types of ambiguous loss, and the one relevant to this study describes the physical
absence of a significant other while they continue to be psychologically present (Boss,
2010). In the case of married widowhood: the husband is physically missing from the
marital home, while psychologically continuing to be a part of the couple. People
experiencing ambiguous loss are filled with conflicting thoughts and feelings. There is no
social or religious ritual for dealing with such a loss, and people are stuck alone in a limbo
of not knowing, with none of the usual supports of grieving and moving on with their lives
(Boss, 2010). Ambiguous loss is an ongoing uncertainty, and over time exhausts those
experiencing it physically and emotionally.
In the context of long term marriages and old age the change in living
arrangements due to nursing home placement are more significant than sleeping in
different places. Traditional social norms dictate that a couple should live in the same
home, and in cases where they cannot live together, living arrangements are considered
to be temporary (Levin, 2004). Other life circumstances in which spouses do not share
living arrangements warrant consideration, and might add perspective to abeyance of
marriage in old age.
Most non-cohabiting circumstances apply to a cohort younger than the cohort of
the women in this study. Originally, Levin & Trost (1999) coined the term of Living Apart
Together (LAT) in reference to couples that advocated against traditional marriage by
choice. At the time, they noticed that the number of people defining themselves as a part
of a couple, while maintaining separate households was on the rise. Levin (2004)
delineates three conditions needed for defining a couple as a LAT couple: both partners
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agree that they are in such a relationship, others perceive them to be a couple and they
live in separate households.
Interestingly, a central issue relevant to couples living apart together, yet
seemingly ignored by researchers, is the issue of choice. All the circumstances and
motivations Levin & Trost (1999) and Levin (2004) describe as reasons for LAT
relationships are such that the couple choose their living arrangement, and are free to
change the circumstances at any time, i.e. it may be perceived as a temporary situation.
Other researchers, such as Rhodes (2002) and Rindfuss & Hervey-Stephen (1990), have
included incarceration, war and military service as reasons for LAT, and though these may
not be choices; they too are temporary circumstances. The situation of "married
widowhood" is not a choice, as was previously demonstrated in that the nursing home
placement was made in a "no option" situation. It is also not a temporary circumstance,
and in the future the spouses may unite or reunite in a shared household. "Married
widowhood" is usually resolved with the death of one spouse. Thus, despite the portrayal
of LAT in the literature as a positive form of couplehood, it would seem that "married
widows" are not in a position to enjoy its possible benefits.
LAT seems to have several possible relevant consequences to couplehood.
Rindfuss & Hervey-Stephen (1990) state that adults continuously change and mature,
often gradually, so that cohabiting couples constantly accommodate their relationship to
each spouse's changing. For couples not living together, the longer they are apart the
greater the likelihood of significant change, that the other spouse might have difficulty in
accommodating. In the current study, additional changes may occur due to the functional
status of the husband. The nursing home placement and separation of living quarters
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increases the difficulty of the community-dwelling wife to adjust to changes that may
occur in her husband.
Another relevant consequence of LAT on couplehood was described by Gross
(1980). She found that daily exchanges between spouses cement their intimacy and sense
of involvement with each other. The proximity and sharing of living space is necessary for
realizing the order bestowing quality in a relationship like marriage. Couples who live
apart do not have one common base which is theirs together and their only home. For
couples in long term marriages it is the idiosyncrasies of everyday life that make up the
minute details of life that binds them together, and disruption of this leaves them
unmoored.
Unlike these researchers, Bawin-Legros & Gauther (2001), also studying LAT
couples, concluded that a couple does not have to be geographically situated in order to
exist as such. They claim that the life of a couple does not depend on their capability to
maintain their existence as a couple, but rather on their capability to preserve
permeability between the private sphere and the external world. The couplehood resides
in the participation of each member in the maintenance of the elements that determine
the identity of the couple and hinder differentiation. Although these conclusions may be
pertinent to the current generation of young people embarking on a "couplehood
career", in this study of women from an age cohort with traditional views of marriage and
its norms, it is unlikely that they would subscribe to this point of view. For the women in
this study, cohabitation is a basic tenet of marriage, and a disruption of this tenet
significantly affects their lived experience.
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4.3 Continuity and disengagement theories
Originally, disengagement theory was proposed as a global theory of aging. Since
its introduction this theory has been subject to much criticism, and research to support it
has usually confirmed only parts of it (Adams, 2004; Hochschild, 1975; Johnson & Barer,
1992; Utz et al., 2002). It has been suggested that, although disengagement theory may
not be a global theory of aging, it has merit when re-conceptualized as a variable process
(Hochschild, 1975). One point to reconsider is that not all forms of disengagement go
together. Hence, there
may be social disengagement without psychological
disengagement, and so forth. Further, as Carp (1968) has found disengagement from
family may be negatively related to disengagement from material possessions, social
activities and relations with other people.
Indeed, Colarusso (2000) has proposed that the contradictory relation an elder
may have towards his/her possessions is a significant form of separation. On one hand,
there is increased attachment to things and increased value may be put on objects. At the
same time, there exists a need to divest one's self of possessions. Both these processes
are an attempt to master the challenge of accepting upcoming death. So we might
consider the process of continuing and disengaging the participants in this study are
undergoing. There is a need to continue the attachment to the husband and the past,
perhaps even in some cases to increase such attachment. At the same time, there is a
need to disengage, seemingly to divest of attachments and the past. The disengaging
process that the community-dwelling wife undergoes from her institutionalized husband
is a form of anticipatory grief and separation preceding his death.
This re-conceptualization of disengagement with various dimensions as
independent allows for seeing an aging person to be in different phases of disengagement
124
or continuing engagement regarding the various dimensions in their lives (Hochschild,
1975). One dimension of a relationship is one's own feelings about it. A person may seem
to be outwardly engaged, while internally feeling disengaged compared to the past
quality of the relationship. Thus, in this study wives may have exhibited behaviors of
continuing their attachment to their husband by visiting frequently or monitoring care,
while they felt emotionally disengaged and distant from him.
A byproduct of emotionally disengaging is decreased worries about others' wellbeing and selectively ignoring potentially bothersome events (Johnson & Barer, 1992). In
the current study, one of the coping strategies the participants used was to selectively
ignore relationships from their past that were incompatible with their current perceived
needs. Friends and family who did not support the community-dwelling wife's coping
strategies were abruptly cut off or gradually diluted.
Similarly, ignoring potentially bothersome events was evident in disengaging
coping strategies used while visiting the husband in the nursing home. Whether it was
during the visit, that they sat away from others; or after the visit, by drawing an imaginary
line between the inside of the nursing home and the outside world; or even prior to the
visit, in demanding others accompany and/or drive them to the nursing home.
Studies of nursing homes and families related to continuity theory tend to find
support for continuous patterns of behavior that family and caregivers present following
the nursing home placement. However, they usually do not pay heed to patterns of
behavior that may indicate a lack in continuity, or active disengagement from the past.
For example, Gladstone, Dupuis & Wexler (2006) suggested that after nursing
home placement, family members continue perceiving themselves in their traditional
125
roles as a part of striving for internal continuity. Their study stresses behaviors and
feelings of family members that reflect continuity of support, contact and perception of
the care role. In referring to changes that may have occurred with regard to these issues,
they focused on the external circumstances of the nursing home environment as
facilitating or discouraging such continuity. The participants in the current study indicate
their experience as continuing such behaviors and feelings, as well as behaviors and
feelings that are of a disengaging nature, such as; changing feelings from romantic love to
maternal love towards the husband, feeling that the husband was no longer the person
they married, going through the motions of visiting, etc.
Continuity theory has also served as a framework for Stadnyk's (2006) study of
community-dwelling spouses. This study focused on the activities of these spouses, and
found that community-dwelling spouses engage in various activities for two purposes:
marriage sustaining and identity sustaining. Similar to the study presented in this
dissertation, the participants in Stadnyk's (2006) study were also heavily involved in their
spouses' life, and they too felt a sense of living in limbo. However, the focus of the
continuity framework does not reveal expressions, feelings or manifestations of
discontinuity or disengaging. Thus, the activities that appear in Stadnyk's (2006) study are
presented as community–dwelling spouses' attempts to continue known pastimes, work
or hobbies from the past that assist in continuing their identity. The present study adds
on to this knowledge that community-dwelling spouses are not only attempting to
continue their past. They are also disengaging from their past in various ways, not all clear
and visible to them, and even in continuing past activities there may be a disengaging
process in another dimension, such as the emotional dimension.
126
Another study that attempted to scrutinize the applicability of continuity theory,
and included a scrutiny of disengagement theory as well, was conducted by Utz, Carr,
Nesse & Wortman (2002). They studied these theories in the context of their relevance to
social activity level in widowhood. It was found that widowhood is not a discrete event
defined by the date of a spouse's death, but rather a process that begins before the
actual death of the spouse. Additionally, they found that continuity theory is an
applicable theory regarding the social participation of older adults: married and widowed
elders exhibited a similar level of social participation as they had displayed throughout
their life course. Though support for disengagement theory as an explanation for social
participation was not found by these researchers, they did find that spouses of ill persons
reduce their levels of social participation. This suggests that elders may experience social
withdrawal in times of spousal illness, such as in the life situation considered in the
current study. Indeed it was demonstrated that for wives whose social disengagement
patterns started during caregiving at home due to time constraints, these did not diminish
upon removal of these constraints. Rather, these social disengagement patterns
continued and in some instances were increased.
4.4 Theoretical implications
This research adds to the current knowledge about "married widowhood" by
expanding on and describing processes community-dwelling wives experience, while their
husband resides in a nursing home. The background for this particular life situation has
been previously reported in the literature, and the findings in this study concur that such
a life situation is very distressing for the wives left at home. All the participants
emphasized that nursing home placement was a necessity, and was done after much
effort on their part to avoid such a move. The placement of their husband in a nursing
127
home has affected the wives in the emotional, social/familial and behavioral aspects of
their lives. For some, there has also been a secondary affect on their physical health.
The central finding in this study is that community–dwelling wives undergo
simultaneous processes of continuing and disengaging from their husband and the past.
This contention is a new posit of these two theories. Thus far, these two theories have
been presented as separate, even competing, theories of aging. The findings suggest that
the continuity and disengagement theories of aging may be theories that complement
each other, rather than competing or contradictory, as was perceived earlier. Continuity
theory includes the proposition that optimal continuity consists also of partial
discontinuity; yet, this is usually conceived as of passive and circumstantial character.
Whereas, it is proposed that in the situation of "married widowhood" both the process of
continuity and the process of disengagement in various life axes is an active process.
As has been suggested by Sahlstein (2004) relational contradictions may occur
simultaneously and even overlap one another at various points in time. For example,
autonomy and connection are in opposition, one can only be understood in conjunction
with the other. Similarly, continuity and disengagement exist in conjunction of one
another in the lives of "married widows".
The findings in this study further support the idea that the disengaging process is
independent in its various dimensions. This has been demonstrated in that the
participants were found to be disengaging in one axis, such as behavioral, while
continuing to be engaged in a different axis, such as emotional. Thus, the disengagement
process is not all-encompassing, and also not solely limited to the sphere of social
interaction. Unlike the global conception of disengagement as a unified process that the
128
older person undergoes in all life dimensions, this study lends support to conceiving
disengagement as a process that may be pertinent to only certain life dimensions. An
older person may be at various stages of disengagement in different life spheres. This
holds true for continuity processes as well.
4.5 Practice implications
One of the contributions this research makes is in addressing for the first time this
unique life situation in the Israeli context. In fact, there was no acceptable terminology
regarding "married widowhood" in the Hebrew language. Hazan (2010) implies that
language represents and manufactures social categories, and lack thereof certain terms in
the Hebrew language may reflect on societal attitudes to missing terms.
At an early stage of preparing the research project, I approached the Committee
for Sociological Terminology at the University of Haifa in order to find an acceptable
translation of "married widowhood" and several other related terms (for example,
ambiguous loss). Though these terms have been a part of the professional gerontological
literature for over twenty years, they have not yet warranted attention in the Israeli
context. Introducing these terms to health care professionals in Hebrew using a uniform
terminology, certified by the Israeli Sociological Society, may serve to encourage the
professional discussion regarding them. Such uniform terminology enables addressing
this situation, which is becoming more and more common in nursing homes, often
overlooked, and certainly not perceived as unique or warranting special consideration.
As mentioned earlier, abeyance of marriage may also be considered as a form of
ambiguous loss, as described by Boss (1999). The emotional ongoing uncertainty
characteristic of ambiguous loss echoes the processes of continuity and disengagement in
129
abeyance of marriage. Over time, it exhausts those experiencing it physically and
emotionally. In regards to practical strategies for coping with ambiguous loss and
complicated grief, Dupuis (2002) and Boss (2010) suggest family counseling. However,
from practical experience, community-dwelling wives do not usually consider this a viable
option. Often, they are more open to emotional assistance from the staff at the nursing
home. Most health care workers are uncertain how to respond to families struggling to
cope with an ambiguous loss. Boss (1999) suggests that communication is key in this
context, and that even telling a family member that one does not know what will happen
in the future is preferable to keeping silent in the face of families' questions. Indeed, the
most recent suggestions regarding coping with ambiguous loss point to the need to
accept a lack of closure in such situations (Boss & Carnes, 2012).
4.6 Recommendations
Married widowhood and ambiguous loss are concepts unfamiliar to nursing home
staffs. Staff generally does not regard spouses of residents to be in particular distress,
unless they exhibit demanding behaviors. The resident is perceived as the client of the
nursing home, and all the resources of the nursing home concentrate on providing proper
nursing care to them. Thus, spouses (and other family members) may receive cursory
treatment to their adjustment to this life situation. Usually, the social worker, who is the
liaison between the nursing home and the family, will offer initial support upon nursing
home placement. However, being unfamiliar with the conflictual processes of "married
widowhood", they may have difficulty in finding the right kind of support needed. Indeed,
these contradictory processes may confuse nursing home staff as to the true nature of
the married widow's relation to her husband. Over time, this confusion may lead to
diminished support, and even scorn from the staff.
131
Health care workers should familiarize themselves with the concepts of "married
widowhood", ambiguous loss and complicated grief. The latter is a normal reaction to
ambiguous loss. It refers to continuous grieving, in which a person remains stuck on and
preoccupied with the lost object, similar to what Freud termed melancholia (Boss, 1999).
Knowing the difference between ordinary loss and ambiguous loss can assist health care
workers in being more empathic and patient with families (Boss, 2010). Spouses and
family members need validation about their feelings from family and friends, as well as
from professionals.
However, educating health care professionals on the interdisciplinary team at the
nursing home is not enough. Front-line staffs are the nursing home workers with whom
spouses and family members have the most interaction. These workers are a main
resource for families in regards to the well-being of the resident, and they constitute
much of the communication with family members by the nursing home staff. Any effort
by the nursing home to provide support and assistance to spouses in abeyance of
marriage must include educating these staff members as to the processes that these
spouses are undergoing and their various possible manifestations.
Another way to assist married widows may be in creating support groups for them
in the nursing home. Such peer support groups have been found to be effective in
providing an emotionally accepting environment, in which participants feel that their
feelings are validated and understood by others in the same life situation (Chien &
Norman, 2009; Fung & Chien, 2002).
Bliezner, Roberto, Wilcox, Barham & Winston (2007) studied ambiguous loss
among couples in which one spouse was diagnosed with Mild Cognitive Impairment. They
131
identified a new role: "care partner". This refers to a stage in the life of a couple that
precedes caregiving as described in the literature. It is a role more of a monitoring nature
rather than hands-on practices of care tasks. I suggest that married widowhood and the
associated abeyance of marriage accompanied by ambiguous loss, merits reconceptualizing the role of the community-dwelling spouse also as "care partner". This
role of "care partner" is not limited only to the initial stages of caregiving, but may also be
applied to advanced stages of caregiving, when the official hands-on care is given by
skilled workers. Nursing home staff, especially social workers, can help spouses find ways
to redefine their relationship with their institutionalized spouse and alternative ways to
be involved in the resident's life, should they choose to do so.
Oftentimes, as stated in the literature review, spouses in abeyance of marriage are
regarded by staff at the nursing home as burdensome and demanding. Changing the
perspective of nursing home staff to viewing these spouses as "care partners" may
facilitate the well-being of the spouse, who will be able to constitute a new role. It may
also influence the quality of care that the resident receives due to the forging of a
partnership between the staff and the community-dwelling spouse. In a more general
sense, nursing home staff would do well to consider the wife as a client, as well as the
resident husband. Viewing her as such will allow for greater tolerance and addressing her
unique needs, in order to best serve the resident and his family. Moreover, it is suggested
that by the simple act of assisting community-dwelling spouses in identifying and
understanding the processes of continuity and disengagement that they are undergoing,
they may find alleviation of at least part of their conflict.
132
4.7 Study limitations
This study is not without limitations, which may also point to new directions of
further research. One obvious limitation is the fact that all the participants were women.
This reflects the reality that most often it is women who will find themselves in this life
situation because, as mentioned in the literature review, men are likely to marry younger
women (especially in this age cohort) and are also more likely to be in need of caregiving
at this time of life.
Also of note, is the assumption that traditional gender roles would likely affect the
lived experience of potential participants. With that in mind, I chose to neutralize such an
affect by limiting the sample to one gender.
Another limitation regarding the sample has to do with the fact that the women
who participated are wives who continue to be involved in their husbands' lives. There
are community dwelling wives who have ceased to be involved with their nursing home
residing husband. These women were not interviewed, having declined to participate
when approached by the contact person in the nursing home. The breadth of the
phenomenon of disconnecting from a spouse upon nursing home placement is unclear,
but such incidences were hinted at by some participants. Several participants intimated
that they knew of such women, but refused to name names, and therefore it was not
possible to approach them and include them in this study. Community dwelling spouses
such as these also refused to participate when approached by the contact person at the
nursing home.
In this study, the condition of the husband at the time of the interview was not
considered to be of impact on the lived experience of the women participating in the
133
study. This assumption was based on the literature regarding the state of "married
widowhood" available at that time. During the undertaking of the study, and after data
gathering was completed, some studies have come to light that suggest there might be a
difference between the experiences of spousal caregivers to dementia patients and
spousal caregivers to non-dementia patients (Gillies, 2011; Mullin, Simpson & Froggart,
2013; O'Shaughnessy, Lee & Lintern, 2010). These studies hint that such differences in
experiences may carry over to the experience of the community dwelling spouse after
nursing home placement.
The participants in this study did not make a differentiation between spouses
suffering from dementia and those that did not. During the interviews it became clear
that most of the husbands suffered from varying degrees of cognitive impairment. In
analyzing the data, this question was raised and it was determined that the phenomenon
as conceptualized in this study was shared by participants whose husbands was suffering
described as suffering from cognitive deficits and by participants whose husbands were
described as lucid. Yet, it would be irresponsible to ignore this possible influence,
especially in light of the studies mentioned above.
4.8 Recommendations for future research
The current study contributes to the existing knowledge about spousal caregiving
and the experiences of community-dwelling wives, whose husbands reside in nursing
homes. Spousal caregiving in not solely done by women. Experts predict that as more
men survive into old age, men's involvement in caregiving will unavoidably increase
(Price, 2005). In the future, an increase in male caregivers will reduce the current
disparity between men and women regarding caregiver issues, among them spousal
experiences after nursing home placement.
134
This study focused on women in this life situation due to the fact that it is more
common among women. However, it is important not to neglect the reality of husbands
whose wives have been institutionalized and they are the community dwelling spouses. It
is feasible to assume, especially in this cohort, that the experience of men as "married
widows" is influenced by their gender: roles, expectations and perceptions. Future
research should also address the experience of men in this life situation and its unique
characteristics.
In light of historical events and changes that have affected marital patterns and
norms of cohorts younger than the one in this study, it is recommended to study
character and effects of "married widowhood" as a life situation in later cohorts.
Sociological trends from the last century such as the increase of divorce, more women
developing full-time careers, and the emergence of cohabitation, may influence the
experiences of people growing old in the coming decades.
As mentioned earlier, recent studies have focused on the influence dementia has
on the experience of caregiving spouses. These studies suggest that the experience of
spouses of dementia patients may be essentially different from the experiences of
spouses providing care to non-dementia care receivers. Juxtaposing these ideas suggests
that the experience of nursing home placement and the quality of life after placement
may be inherently different due to the illness of the care receiver. Further research
should consider the issue of the condition of the spouse in the nursing home as possibly
influencing the state of abeyance in marriage that the community dwelling spouse
experiences. In particular, perceptions of the marital relationship should be addressed,
and their influence on the quality of life of the community-dwelling spouse.
135
Another issue worth considering for future research of this phenomenon pertains
to changes over time, which may affect the experience of "married widowhood". The
participants in this study were interviewed at different times in their experience as
"married widows", ranging from 1 month to 13 years. While the processes indentified in
the study are prolonged and characteristic of the "married widowhood" experience,
regardless of its temporal aspect, perhaps conducting several interviews with the same
participants at different time points would produce rich data about this experience over
time. Also, an interesting line of research might be to follow up with "married widows"
after the death of their spouse, and learn about their experience of widowhood.
Contrasting such widowhood to widow/ers who have not experienced "married
widowhood" would enrich our understanding of widowhood in general.
136
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6. Appendices
Appendix 1 – Information about study participants
(Presented in alphabetical order)
Betti11: age 70, born in Argentina and came to Israel at a young age. She worked as a
secretary in city hall, and continues to volunteer there. Her husband has been in the nursing
home for the past few months, and she visits two to three times a week, always
accompanied by a relative. They have been married for forty-eight years and have three
children and grandchildren.
Cherna: age 78, born in Romania and came to Israel as a young girl. She was a
homemaker. Her husband has been in the nursing home for half a year, and she visits daily.
They have been married for fifty years, and have three children and several grandchildren.
Dina: age 81, born in the USA and came to Israel in mid-life. She worked as a secretary.
Her husband has been in the nursing home for two years, and she visits daily. They have
been married for sixty years, and have six children (one killed in military action) and
several grandchildren.
Dorona: age 76, born in Israel on a kibbutz. She worked as nurse in a large hospital. Her
husband has been in the nursing home for four years, and she visits twice a week with her
retarded daughter. They have been married for fifty six years and have two daughters and
three grandchildren.
Esther: age 69, a religious woman, born in Morocco and came to Israel at a young age. She
continues to work as a nanny, and worked in the past as a secretary. Her husband has been
in the nursing home for nine months, and she visits daily. They have been married for
years, and have six children and several grandchildren.
11
All names are pseudonyms in order to ensure anonymity of the participants.
157
Fruma: age 80, born in Israel. She worked as a Hebrew teacher for young children, and
then as a sewing teacher for adults. Her husband has been in the nursing home for slightly
over a year and she visits daily. They have been married for fifty six years, and have three
children and grandchildren.
Hava: age 65, born in Israel. She was a homemaker. Her husband has been in the nursing
home for three years, and she visits three to four times a week. They have been married for
forty six years, and have three daughters and two grandchildren.
Haya: age 77, born in Egypt and came to Israel at a young age. She was a homemaker. Her
husband has been in the nursing home for half a year, and she visits two to three times
week accompanied by her son. They have been married for forty years and have two
children and three grandchildren.
Iren: age 65, born in Tunisia and came to Israel at a young age. She continues to work as a
nanny and in the past kept a shop with her husband. Her husband has been in the nursing
home for six years and she visits twice a week. They have been married for forty eight
years, and have three children and several grandchildren.
Masudi: age 80, born in Morocco and came to Israel in her late teens. She worked as a
secretary. Her husband has been in the nursing home for two years, and she visits twice a
week. They have been married for sixty years, and have four children (one of them is
retarded and resides in an institution) and several grandchildren.
Maya: age 73, born in Israel. She worked as an organizer for a foundation. Her husband
has been in the nursing home for half a year, and she visits three times a week. They have
been married for fifty seven years, and have three children and several grandchildren.
158
Mazal: age 71, born in Israel. She worked as a teacher in secretarial school and kept a shop
with her husband. Her husband has been in the nursing home for seven years, and she visits
daily. They have been married for fifty two years, and have three children and several
grandchildren.
Nili: age 77, born in Turkey and came to Israel at a young age. She worked as a
kindergarten teacher's assistant. Her husband has been in the nursing home for half a year,
and she visits daily. They have been married for sixty years, and they have three children
and several grandchildren.
Rachel: age 84, born in Italy and came to Israel in her late teens. Her husband has been in
the nursing home for slightly more than two years, and she visits two to three times a week
accompanied by a relative, usually her sister. They have been married for sixty two years,
and have three children and grandchildren.
Riva: age 87, born in the Russia and came to Israel in mid-life. She worked as an
accountant. Her husband has been in the nursing home for a year and a half, and she visits
two to three times a week, always accompanied by her son. They have been married for
sixty four years, and have one son and two grandchildren.
Rivka: age 80, born in Israel. She worked as a secretary. Her husband has been in the
nursing home for a month, and she visits two to three times a week. For both of them it is
their second marriage (she was divorced and he was widowed). They have been married
for thirty three years, and she has one daughter from her previous marriage and two
grandchildren (he has two children from the previous marriage).
Ruth: age 76, born in Poland and is a Holocaust survivor. She came to Israel as a teenager
after the war, and worked as a kindergarten teacher. Her husband has been in the nursing
159
home for the four years, and she visits daily. They have been married for sixty years, and
have two daughters and grandchildren.
Sara: age 78, born in Morocco and came to Israel as a young girl. She worked as a cleaner.
Her husband has been in the nursing home for three months, and she visits daily. They
have been married for sixty years and have six children and several grandchildren.
Sarina: age 65, born in Israel. She works as a nurse's aide. Her husband has been in the
nursing home for a year, and she visits daily. They have been married for thirty seven
years, and have four children and several grandchildren.
Shira: age 76, born in Bulgaria and came to Israel at a young age. She worked in the field
of cosmetics. Her husband has been in the nursing home for four years, and she visits
approximately twice a week. For both of them it is their second marriage (she was divorced
and he was widowed). She has two daughters from her first marriage, and three
grandchildren.
Simcha: age 76, born in Israel. She worked as a secretary. Her husband has been in the
nursing home for two years, and she visits daily. They have been married for sixty years,
and they have four children and several grandchildren.
Sophie: age 69, born in Australia and came to Israel in mid-life. She worked as a university
professor. Her husband has been in the nursing home for one year, and she visit four times
a week. They have been married for forty eight years, and have two children and three
grandchildren.
Suzie: age 86, born in Germany and came to Israel in her late teens. She worked as a
secretary. Her husband has been in the nursing home for a month, and she visits daily.
161
They have been married for sixty seven years, and have two children and several
grandchildren.
Tala: age 78, born in Israel. She worked as a teacher. Her husband has been in the nursing
home for a year and a half, and she visits once a week. They have been married for thirty
four years, and he has two children and several grandchildren from a previous marriage,
but no shared children. She is an artist.
Tova: age 77, born in Romania and came to Israel as a young girl. She worked as a nurse.
Her husband has been in the nursing home for a year and a half, and she visits daily. They
have been married for sixty years, and have three children and several grandchildren.
Yaffa: age 73, born in Poland and came to Israel as a young girl. She was a homemaker.
Her husband has been in the nursing home for thirteen years, and she visits daily. They
have been married for fifty four years, and have two sons and several grandchildren.
Yochi: age 84, born in Bulgaria and came to Israel with her husband in her early twenties.
She worked as a secretary. Her husband has been in the nursing home for half a year, and
she visits daily. They have been married for sixty three years, and have two sons, five
grandchildren and three great grandchildren.
Zari: age 73, born in Morocco and came to Israel as a married young woman. She worked
as a maid in a hotel. Her husband has been in the nursing home for four and a half years,
and she visits approximately once a month. They have been married for fifty two years,
and have ten children and several grandchildren.
161
Appendix 2 – Interview guide
-
How long has your marriage lasted?
-
Why did you marry him?
-
How was your couplehood before he became ill?
-
What did you use to do together?
-
Describe your husband before he became ill.
-
What was the division of roles and labor inside and outside of the home?
-
How did you feel during the period of caregiving at home? (if there was such a
period)
-
What brought about the decision on nursing home placement?
-
Was it a joint decision?
-
How did other family members respond to this decision?
-
Describe the process of choosing the specific nursing home.
-
How did you feel on the day of the nursing home placement?
-
How long has your husband been in a nursing home?
-
How has your life changed since the nursing home placement?
-
What has changed about your feeling or perception of the home since he moved to
the nursing home?
-
What do you currently do that you had not done before?
-
What did you use to do that you don't any longer?
-
When do you visit your husband? For how long?
-
What do you do during the visit?
-
How are your relations with the staff?
-
What do you think about the care that your husband receives at the nursing home?
-
What would you like to change or maintain regarding his care there?
-
What is your current place in your husband's care?
-
What roles in his care do you have now compared to the past?
-
Describe your typical day since the nursing home placement.
-
How is your health? Has it changed since the nursing home placement?
-
How do you cope with the changes in roles that you had in the past?
-
What has changed, if at all, in your social relations?
-
What does your social environment enable or limit you to do since the nursing
home placement?
-
How has the nursing home placement affected your perception of your marriage?
162
-
What has changed in your couplehood?
-
What has not changed in your couplehood?
-
What would you like to change or maintain in your life?
-
How did you imagine these years of your life?
163
Appendix 3 –Participant's letter of consent
‫הפקולטה למדעי הרווחה והבריאות‬
‫החוג לגרונטולוגיה – לימודי הזקנה‬
Faculty of Social Welfare & Health Sciences
Department of Gerontology
Dear Madam,
My name is Dana Peer, and I am conducting a study as a part of my studies at the
Gerontology dept. at the University of Haifa. I am interested in the experiences of married
community-dwelling elder women, whose husband resides in a nursing home. Your
cooperation will greatly assist me in conducting the study.
The study requires conducting an interview at the time and place of your
convenience. Each interview is estimated to last approximately two hours. The interview
will be recorded. All the information in the interview will be strictly confidential and
used for research proposes only. No information will be passed on to any other party,
and I promise to keep all the information anonymous and confidential. To this end,
personal information (name, age, place of living) will be changed in the research paper.
I thank you for your cooperation.
I hereby agree to participate in this study. I understand that I may change my mind at any
time, and stop my participation without any consequences to me or to my husband.
Date: _________
Name: ____________________
Signature: _____________________
164
Appendix 4 - Example of data analysis process
Loading categories: after having identified the main categories from the data, I compiled
a list/map of the relevant issues for each participant, as presented in the table below.
Each column represented a category, and the subcategories were indicated in different
colors. At this point, I chose to short succinct headlines for indicating the relevant issues,
based on how they had correspondingly appeared in the interview data.
Red – emotional, green – behavioral, blue – social, family, purple – social, not children
Name
Betty
Continuing past
Daily phone call and feels she
visits often, care monitoring,
returned to cooking, went
abroad, shows with son in law,
reading and computer, visits
club, grandkids sleep over,
children supportive, takes care
of grandkids at daughter's
house, continued not speaking
to eldest daughter, helps son
with car, financial assistance
to kids
Disengaging from past
No anniversary celebration,
no gifts from husband,
rationalizes separate lives,
feels he's a stranger, not a
partner, doesn't cook for
herself, no longer drinks
coffee alone, knits, stopped
singing and exercise
groups, always visits
accompanied
Cherna
Daily visit, brings food, shares
experiences, care monitor,
cleans house alone, daughter
brings medications.
Dina
Daily visit for feeding,
caresses, shares experiences,
believes he feels her, thinks
about him at home, same
goodbye line, misses him, care
monitor volunteers at shop
and NH, exercises,, contact
with kids as before, same
Doesn't know her, calls her
by another name, cooks
and throws away, no
grooming, children assist
and support, hardly
attends family occasions,
impatience for friends,
short visits and go to NH,
hardly leaves house not for
NH
Thinks about his death and
aftermath, less lived space
– doesn't drive and
holidays not at kids homes,
eats badly, stopped
cooking, crafts, some kids
do not visit because of his
condition, partial visit from
165
Abeyance
Initially shut out from world,
house too large, unclear
marital status, new coping
needed, it's not the same,
Living alone, anger, guilt,
constant misery, helplessness,
anticipatory grief, separation
between worlds, avoiding
activities due to
physical/mental, exhaustion,
hard to be home alone,
especially difficult on holidays,
alone while with family, makes
her feel old, easier to leave
than come home to empty
house, shame, takes sedatives
Suffers his pain due to care
problems, views not visiting
twice daily as a problem,
discrepancy between external
good circumstances and
internal feelings, waits for
phone that he passed,
helplessness, hurts her health,
constant anxiety and worry
Loneliness, house is quiet,
stress effects her health,
doesn't visit – vacation day,
deliberates whether to go for
holiday because something
might happen to him, her
reason for living is to care for
him and wants to die after
Dorona
Esther
Fruma
Hava
Haya
Irene
relations with others, good
neighbors
Worries about him above
anything else, partial phone
talk, shares experiences,
strong feeling of love, makes
affectionate gestures to him,
relations with kids as before,
buys them gifts, a loner at
heart, has guests as before.
Daily visit, transferred to
closer NH, less happy, brings
food, remembers good times,
continues to care for 2 sons at
home, works
Daily visit, close care monitor,
calls her as sign he needs her,
she brings him light,
commitment, reading and tv,
sons visit often and go with
her to NH, assist in
technology, continued
friendships and socializing
Fiscal priority, daily visit and
report if not visiting, brings
him what he wants, laundry,
feels offended if she is not his
first choice, daughter lives at
home, babysits grandkids,
singing group, very close to
live in daughter, financial help
to kids, bad neighbors
Gardening, babysits grandkids
sometimes, piano in home so
grandson can play, continued
contact with son
Care monitor, long visit,
one son on holidays, hardly
goes out to socialize
Weekly visit (used to be
more frequent),
disappointed at visit,
doesn't visit when feeling
low, feels he's changed,
doesn't buy clothes,
doesn't go out, has home
help, no support for NH
placement, avoids
company to avoid pity or
gossip, alone on holidays.
Used to him not being
home and accepts it,
doesn't want to socialize,
negative reactions from
others
Rationale that he is better
off there, used to and
accepted situation, dresses
and goes to NH, afternoon
for errands, shopping, no
energy for lectures etc.,
hard to visit kids that live
far, many friends died or
are immobilized and social
net therefore small, no
contact with neighbors
Other activities more
important than visit, less
contact over time, runs
bank accounts and errands
he did, dependent on
daughter to do what he
used to do, trying to do
them herself, partially
shares with friends
Visits only with son, no real
communication, doesn’t
know her, repulsed by him,
stopped taking him home,
doesn't go to club,
daughter recently left
home and there is a rift
and few visits to her, son as
before and accompanies
visits, few friends because
they died or moved, has to
go far to find attachments
Less visits, visits a wall,
166
him, easier to leave house
than come back to empty one
Don't let anyone pity me
Leisure time for herself only if
someone else visits husband,
situation is from above,
uncertainty about future,
avoids making plans due to
uncertainty, coping by
avoidance
Takes care of others at
expense of self, loneliness
Surprise, doesn't understand
situation, constantly thinking
and trying to process
Boredom, house is quiet, does
worries he doesn't suffer,
keeps home tidy and clean,
works, uses computer, hides
feelings from kids, continues
to be giving parent, goes out
for coffee with friends
Masudi
Care monitor, commitment,
nothing has changed in house,
cooks for kids on holidays,
goes to club, visits retarded
son in group home
Maya
Care monitor, worries about
him, hard to say goodbye,
phones daily, still caregiver, no
relief, goes abroad, studies,
babysits grandkids, stable
relations with kids, kids don't
appreciate her time and
occupations, sometimes call,
set family meetings, cares for
her mother, friends stay in
touch and call, goes to social
events
Mazal
Daily visit, tastes his food, care
monitor, brings food, goes to
theater, reads a lot, the giving
parent, kids are source of
support, sisters are social
change in relation only
from her to him, less
expenditures, can't buy
what she wants, not fixing
AC – no money, constructs
weeks so there are errands
every day, no patience for
tv, difficulty to sit for long,
started folk dancing and
went abroad, doesn't
invite kids to her house –
goes to them with food,
friends took her abroad,
uncomfortable going out
and socializing with other
couples, distance from
family, sits at home Friday
nights, negative reactions
to NHP
Holidays at kids homes and
doesn't like it, doesn’t cook
for herself, different
shopping, cleans a little,
constructs time around
errands, doesn't go on trips
or out, visits NH with kids,
few friends because they
died, less contact with
extended family because of
age and distance
Like being with a child, NHP
was with separation and
grieving, less worried about
details of his life,
considering another
relationship, his death as a
release, doesn't go out,
buys and throws out food,
eats sandwiches, redid
garden he ruined, house
too large, children visit
independently on certain
days, some friends visit NH,
stopped entertaining at
home, hardly goes out, no
energy to sustain ties.
Doesn't know her, doesn't
feel married, feels free,
plays cards in evenings,
grandkids haven't seen him
since NHP, kids don't share
167
everything alone, no relief,
expecting/dreading call,
sadness, thinks of herself as
old and about fate, constructs
time so as to overcome
loneliness, life has stopped,
unclear marital status,
avoiding going on with life,
show outward emotional
coping, feels closed circle,
frustration, I am nothing,
emptiness,
Relief since he left, no option
No relief, helplessness,
doesn't want to visit, people
speak as if he is dead, absent
and present, uncertainty,
twilight zone, alone at home,
going to visit takes up a lot of
time
Knows about care problems
and chooses to repress, quiet
at home as a soother and
blocks out world, guilt, visits
daily for kids, happy at home,
resource and goes out with
them
Nili
Daily visit, shaves him, visits
beach, saves his spot in living
room, falls asleep with
newspaper, watches a lot of
tv, kids are supportive,
meeting at coffee shop with
friends, calls when not visiting
Rachel
Keeps his place at shul, calls
her name as a sign of missing
her, continues cooking and
club, kids are supportive,
support group, natural loner,
close to sisters,
Riva
Worries about his wellbeing
before visit, home is the same,
son is supportive and gives her
gifts for the home.
Rebecca
Choosing NH, care monitor,
difficulty saying goodbye,
home is same, daughter lives
far away and only partial help,
relations with his daughter
were always bad, support
from friends
Long daily visit, signs that he
needs her, worries and
agonizes over him, tries to
cheer him, volunteering, read
much, plays, computer, home
exercise, kids and grandkids
Ruth
difficulties with her –
likewise, concerned with
not being a bother to her
in-law neighbors, correct
relations
Alone 4 years, doesn't
know her, feels free, buys
prepared food, cleans less,
little laundry, afraid of
strangers at door, visits
daughter for weekend,
holiday at son's, grandkids
have not been to NH,
daughter comes to visit her
and father, doesn't want to
partake in support group
Has already gone thru
grieving process while at
home, change in his
character, sometimes
doesn't know her, calls
everyone her name, live
the moment, visits with no
feeling, was lonely when he
was home, friends died or
moved away or fell ill.
Visits only with son,
difficulty to see all old
people there, change in his
priorities, no real
communication, relief
when visit is over, new
bed, feels free, no cooking
and bored of plain diet, no
new clothes, house too big,
no phone calls, watches tv
at ease, visits son, friends
died
No real communication,
her situation is different
from his, fight with kids
due to money, bad turn of
relations with his son
because of money for NH,
friends died or ill
Views him as child, no
feeling of sharing, maternal
feelings, no anniversary
celebration, his death as a
release for both, doesn't
invite family over together,
168
hopes this doesn't happen to
her, NH as a pleasant social
environment, puts off what
she wants to do until he dies,
waiting for him to die.
Focuses felling old,
helplessness with staff, no
choice, can't not visit, empty
house, relief as well as
difficulty: less bother and
stress but more loneliness, like
widow except for visiting NH
and not cemetery, burden to
visit daily but also fills her, not
completely alone because he
is alive and she visits him
Not a part of her life, no
feeling of home but feeling of
connection to place where
she has lived many years, long
separation, lives the in the
moment.
Feels better on days she
doesn't visit, bored, holidays
at home are sad, satisfied with
her lot, loneliness, pain that
life is over
Worry and death anxiety
Dons mask outside of home,
doesn't share feelings,
loneliness, no pity, empathizes
with his pain, focuses her
feeling old, wishes for his
death, guilt, relief, anxious
are very supportive,
independent relation with
grandkids, goes out with
friends.
Sarah
Sarina
Daily visit because he
demands, cleans eyes and
mouth, home is same, kids are
supportive
Supports herself and son,
shops a lot and gifts for
grandkids, keeps his things at
home, continues cooking for
self, kids are supportive, visit
her for holidays, friends take
her out
Shira
Shares experiences, brings
food, care monitor, buys
cheap, prefers to purchase
services, tv, kids assist with
authorities, visits friends, good
neighbors
Simcha
Daily visit, Feeds and grooms
him, misses him, fears his
death, prefers it like this,
home is same, cooks, club,
trips, exercise at home, reads
psalms, relations as beforesome good some not, financial
support for one son, close to
sisters, sits on bench outside
and chats with neighbors, trips
with work friends, phone calls
to distant friends
Daily visit, shares experiences,
coffee shops with friends,
writes poetry, kids are
Sophie
every morning waits for
daily call from daughter,
daughters are go between
her and NH, shares more
emotional burdens, social
meeting with mask on,
partial sharing with friends,
friends died or ill
Cons him into letting her
leave, sleeps at kids on
weekends, no cooking, no
friends – each to his own
Gave away some of his
stuff to family member,
picks up hitchhikers,
singing club, lost much
weight, reads a lot, free at
home, grandkids don't visit
NH, initially avoided
celebrations, extended
family and friends don't
visit NH
He is better off than she,
less visiting, free to decide
without him and enjoys it,
doesn't understand him –
partial contact, buys
prepared food, enjoys
spending money as she
sees fit, no exercise, no
going out, unclear
schedule, grandson lives
with her for her own good,
kids dismiss her wishes,
physical disability limits
socializing, friends died
Afraid to sleep alone, put
another lock on door,
cleaning lady, goes to kids
for holidays, lids invite her
for weekends and doesn't
go, friends are far and hard
to visit, doesn't share his
condition.
and agonizes about his
wellbeing, shame, holidays are
a punishment, ambivalent
about info about him- wants
and doesn't want to know
Relief with NHP, less
visiting, sleeps in another
room, no cooking, relief
Sadness and missing what will
not be anymore
169
Difficulty separating for long
time, emotionally exhausted,
not visiting is a relief if
someone else visits, moral
duty, helplessness, empty
house and gotten used to it,
surprised at ability to cope,
separates between life areas
Wishes she doesn't suffer like
him, bitterness, loneliness,
visits out of duty
Wishes she doesn't suffer like
him, agonizes for him,
exhausted of life, and wants
her own corner. Split – cares
for him and goes out, anxious
and worried about him when
she is not there, fears, holds
onto him so he doesn't dieprefers this situation
supportive, goes out with
friends, friends are very
supportive
Suzie
Daily visit, invests in
entertaining him, tries to
accommodate him, home is
same, kids live far and are not
source of support
Tala
Weekly visit, daily calls,
heartfelt discussions, go
between him and staff, keeps
his things, hears noises and
thinks it is him, thinks to lower
tv for him, writes books, club
and trips, tv, computer going
abroad, drawing, cold relation
with his son, relation with
brother is limited source of
support, natural loner
His reaction as a sign she
brings him happiness, calls her
name, cleaning lady, bridge
club, computer, kids visit
weekends, kids are
supportive, keeps her
problems from them
Tova
Yaffa
Speaks in plural, daily visit,
sleeps there when he is ill,
feels his pain, brings him
specialties, caresses him, he is
the same, morning kiss, wants
to be with him as long as he
breathes, cleans home alone,
reads a lot, loose relation to
grandkids that sometime visit
her, phone calls to son abroad
Yochi
Speaks in plural, double daily
visit, takes responsibility for
his actions, her mood based
from errands for him,
counts her money, new lit
clubs, negative responses
from acquaintances
Maternal feelings,
rationalizes it is good for
him there, regression to
loneliness – known from
past, kids come for limited
time to assist, holidays by
herself by choice
Less calls because of his
hearing, doesn't want her
to visit more often, made
some changes to home,
moved bed, pays his son's
share, bad relations with
his son's wife
Maternal feelings, different
from who he was, cooks for
kids, little laundry, tries to
save money, bridge at
home sometimes, no trips,
goes to kids for holidays,
goes out with daughter in
TLV, they visit him and go
out with her for lunch
Showers 3Xdaily, awakens
early, cleans home in parts,
sleeps in different room,
little laundry, eats cold
food – no cooking, takes
sedatives, doesn't drink
coffee late, takes care of
finances, puts on makeup
in kitchen, tv moved to
other room, estranged with
son due to NH payments,
holidays at NH, doesn't visit
son's home, doesn't go to
occasions, cold relations
with DIL, friends died, cut
off from anyone not
sympathetic to her actions
Copes alone with all her
problems, loss of interest
in homecare, wears old
171
Guilt, large hole left by lack of
instrumental caring for him,
lives in the moment, takes
sedatives
Easier not to leave home than
come back to empty one, out
all day, emptiness, continues
to go for him and not because
she wants to, frustration,
cares for others, lives in the
moment
No life outside of route – NH –
home, helplessness, empty
home, waiting for phone call
of his death, worry and
anxiety, her life project, her
world came down on her,
mask when leaving home,
goes home and leaves her
whole world at NH
Loneliness, aloneness
on his behavior, sleeps on
same side of bed, volunteers,
cold relations with DIL
Zari
Home is same, kids all over
world and source of support,
sometimes visit, prefer to visit
him
clothes, no cooking,
stopped exercise and part
of volunteering, estranged
from elder son over
finances, cold relation with
other son. Alone while very
ill, cut off all contacts and
neglects contacts
Visits once in a few
months, more worried
about instituted son,
showers 4Xdaily, buys little
food, cooks for kids,
cleaning lady, needed to
buy assistance when ill,
friends died or moved
away, neighbors all left
171
‫נשים זקנות בין נישואין לבין אלמנות‬
‫מאת‪ :‬דנה פאר‬
‫תקציר‬
‫רקע מדעי‪ :‬מטרת מחקר זה הינה להבין את חווית החיים של נשים זקנות שהן אלמנות בנישואין ( ‪married‬‬
‫‪.)widows‬‬
‫‪12‬‬
‫מונח זה מתייחס לאנשים זקנים‪ ,‬שבני זוגם מזה שנים רבות‪ ,‬עברו להתגורר בבית אבות בשל‬
‫מגבלות פיסיות ותפקודיות‪ ,‬בעוד הם ממשיכים להתגורר בקהילה‪ .‬לאור הנטייה של גברים להינשא לנשים‬
‫הצעירות מהם‪ ,‬ולאור ההבדלים בתוחלת חיים בין גברים ונשים‪ ,‬שכיחות נשים שהן אלמנות בנישואין גבוהה‬
‫משכיחות הגברים במצב חיים זה‪ .‬על כן‪ ,‬מחקר זה מתמקד בחוויה של נשים שהן אלמנות בנישואין בישראל‪.‬‬
‫באופן מסורתי מתמקדים מחקרים בנוגע למעבר לבית אבות במצבו הרגשי של הזקן העובר לשם‪ ,‬ולא‬
‫ברגשותיהם של המטפלים הנותרים בביתם לאחר אירוע זה (‪ .)Kellett, 1999‬מחקרים שהתמקדו בבני‬
‫המשפחה מצאו שאלו חווים‪ ,‬לצד ההקלה בטיפול האינטנסיבי‪ ,‬רגשות של אמביוולנטיות בנוגע למעבר לבית‬
‫אבות‪ ,‬נקיפות מצפון‪ ,‬אשמה‪ ,‬לעתים דיכאון ועוד (‪ .)Bond et al., 2003‬עבור מטפל משפחתי המעניק טיפול‬
‫לזקן חולה‪ ,‬המשך הטיפול בבית והימנעות ממעבר לבית אבות הוא גורם בעל חשיבות מרכזית‪ ,‬ומהווה נקודת‬
‫סיפוק משמעותית‪ .‬הדימוי של "המטפל האידיאלי" יוצר לחץ להמשיך ולהתמודד גם כאשר נדרש טיפול‬
‫אינטנסיבי הולך וגובר לזקן החולה‪ ,‬ובשל כך ההחלטה להעביר לבית אבות היא קשה מבחינה רגשית‬
‫(‪ .)Gwyther, 1990‬במצב זה יש קושי רב לכל בני המשפחה‪ ,‬אך המערכת הזוגית היא המושפעת ביותר‪.‬‬
‫זקנים בנישואין ארוכי טווח מצפים כי ימשיכו להתגורר יחדיו עד יום מותם‪ ,‬והמצב החדש שנוצר עם יציאתו‬
‫של אחד מבני הזוג לבית אבות לרוב מלווה בקשיים רבים ובלתי צפויים‪.‬‬
‫במצב של ערעור סידור המגורים המוכר ושינויים בתפקידים עשויה האישה המתגוררת בקהילה לחוות‬
‫רגשות אשם‪ ,‬אבל‪ ,‬צער‪ ,‬הקלה ועוד‪ .‬לאחר שנים רבות של נישואין‪ ,‬התפיסה של עצמה כאישה נשואה ומה‬
‫המשמעות של להיות נשואה‪ ,‬נבדקת מחדש‪ .‬בנוסף‪ ,‬האישה לעתים קרובות בודדה מבחינה חברתית ואינה יכולה‬
‫‪ 12‬תרגום מונח זה לעברית נקבע בייעוץ ובאישור הועדה למינוח סוציולוגי באוניברסיטת חיפה (יוני ‪.)2119‬‬
‫‪1‬‬
‫לשתף בקשייה ולקבל תמיכה‪ .‬תחושת ה כי נישואיה אינם ולא יהיו עוד כפי שהיו בעבר אינה בהכרח מקבלת‬
‫הכרה ואפשרות לביטוי בחברה‪.‬‬
‫מחקרים קודמים שנערכו ביחס למצב חיים ייחודי זה‪ ,‬התייחסו לתפיסות בני הזוג את הנישואין‬
‫ובהתאם לכך העלו מספר טיפולוגיות (‪ )Gladstone, 1995; Kaplan et al., 1995; Kaplan, 2001‬או‬
‫שתיארו תהליך של הסתגלות למצב זה (‪.)Rosenthal & Dawson, 1991‬‬
‫במחקר זה נבחרה מסגרת התייחסות פנומנולוגית בכדי להבין את חוויית החיים ההוליסטית של האישה‬
‫הזקנה הנשארת בקהילה‪ ,‬בסיטואציית חיים חדשה וייחודית‪ :‬לכאורה מערכת הנישואין ממשיכה להתקיים‪ ,‬אך‬
‫לא במובן הקלאסי והמוכר שהיה במשך שנים רבות‪.‬‬
‫שיטה‪ :‬לאור מיעוט מחקרים בנושא זה‪ ,‬מחקר זה נקט בשיטת מחקר איכותנית בפרספקטיבה פנומנולוגית‪.‬‬
‫נערכו ‪ 28‬ראיונות חצי מובנים עם נשים בנות ‪ ,+65‬המתגוררות בקהילה והבעל שלהן מזה ‪ 31‬שנה יותר‬
‫מתגורר בבית אבות‪ ,‬ואשר דוברות עברית‪ .‬גיל ממוצע של המשתפות היה ‪ .76‬כולן טפלו קודם לכן בבעליהן‬
‫בבית וממוצע זמן הטיפול בבית היה ‪ 4‬שנים‪ .‬זמן מגורים ממוצע של הבעל בבית אבות היה קצת יותר משנתיים‪.‬‬
‫המשתתפות היו ילידות מגוון ארצות‪ ,‬ומקום הלידה השכיח היה ישראל (למעשה פלשתינה)‪ .‬מספר ילדים‬
‫ממוצע של בני הזוג היה ‪( 3‬טווח של ‪ .)1-11‬כמחצית המשתתפות נהגו לבקר את הבעל בית האבות באופן יומי‪,‬‬
‫והיתר לרוב נהגו לעשות זאת ‪ 2-3‬פעמים בשבוע‪.‬‬
‫לאחר איסוף הנתונים באמצעות הראיונות שערכה החוקרת‪ ,‬נכתב תמלול של כל ראיון תוך שינוי‬
‫פרטים מזהים לצורך שמירה על פרטיות המשתתפות‪ .‬בהמשך נערך ניתוח נתונים במסורת השיטה המעוגנת‬
‫בשדה (‪ .)Strauss & Corbin, 1998‬מתוך הנתונים נמצאו תמות מרכזיות‪ ,‬שגובשו בהמשך לכדי מודל‬
‫המבוסס על מחקר זה‪ .‬לצורך הרחבת יריעת אמינות הממצאים נעשה שימוש במשובים מקבוצת עמיתים ומשוב‬
‫של אחת המשתתפות לממצאים עצמם‪.‬‬
‫ממצאים‪ :‬ראשית יש להתייחס לכך כי כל המשתתפות הדגישו כי ההחלטה להעביר את הבעל לבית אבות‬
‫התקבלה במצב של "אין ברירה"‪ .‬כולן תיאור מסכת טיפול בבית‪ ,‬שבה השקיעו מאמצים ומשאבים לצורך מתן‬
‫טיפול אופטימאלי בבית‪ ,‬וכאשר הדבר כבר לא היה אפשרי‪ ,‬התקבלה ההחלטה להעביר לבית אבות‪.‬‬
‫‪2‬‬
‫קבלת ההחלטה להעביר לבית אבות נעשתה במספר מסלולים‪ ,‬שכללו בני משפחה ואנשי מקצוע‪ .‬הללו‬
‫השפיעו על החלטה באופנים שונים‪ ,‬וכך גם מידת האחריות שהאישה מייחסת לחלקם בהחלטה‪ .‬ממצאים אלו‪,‬‬
‫כמו גם תפיסת הצורך להעברה כבלתי נמנע‪ ,‬תואמים את הספרות הגרונטולוגית בנושא העברה לבית אבות‬
‫( ;‪Abendorth et al., 2012; Buhr et al., 2006; Couture et al., 2012; Ducharme et al., 2012‬‬
‫‪.)McLennon et al., 2010‬‬
‫הממצא המרכזי במחקר זה הינו שנשים במצב של אלמנות בנישואין חוות תהליכים של המשכיות‬
‫והתנתקות מהבעל שלהן ומחייהן בעבר‪ .‬תהליכים אלו‪ ,‬הקיימ ים במקביל והם גם קונפליקטואליים‪ ,‬מותירים את‬
‫האישה במצב של נישואין שהם תלויים ועומדים – מצב של בין לבין‪ .‬תהליכי ההמשכיות וההתנתקות מתרכזים‬
‫על פני שלושה צירים‪ :‬רגשי‪ ,‬חברתי והתנהגותי‪ .‬בכל אחד מהצירים ייתכן שהאישה תחווה תהליך של המשכיות‬
‫במקביל לתהליך של התנתקות‪.‬‬
‫תהליכים של המשכיות הקשר עם הבעל באים לידי ביטוי בציר הרגשי בכך שהאישה ממשיכה לחוות‬
‫קשר לבעלה‪ ,‬על אף שחלו שינויים מהותיים בהתנהגותו ואף במראהו‪ .‬הנשים נוטות לייחס להתנהגויות שונות‬
‫של הבעל פרשנות של יחס אישי והתכוונות אליהן‪ ,‬בשונה מהאופן ששאר הסובבים מפרשים התנהגויות אלו‪.‬‬
‫פרשנויות אלו מחזקות את ההיקשרות שלהן אליו‪ ,‬ומחזקת את תחושתן כי הן ממשיכות להיות המטפלות‬
‫העיקריות של הבעל‪ ,‬על אף שאינן מבצעות את הטיפול הפיזי הישיר‪ .‬תפקיד המטפל מתרכז עתה במימד של‬
‫השגחה על איכות הטיפול הניתן לבעל‪ ,‬אך חשיבות תפקידן אינה מופחתת‪.‬‬
‫בציר החברתי תהליכים של המשכיות מתייחסים לקשרים עם משפחה גרעינית ומורחבת וחברים‪.‬‬
‫האישה לרוב ממשיכה לשמר את מאפייני התפקיד שלה כאם כלפי ילדיה‪ .‬לעתים הדבר כרוך במחיר אישי של‬
‫אי שיתופם של הילדים בקשייה‪ ,‬והעמדת פנים של יכולת התמודדות שהינה מעבר ליכולתה האמיתית‪.‬‬
‫המשכיות קשרים חברתיים מהעבר מחוץ למשפחה לרוב מאופיין בהבעת תמיכה של חברים‪ .‬נשים שהיו‬
‫מתבודדות בעבר ממשיכות גם הן את דפוסן החברתי‪.‬‬
‫בציר ההתנהגותי הנשים ממשיכות לשמר הרגלים ודפוסים מהעבר על אף השינוי שחל עם מעבר‬
‫הבעל לבית האבות‪ .‬כך נמצא כי המקום הפיזי שהבעל תופס בחייהן הינו נושא שטומן בחוב אי וודאות‪ ,‬ורבות‬
‫משמרות את קיומו במרחב הביתי‪ ,‬חרף העובדה שאינו משתמש בו ואינו צפוי לעשות זאת שוב בעתיד‪.‬‬
‫‪3‬‬
‫משתתפות שמתגוררות עם ילדיהן הבוגרים ממשיכות לבצע מטלות בית כפי שעשו בעבר‪ ,‬ויש במגורים‬
‫משותפים אלו משום גורם המשמר את תפקידן ותפקודן כפי שהיה בעבר‪.‬‬
‫כאמור במקביל לתהליך של המשכיות חוות המשתתפות תהליך של התנתקות מהבעל ומהעבר‪ .‬גם‬
‫תהליך זה מתרכז על שלושת הצירים שהוזכרו‪ .‬תהליכים של התנתקות באים לידי ביטוי בציר הרגשי בשינויים‬
‫ברגשות של האישה כלפי בעלה‪ ,‬לעתים על רקע מחלה דמנטית‪ ,‬אך לא רק‪ .‬ניתן לראות כי קיימת נטייה של‬
‫מעבר מרגשות של אהבה זוגית לרגשות המאפיינים אמהות כלפי הבעל‪ .‬בחינה מעמיקה של אופי ביקורים‬
‫יומיים בבית האבות‪ ,‬הנתפסים כסממן למסירות האישה לבעלה‪ ,‬מגלה אף היא תהליך של התנתקות רגשית‬
‫שהאישה חווה‪.‬‬
‫תהליך ההתנתקות קיים בציר החברתי הן ברמת התנתקות מבני משפחה‪ ,‬קרובים ורחוקים‪ ,‬והם ברמת‬
‫חברים‪ .‬לעתים המעבר של הבעל לבית האבות מגביל את האפשרויות האובייקטיביות של האישה להמשיך‬
‫לקיים קשרים חברתיים כבעבר‪ ,‬לעתים ההתנתקות היא על תחושה של רקע היעדר תמיכה ואמפתיה למצבה‬
‫הנוכחי ע"י הסובבים אותה‪ .‬אירועים משפחתיים וחגים הם נקודות זמן משמעותיים‪ ,‬שבהם האישה חשה במיוחד‬
‫בשינוי שחל בחייה‪ ,‬ולא פעם מורגש תהליך התנתקות בפרט בנקודות זמן אלו‪ .‬ביחס לחברים‪ ,‬הנשים במחקר‬
‫זה תארו תהליך מובהק של התנתקות מקשרים חברתיים‪ ,‬לעתים ארוכי שנים‪ ,‬מחברים שנתפסים כי אינם‬
‫תומכים בדרך חייהן הנוכחית‪.‬‬
‫בנוסף לצירים אלו‪ ,‬תהליך התנתקות מקבל ביטוי גם בציר ההתנהגותי‪ .‬המעבר לבית האבות משפיע‬
‫על הרגלי החיים של האישה‪ :‬אכילה‪ ,‬שינה‪ ,‬תחזוקת הבית ופעילויות פנאי‪ .‬גם מרחב המחיה עשוי לעבור‬
‫שינויים המהווים ביטוי לתהליך זה‪ .‬שינוי משמעותי ובלתי צפוי מתרחש ביחס לשימוש בכספים‪ .‬עם המעבר של‬
‫הבעל לבית האבות‪ ,‬הנשים נדרשות לעסוק בענייניהן הפיננסים‪ ,‬מה שהיה בעבר לרוב נחלתו של הבעל‪ .‬כעת‬
‫ניהול הכספים מהווה ביטוי של התנתקת מהבעל ומתפקידים מסורתיים בזוגיות‪ .‬שינוי זה מביא לעתים חופש רב‬
‫יותר בהוצאות ולעתים דווקא צורך בהצטמצמות והתחשבנות בהוצאות‪ ,‬דבר נוסף שלא היה מוכר מן העבר‪.‬‬
‫דיון‪ :‬מחקר זה חקר את חווית של אלמנות בנישואין‪ ,‬ומציע כי זו כרוכה בקיומן של שני תהליכים מקבילים ובו‬
‫זמניים‪ ,‬אך מנוגדים‪ ,‬של המשכיות והתנתקות מהבעל הגר בבית אבות ומן העבר שלהן איתו‪ .‬המודל של מחקר‬
‫‪4‬‬
‫זה מציג כי הנשים במצב חיים זה נמשכות בו זמנית לשני קצוות הפוכים‪ :‬המשכיות והתנתקות‪ ,‬כך שהן נותרות‬
‫תקועות ואינן יכולות להמשיך הלאה בחייהן‪.‬‬
‫המצב שבו שני תהליכים אלו מתקיימים במקביל מותיר את האישה בדילמה בנוגע לזהותה כנשואה‬
‫ומעמדה האישי‪ .‬חלק מהנ שים משתמשות בשיטת אלימינציה לבחינת מעמדן האישי‪ ,‬אך שיטה זו יכולה להניב‬
‫תשובות סותרות‪ :‬חלקן מסיקות כי הן ממשיכות להיות נשואות בעוד אחרות מסיקות כי אינן תואמות לאף‬
‫הגדרה קיימת של מעמד אישי‪ ,‬כפי שהוגדר ע"י אחת המשתתפות "חיים במצב של לימבו"‪ .‬לאחר שנים כה‬
‫רבות של נישואין‪ ,‬וקשירת זהותן עם היותן נשואות‪ ,‬השינוי במצב האישי משפיע על כל חווית החיים שלהן‪.‬‬
‫מבט על מצבים אחרים שבהם בני הזוג אינם חיים יחדיו‪ ,‬לרב בקרב זוגות בגילאים צעירים יותר‪ ,‬מגלה אף הוא‬
‫כי ישנה חשיבות מכרעת למגורים משותפים לצורך קיום ושימור תחושת זוגיות ושיתוף בחיי נישואין‪.‬‬
‫השלכות תיאורטיות‪ :‬עד כה נתפסו תיאוריית ההמשכיות ותיאוריית ההתנתקות כתיאוריות מקיפות בעולם‬
‫הגרונטולוגי‪ .‬לאור ממצאי מחקר זה‪ ,‬מוצע לשקול להמשיג מחדש את התפיסה של התנתקות כתהליך כוללני‬
‫ואחיד בחיי הזקן‪ .‬כבר בעבר הציעו חוקרים (‪ )Carp, 1968, Hochschild, 1975‬כי תהליך התנתקות אינו‬
‫מתקיים במידה זהה בכל תחומי החיים ובכל הקשרים החברתיים של הזקן‪ .‬המשגה מחדש מאפשרת גם לכלול‬
‫התנתקות שאינה חברתית בלבד אלא גם התנתקות בהיבטים שונים של החיים‪ ,‬כגון התנתקות מהרגלי מהעבר‬
‫או מחפצים‪ .‬במקביל‪ ,‬בדומה למחקרים אחרים (‪ ,)Stadnyk, 2006; Utz et al., 2002‬נמצא כי המשכיות‬
‫הינה חלק משמעותי בחיי הנשים הזקנות‪ ,‬וגם לכך יש מקום‪ .‬בחוויה של נשים אלו אין סתירה בין תהליכי‬
‫המשכיות וההתנתקות‪ ,‬אלא הם מתקיימים באופן עצמאי ומקביל בכל תחום בחיים‪.‬‬
‫השלכות מעשיות‪ :‬במסגרת יישומי המחקר מוצע לאנשי מקצוע ללמוד ולהכיר את המושג "אי וודאות‬
‫באובדן"‬
‫‪13‬‬
‫(‪ .)Boss, 1999‬מושג זה מתייחס מצבים שבהם אדם נוכח מבחינה פיזית אך נפקד מבחינה‬
‫פסיכולוגית‪ .‬זה מתאים גם למצב שבו הנישואין תלויים ועומדים אך אינם נחווים בחיי נישואין מלאים ומוכרים‬
‫כפי שהיו העבר‪ .‬אנשים החווים מצב זה זקוקים לתמיכה והכלה של רגשותיהם‪ ,‬והעמקת הידע של אנשי מקצוע‬
‫העובדים בבית האבות בנושא זה יאפשר להם להיות אמפתיים יותר ולהבין את החוויה של נשים במצב זה‪ .‬כל‬
‫זה עשוי להביא לסובלנות של הצוות כלפי נשים אלו‪ ,‬ואולי אף למצוא דרכים לשתף אותן בטיפול‪ ,‬ולא לחוות‬
‫‪13‬‬
‫תרגום מונח זה לעברית נקבע בייעוץ ובאישור הועדה למינוח סוציולוגי באוניברסיטת חיפה (יוני ‪.)2119‬‬
‫‪5‬‬
‫אותן כמטרד‪ ,‬כפי שקורה רבות כיום‪ .‬בהמשך לכך‪ ,‬מוצע לחשוב מחדש על תפיסת התפקיד של הנשים במצב זה‬
‫כ"שותפות טיפול"‪ -‬מצב הדומה למצב שקיים לפני שהבעל הזקן זקוק לטיפול אינסטרומנטלי ממשי‪ ,‬ובכך‬
‫להגדיר מחדש את מקומן בחיי הבעל ובית האבות‪.‬‬
‫מגבלות‪ :‬מחקר זה כמובן אינו חף ממגבלות‪ .‬ראשית‪ ,‬המחקר נערך במסורת המחקר האיכותני‪ ,‬ובהתאם לכך‬
‫המדגם הינו קטן ולא ניתן להכליל ממחקר זה על אוכלוסיית האנשים הנמצאים במצב חיים זה‪ .‬כמו כן‪ ,‬המחקר‬
‫נערך עם נשים שממשיכות להיות בקשר עם הבעל שלהן בבית האבות‪ .‬אך ידוע כי ישנן נשים שאינן ממשיכות‬
‫את הקשר עם בן הזוג שהועבר לבית אבות‪ ,‬וחלק מהמשתתפות אף רמזו לכך‪ .‬אולם‪ ,‬מאמצים לאתר נשים‬
‫כאלו ולהשיג את הסכמתן להשתתף במחקר העלו חרס‪ .‬מעבר לגודל המדגם‪ ,‬יש לציין גם כי המחקר התמקד‬
‫בנשים במצב חיים זה ולא כלל גברים באופן מכוון‪ ,‬מהטעמים שהוזכרו לעיל‪ .‬ניתן להניח כי הכללת גברים‬
‫באוכלוסיית מחקר תשפיע על ממצאים בעלי ייחוס מגדרי‪.‬‬
‫בנוסף‪ ,‬במהלך המחקר המשכתי להתעדכן בספרות המחקרית‪ ,‬ובשלב מתקדם של ניתוח הממצאים‬
‫נמצאו מספר מחקרים שהעלו אפשרות כי יש השפעה של מצבו של הבעל המתגורר בבית האבות על מידת‬
‫הסתגלותה של האישה למצב חיים זה ( ;‪Gillies, 2011; Mullin, Simpson & Froggart, 2013‬‬
‫‪ .)O'Shaughnessy, Lee & Lintern, 2010‬בדיקת אפשרות זו בנתונים שנאספו העלה כי לא ניכרת השפעה‬
‫מהסוג שחוקרים אלו העלו‪ ,‬אך ייתכן כי התייחסות ספציפית ונרחבת יותר לעניין זה במהלך איסוף הנתונים היה‬
‫מעלה ממצאים שונים‪.‬‬
‫המלצות למחקרי המשך‪ :‬בנוסף לאמור לעיל בנוגע לכיוון עתידי למחקר‪ ,‬מומלץ כי מחקר עתידי יתייחס‬
‫לנושא המגדר בהקשר למצב חיים זה‪ .‬מהסיבות שהוזכרו קודם‪ ,‬במחקר זה בחרתי להתמקד בחוויה של נשים‬
‫שהן "אלמנות בנישואין"‪ .‬עם העלייה בתוחלת החיים‪ ,‬עולה במקביל גם מספרם של גברים הנקלעים למצב חיים‬
‫זה‪ .‬יש יסוד להניח כי יש השפעה של מגדר על החוויה של "אלמנות בנישואין"‪ ,‬ורצוי שמחקר עתידי יתייחס‬
‫לכך‪ ,‬בכדי להרחיב את ההבנה וההתייחסות לתופעה‪ .‬היבט נוסף שמומלץ להתייחס אליו במחקר עתידי הינו‬
‫ההיבט של זמן והשפעתו על החוויה‪ .‬הנשים במחקר זה היו במצב של "אלמנות בנישואין" בין חודש לבין ‪13‬‬
‫שנים‪ .‬אף כי נראה שהחוויה שלהן לא הושפעה מההיבט הטמפורלי של משך החוויה‪ ,‬ייתכן כי מחקר שיבדוק‬
‫מדגם מסוים במספר נקודות זמן יוכל להאיר היבטים נוספים את התופעה‪.‬‬
‫‪6‬‬
‫נשים זקנות בין נישואין לבין אלמנות‬
‫מאת‪ :‬דנה פאר‬
‫בהדרכת‪ :‬פרופ' אריאלה לבנשטיין‬
‫חיבור לשם קבלת התואר "דוקטור לפילוסופיה"‬
‫אוניברסיטת חיפה‬
‫הפקולטה ללימודי רווחה ובריאות‬
‫החוג לגרונטולוגיה‬
‫אוגוסט‪1014 ,‬‬
‫‪7‬‬
‫נשים זקנות בין נישואין לבין אלמנות‬
‫דנה פאר‬
‫חיבור לשם קבלת התואר "דוקטור לפילוסופיה"‬
‫אוניברסיטת חיפה‬
‫הפקולטה ללימודי רווחה ובריאות‬
‫החוג לגרונטולוגיה‬
‫אוגוסט‪1014 ,‬‬
‫‪8‬‬