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. Author manuscript; available in PMC: 2017 Sep 1.
Published in final edited form as: Rehabil Nurs. 2015 Nov 6;41(5):260–269. doi: 10.1002/rnj.252

Spousal Caregivers of Coronary Artery Bypass Surgery Patients: Differences between Caregivers with Low vs. High Caregiving Demands

Esther O Park 1, Bernice C Yates 2, Jane Meza 3, Karl Kosloski 4, Carol Pullen 5
PMCID: PMC4860178  NIHMSID: NIHMS723202  PMID: 26543015

Abstract

Purpose

Compared to non-caregivers, caregivers have higher rates of depressive symptoms, caregiver strain, less mutuality, and health care visits. However, few investigators have examined family caregivers after coronary artery bypass surgery. The purpose of this study was to examine differences in caregiving difficulties, mutuality (i.e., open communication; avoiding sad thoughts), and depressive symptoms based on low verses high caregiving demands among spousal caregivers.

Design

A descriptive, comparative design was used to examine 33 spousal caregivers of CAB surgery patients (16 in low and 17 in high caregiving demand groups).

Methods

Measures included: Caregiving Burden Scale, Mutuality and Interpersonal Sensitivity Scale, and Patient Health Questionnaire-9. Groups were compared using Mann-Whitney U statistics.

Findings

It was found that caregivers with high caregiving demands reported more caregiving difficulties and more open communication about the surgery compared to caregivers with low demands.

Conclusion

Caregivers with greater caregiving demands may need additional support to assist them with the caregiving situation.

Keywords: Caregiving Demand, Caregiving Difficulty, Mutuality, Depressive symptoms, Coronary artery bypass surgery

Introduction

In 2014, it was estimated that there were 66 million informal caregivers caring for their family members (Mozaffarian et al., 2015). Of these caregivers, 408,000 were caring for coronary artery bypass (CAB) surgery patients (American Heart Association, 2014). In addition, the cost of hospital stays for CAB surgery patients was greater than $ 44 billion (Go et al., 2014). Because of this high costs, insurance companies have reduced reimbursements and forced hospitals to discharge CAB patients earlier, putting heavier caregiving demands on informal caregivers. Because they are hospitalized only 3-4 days, CAB patients are often sicker and require more care when they are discharged. Thus, the need for informal caregiving from spouses or family members to manage and maintain the health status of the patients following CAB surgery is great.

Within the context of heart surgery, health care professionals frequently expect the spouse or other family members to assume the caregiver role post coronary artery bypass (CAB) surgery to assist the patients with activities of daily living and to ensure that patients adhere with the requested risk factor modifications. This is often with little or no information or support for the process (Halm & Bakas, 2007; Halm, Treat-Jacobson, Lindquist, & Savik, 2007; Robley, Ballard, Holtzman, & Cooper, 2010; Stolarik, Lindsay, Sherrard, & Woodend, 2000). In addition, caregivers were found to have higher rates of depressive symptoms (Aggarwal, Liao, Christian, & Mosca, 2008) and caregiver strain (Savundranayagam, Montgomery, & Kosloski, 2010), less mutuality (Schumacher et al., 2008), and incur more health care visits (Savundranayagam et al.) compared to non-caregivers. However, few investigators have examined family caregivers after coronary artery bypass (CAB) surgery. Thus, the purpose of this study was to examine differences in caregiving difficulties, mutuality (i.e., open communication; avoiding sad thoughts), and depressive symptoms based on low verses high caregiving demands among spousal caregivers of Coronary Artery Bypass surgery patients.

Review of Literature

Once a family member becomes an informal caregiver, caregiving activities are usually added on to their daily routine. Some caregivers change their work schedule or decrease their hours of work to accommodate the time needed for caregiving (Ågren et al., 2010; Theobald & McMurray, 2004). Others may quit work and become full-time caregivers (Mahrer-Imhof, Hoffmann, & Froelicher, 2007). Frequently reported caregiving demands of spousal caregivers of CAB surgery patients included responsibility for care (e.g., managing symptoms, changing eating habits), providing transportation (Halm & Bakas, 2007), and additional household tasks (Halm, Treat-Jacobson, Lindquist, & Savik, 2006; Halm et al., 2007). Theobald and McMurray (2004) examined spousal caregivers of patients after CAB surgery and found that caregiving experiences were often unexpected and unanticipated. Schumacher et al. (2008) found in caregivers of cancer patients that caregiving demand had a larger effect on caregiver outcomes than expected. When caregiving demand was high, there was a greater risk for depression, total mood disturbance and fatigue (Schumacher et al.). In light of these findings, there is a need to better understand the caregiving demands faced by spouses of CAB patients.

Compared to caregivers with fewer demands, it was expected that caregivers with greater caregiving demands would also experience more caregiving difficulties because of the sheer amount of tasks and activities they may be involved in. Although this proposition has been tested in other caregiving populations (Schumacher et al., 2008; Shyu et al., 2013), it has not been examined in caregivers of CAB surgery patients. Frequently reported difficulties of spousal caregivers of CAB surgery patients include managing behavioral problems, providing emotional support, additional household tasks, and managing finances, bills and forms related to the illness (Halm & Bakas, 2007; Park et al., 2013). Recent evidence suggests that different aspects of caregiving may have different effects on health outcomes. In spousal caregivers of elders, Savundranayagam et al. (2011) found that greater objective burden (demand or time) was related to the number of hours per week assisting the family member with activities of daily living while greater stress burden (i.e., nervous and depressed) was the only type of caregiving burden related to the caregiver's self-rated health.

According to a growing body of literature, mutuality in the caregiving relationship has significant positive effects on caregiving outcomes (Cochrane, Lewis, & Griffith, 2011; Lewis, Fletcher, Cochrane, & Fann, 2008; Lewis, 2009; Northouse et al., 2007; Schumacher, Stewart, & Archbold, 2007; Schumacher et al., 2008). Prior research has found that greater mutuality, defined as the positive aspects of the relationship, in both spousal and other relationships was inversely related to caregiving outcomes such as depressive symptoms, caregiving difficulty, anger, anxiety, and uncertainty (Northouse et al., 2007; Schumacher et al., 2008). In CAB surgery patients, Kneeshaw et al. (1999) examined mutuality in caregivers that included spouses, adult children (daughters and sons), and nieces. In this study, a significant decrease was found in mutuality between hospital discharge and 3 months later suggesting that there was stress in the caregiver-care recipient relationship during this time frame. A more recent study found that greater mutuality was related to improved perceptions of how their lives had changed since providing care for a family member (r = 0.34, p = 0.02) (Halm & Bakas, 2007). Because of the few studies in caregivers of CAB surgery patients, more studies are needed. In this study, mutuality was defined as open communication and avoidance of sad thoughts among CAB patients and spouses. This definition was derived from the original mutuality scale developed in the contest of breast cancer (Lewis & Deal, 1995; Lewis, 2009).

Depressive symptoms have been studied as one of the main health outcomes in caregiving research. Researchers have demonstrated that depression is a common sequela associated with chronic illness for patients, but less consideration has been given to the psychological outcomes experienced by their caregivers. Health professionals, family, and friends tend to overlook the needs of the caregivers of cardiac patients, especially if there is no outward evidence of distress, because the patient's illness is more salient (Rankin & Monahan, 1991). In one of the few studies involving spousal caregivers of CAB patients participating in cardiac rehabilitation, 66% reported psychological distress (O'Farrell, Murray, & Hotz, 2000).

Conceptual Framework

The conceptual model guiding this study was derived from stress and coping theory (Lazarus & Folkman, 1984) and prior research (see Figure 1). The central proposition that was tested was that compared to caregivers with fewer demands, caregivers with greater demands would experience more caregiving difficulties, less mutuality (open communication; avoidance of sad thoughts), and more depressive symptoms. Caregiving demands and caregiving difficulties were defined based on Lazarus and Folkman's stress and coping framework: although caregiving demand and difficulty are commonly conceptualized as situational factors based on Lazarus’ theory, we modified the original framework and in this study we conceptualized caregiving demand as an antecedent situational factor and caregiving difficulty as an outcome. Caregiving demand was defined as the appraisal of the perceived time spent in tasks and behaviors that make up caregiving (Oberst, Thomas, Gass, & Ward, 1989). The outcomes of the caregiving process were conceptualized as caregiving difficulties, mutuality (open communication; avoidance of sad thoughts), and depressive symptoms. Caregiving difficulty was defined as the perceived bothersomeness of the caregiving activities (Oberst et al., 1989). Mutuality was defined as illness-related open communication avoiding sad thoughts between caregiver and care recipient (Lewis & Deal, 1995). Depressive symptoms were defined as the frequency of symptoms such as feelings of sadness and loss of interest (Kroenke, Spitzer, & Williams, 2001). With greater caregiving demands, it was posited that caregivers would also report greater caregiving difficulties because they often prioritize patients’ needs over their own during the illness situation and the time of active caregiving may act as a barrier for spouses to engage in exercise, healthy eating, or other stress reducing behaviors (Ross, Sundaramurthi, & Bevans, 2013). Further, it is likely that greater caregiving demands may increase mutuality by providing the couple with more opportunities to engage in illness-related communication (Northouse et al., 2007; Song et al., 2012); and thus facilitate more shared understanding about the illness (Lewis et al., 2008). Similarly, it seems that greater caregiving demands might function to increase depressive symptoms by isolating caregivers from their usual work and family roles and responsibilities. Indeed, in prior research, caregivers complained of a lack of time to engage in social relationships (Sherwood, Given, Given, & VonEye, 2005), which, in turn, may contribute to the caregiver's feelings of depressive symptoms (Coy et al., 2013; Scott et al., 2000; Shyu et al., 2010; Yang et al., 2014). Thus, the purpose of this study was to examine differences between spousal CAB caregivers with low caregiving demands vs. high caregiving demands in caregiving difficulties, mutuality, and depressive symptoms.

Figure 1.

Figure 1

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Study Model of Differences in Caregiving Difficulty, Mutuality, and Depressive Symptoms between Caregivers with Low vs. High Caregiving Demands

Methods

Design

This study was a secondary analysis, using a descriptive comparative design, of baseline data from caregivers who were involved in a larger study titled: “Reducing Risk in Cardiac Rehabilitation: Partners Together in Health (PaTH) Intervention” (Yates et al., 2015). Sample/Inclusion criteria

The clinical recruitment sites for the PaTH Intervention study were an academic medical center and a community hospital in a large Midwestern metropolitan area. Self-administered questionnaires were completed at home. The target population included consecutive CAB surgery patients who planned to participate in cardiac rehabilitation and their spouses/partners. The caregivers included in this study were spousal caregivers, > 19 years of age, as the majority of the patients where the study was conducted were married and at the point in their lives where the patient and spouse constituted the family unit. The sample size for this study was determined by logistical and budgetary constraints as the study was considered an exploratory study with results being used to guide further research.

Measures

Demographic information was measured to describe the sample including: age, gender, race, ethnicity, education, income, and work status.

Caregiving demand and difficulty

The Caregiving Burden Scale (CBS, Oberst et al., 1989) was used to measure caregiving demand and difficulty. Using this scale, caregiving demand was defined as the perceived amount of time required to do caregiving tasks and caregiving difficulty as the amount of perceived bothersomeness of the caregiving activities (Carey, Oberst, McCubbin, & Hughes, 1991; Oberst et al., 1989). For each factor, spouses responded to 15 items and scores ranged from 15 to 75, based on five point Likert scales with response sets of 1= none to 5 = a great deal. Higher scores denoted greater caregiving demand and difficulty. Although the caregiver may not spend much time (low demand) in caregiving tasks, they may perceive them as very difficult and vice versa. For example, there may be low demands reported for managing behavior problems or moods because it rarely occurs (low demand score); but when it does occur, it is very difficult and challenging for the caregiver to manage (higher difficulty score). In a sample of caregivers of CAB patients, Halm et al. (2006) reported internal consistency reliabilities of 0.91 for demand and 0.93 for difficulty scales in caregivers of CAB patients. In this study, Cronbach alphas for caregiving demand and difficulty were 0.89 and 0.91, respectively.

Mutuality was measured by the Mutuality and Interpersonal Sensitivity Scale (Lewis & Deal, 1995). This 32-item scale was originally developed to measure communication about breast cancer based on the theoretical dimensions of mutuality and interpersonal sensitivity (Lewis, 2009). Two subscales have been empirically derived from this total scale including Open Communication and Avoiding Sad Communication (Lewis, 2009) and were used in this study to measure mutuality. Permission was obtained from the author to adapt the questionnaire and “breast cancer” was changed to “heart surgery” in each item. Both subscales were measured on a 5-point Likert scale ranging from 5 = always true to 1 = never true. Items were summed to compute a total subscale score. The Open Communication subscale (8 items) measures the shared communication, feelings, and understanding about the heart surgery. Example items included: “We check in with each other to see how we are doing about the heart surgery”; and “When we don't understand what the other is feeling about the heart surgery, we try to figure it out together.”

The Avoiding Sad Thoughts subscale (9 items) measures the heightened levels of eliciting, attending to, and being aware of the other's feelings and thoughts about the heart disease or its impact. Example items included: “We don't talk together about the sadness I feel about the heart surgery”; and “Sad thoughts about the heart surgery are hard for us to talk about.” These items were recoded so that a higher score denoted more avoidance of sad talk about the heart surgery. In this study, the Cronbach alpha for the Open Communication subscale was 0.88 and for the Avoiding Sad Thoughts subscale was 0.83.

Depressive symptoms. In this study, depressive symptoms were defined as self-reported persistent feelings of hopelessness or sadness that interfered with the ability to work, sleep, eat or enjoy once pleasurable activities (Kroenke et al., 2001). Depressive symptoms were measured using the Patient Health Questionnaire (PHQ-9). The PHQ-9 has nine depressive symptoms, and is used to indicate the frequency of symptoms over the previous 2 weeks using a Likert-scale from 0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day. Summed scores ranged from 0 to 27 with threshold values of 5, 10, and 20 to indicate mild, moderate, moderately severe, and severe depression, respectively (Kroenke et al.). Internal consistency reliability was demonstrated in primary care patients and women with Cronbach alpha coefficients of .89 and .86 respectively; test-retest reliability was .84 in primary care patients over a 48 hour time frame (Kroenke et al.). Construct validity was further demonstrated in a sample of 6000 patients from primary care and obstetrics-gynecology clinics by significant associations between each of the depression severity levels and validated measures of mental, social, and role functioning as well as self-reported disability days, clinic visits, and amount of difficulty attributed by patients to their symptoms (Kroenke et al.). In the current study, the Cronbach alpha for this scale was 0.90.

Procedures

The study was approved by the Institutional Review Boards at the university and clinical sites where the study was conducted. For this study, inpatient and outpatient cardiac rehabilitation staff from both clinical sites informed potential subjects about the study and notified the research personnel if the person was interested in hearing more information about the study. Following referral, each participant was provided with information about the study by research staff close to the start of the cardiac rehabilitation program. Written informed consent was obtained and a copy of the signed consent form was given to each study participant. Following the informed consent process, caregivers received the questionnaire packet to complete and return to the in-person data collection visit at baseline. Baseline questionnaires were completed prior to the delivery of any intervention strategies.

Data Analysis

Two groups of caregivers were created based on the median score for caregiving demand: scores less than the median (Mdn = 34, Range 15 - 63) were denoted as less caregiving demand group and scores > 34 reflected greater caregiving demand groups. Because of the small sample size, nonparametric statistics (Mann-Whitney U test) were used to compare the differences between those low vs. high in caregiving demand on the following outcomes: caregiving difficulties, mutuality (open communication and avoiding sad communication), and depressive symptoms. Data were analyzed using SPSS version 22 (IBM Corp., 2013). Four subjects (11%) had missing data for one or more items on measures. Imputing data using single imputation methods (i.e., mean substitution) could result in underestimation of the variance (Rosner, 2006); therefore, missing data were left untreated in analysis. The level of significance for the study was p < 0.05.

Results

Caregivers in both groups were, on average, 63 years of age and about 2 ½ weeks after the patient's discharge from the hospital (see Table 1). The majority of caregivers were Caucasian females who were employed outside the home in professional or administrative positions and had annual household incomes between $40-70,000 per year. The median time since discharge for caregivers at the academic medical center (n=9) was 21 days (Range = 16-78 days) and for caregivers (n=24) at the community hospital was 11 days (Range = 4-52 days). Although the time since discharge differed between the two clinical sites, none of the remaining demographic or study variables differed between the two clinical sites.

Table 1.

Description of Demographic Characteristics in the Two Groups

Characteristic Low Caregiving Demands Group (N=16) High Caregiving Demands Group (N=17) Mann Whitney U statistic
Median (Range) Median (Range)
Age (in years) 62.5 (33-76) 63 (29-76) 0.76
Time Since hospital Discharge (in days) 17.5 (4-29) 16 (9-60) 0.85
N (%) N (%) Chi-Square statistic
Gender
    Female 11 (68.7%) 16 (94.1%) 0.07 (Fisher's exact test)
Work status
    Yes 8 (50%) 11 (64.7 %)
    No 1(6.3%) 0 (0%) 0.47
    Retired 7 (43.7%) 6 (35.3%)
Income
    < $40,000 1 (6.3%) 3 (17.6%)
    $40,000-70,000 6 (37.5%) 10 (58.8 %) 0.23
    > $70,000 9 (56.2%) 4 (76.4%)
Race/ethnicity
    Caucasian 16 (100%) 15 (88.2%) 0.26
    Hispanic 0 2 (11.8%)
Job type:
    Professional 6 (40%) 6 (35.3%)
    Technical/Sales 2 (13.3%) 1 (5.9%) 0.22
    Administrative 2 (13.3%) 7 (41.2%)
    Other 5 (33.4%) 3 (17.6%)
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Note. CAB = Coronary Artery Bypass. Numbers do not add up to the total sample size per group due to missing data.

Compared to the low caregiving demand group, the high caregiving demand group reported significantly greater caregiving difficulty (p=0.035) and more open communication (p=0.038) (see Table 2). There was a trend toward the greater caregiving demand group to also be more likely to avoid communication about sad thoughts (p=0.081). There were minimal depressive symptoms among the caregivers and no differences between groups.

Table 2.

Mann-Whitney U Comparisons of Study Variables in Low vs. High Caregiving Demand Groups

Study Variables Low Caregiving Demands Group (N=16) Median (range) High Caregiving Demands Group (N=17) Median (range) Mann-Whitney U statistics
Caregiving difficulty 18.5 (15-25) 26 (15-52) 78.0 (p=.035)
Depressive symptom 1 (0-3) 1 (0-20) 105.5 (p=0.402)
Open Communication 22 (16-35) 28 (16-45) 78.5 (p=.038)
Avoiding Sad Thoughts 26 (13-44) 32 (18-50) 87.5 (p=0.081)
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Discussion

Caregivers with greater caregiving demands reported significantly more caregiving difficulty and higher levels of open communication about the heart surgery compared to caregivers with less caregiving demand. Previous research has found that caregivers of patients with dementia (Shyu et al., 2010) and coronary revascularization procedures (Aggarwal et al., 2008) who reported greater caregiving burden also had more caregiving difficulties. Similarly, Schumacher et al. (2008) found a positive relationship (r = .56) between caregiving demand and difficulties in family caregivers of patients with cancer. It is likely that if more time is spent in caregiving activities, there is a cumulative effect with the concomitant perception of greater difficulties. In addition, it may be that caregivers reported greater caregiving difficulties because they prioritized patients’ needs over their own during the illness situation and the time of active caregiving may act as a barrier for spouses to engage in health promoting behaviors such as exercise and healthy eating. Although we found that spouses in the greater demand group reported more difficulties, the explanation for why spouses experienced more difficulties needs to be tested in future research. Based on Lazarus and Folkman's framework (1984), it is likely that there are mediating variables between time and difficulties that need to be tested in future studies such as appraisal of the caregiving situation as challenge vs. threat, coping skills, or the length of time or the amount of preparedness for the caregiving role (Schumacher et al., 2008).

Comparing across studies where the Caregiving Burden Scale was used to measure caregiving demand, the highest demand scores were found in caregivers of stroke survivors (M=41.5; Bakas, Austin, Jessup, Williams, & Oberst, 2004), followed by caregivers of CAB surgery patients (M=37) (Halm et al., 2006), and cancer patients (M=30.3 in lung cancer [Bakas, Lewis, & Parsons, 2001]; M=30.1 in varied cancers [Carey et al., 1991]). The lowest demands were found in another earlier study of caregivers of CAB surgery patients (M=27.8 [Stolarik et al., 2000]). Comparing across these same studies, the highest difficulty scores were found in caregivers of stroke patients (M=30.3; Bakas et al., 2004), followed by caregivers of cancer patients (M=23.2 in lung cancer [Bakas et al., 2001]; M=24.4 in varied cancers [Carey et al., 1991]), and then by caregivers of CAB surgery patients (M=24 [Stolarik et al., 2000]; M=19 [Halm et al., 2006). In the Stolarik et al. (2000) study, caregivers were rating their caregiving experiences one week after CAB surgery which may account for their slightly higher score than Halm et al. who had caregivers rate demands and difficulties, in a cross-sectional study, at 3, 6, and 12 months post CAB surgery. In the current study, even though the scores may seem only “slightly difficult” for the high demand group, the scores are comparable to what prior investigators have obtained with the scale. The scores also are in line with caregiving difficulty scores in other populations (lower scores than for caregivers of stroke and cancer populations) and similar scores for CAB surgery caregivers.

It is interesting to note that caregiving demand subscale scores are consistently higher than caregiving difficulty in this study and in prior studies involving CAB surgery patients (Halm & Bakas, 2007; Stolarik et al., 2000), stroke caregivers (Bakas et al., 2004), and cancer caregivers (Bakas et al., 2001; Carey et al., 1991). It appears to require more time to provide care than it is perceived as an effort or bothersome. In addition, when caregivers do encounter difficulties with caregiving, they may also experience concern and compassion for their loved one having to suffer and thus rate the difficulty lower than it actually is.

In this study, it was found that the high caregiving demand group also reported more open communication (mutuality) about the heart surgery than the low caregiving demand group. Prior studies found the opposite finding, that mutuality was negatively related to caregiving burden in CAB surgery caregivers (Halm et al., 2007; Kneeshaw et al., 1999). However, in these prior studies, mutuality was examined as the quality of the relationship between an informal caregiver and care receiver (i.e., how close you feel, how much love you feel, how much emotional support received). In contrast, mutuality in this study was measured by open communication and avoiding sad thoughts about the heart disease (Lewis & Deal, 1995). Because of the differences in how mutuality was defined and measured in the current study compared to earlier studies, it seems plausible that open communication may have been higher in the high demand group because the couples were faced with more tasks and difficulties and more discussion of the caregiving activities was required. More research is needed to compare these two measures of mutuality for the unique contributions they make to our understanding of the caregiving and care receiver experiences.

There was a trend for spousal caregivers of CAB patients with greater demands to be more likely to avoid discussing sad thoughts associated with the heart surgery. Based on current evidence, it was anticipated that more time spent in caregiving activities (greater demands) would also increase the opportunity and need to talk about the heart surgery because the couple is discussing potentially challenging and difficult caregiving issues (Cochrane et al., 2011; Lewis et al., 2008; Lewis, 2009). Future research is needed to better understand the relationship between avoiding communication about sad thoughts and caregiving demands in caregivers of CAB patients.

There was no difference found between the low vs. high caregiving demands groups in depressive symptoms. Although prior research has found that depressive symptoms were a significant problem for caregivers of cardiac patients (Chung, Moser, Lennie, & Rayens, 2010; Halm & Bakas, 2007; O'Farrell et al., 2000), there were several possible reasons why depressive symptoms were not different between the two groups. Caregivers who were experiencing depression may not have consented to be in the study due to lack of energy. In addition, the recruitment strategies may not have adequately extended to these caregivers. It is also possible that these were caregivers who “planned” to participate in cardiac rehabilitation with their partners, so they may not want to reveal their depressive symptoms thinking it may jeopardize their opportunity to participate in either cardiac rehabilitation or the study. In the current study, 6% of partners (n=2) reported depression. In the general population, 4.8% of people without a chronic illness were found to have major depression; compared to a prevalence of 8% to 17% for those people with a chronic illness (Lichtman et al., 2008). Thus, the incidence of depression in this sample was similar to the general population.

Although not statistically significant, there were 29% males in the low caregiving demand group (n=5) versus 6% (n=1) in the high demand group suggesting that male caregivers in this study experienced fewer demands. Prior studies were mixed in relation to gender. Although two studies in caregivers of CAB surgery patients found that male caregivers experienced more challenges and burden than female caregivers (Whitsitt, 2010), the majority of prior studies found that female caregivers reported greater caregiving demand and difficulty than male caregivers (Barusch & Spaid, 1994; Halm et al., 2006; Kamilovich, 1994; Lutzky & Knight, 1994; Rohrbaugh et al., 2002; Schumacher et al., 2008; Sherwood et al., 2005; Yee & Schulz, 2000). One possible reason for the greater difficulties in female caregivers of CAB surgery patients in earlier studies may be due to the struggle to relinquish traditional gender roles and attitudes (Whitsitt, 2010). Women may be more willing to take on the caregiving role than men are and so they allow themselves to get overloaded (Halm & Bakas, 2007; Whitsitt, 2010). In contrast, men are perhaps more realistic and willing to hire outside support for assistance with caregiving. Because of the small number of men in this study, however; more studies are needed examining gender differences in caregiving.

Limitations

There were several limitations in the study. First, the sample size was small. A larger sample size would have allowed the use of parametric statistics and multivariate analysis to draw conclusions with more confidence. The findings were also limited by the differences in the length of time since discharge between the CAB surgery caregivers at the two clinical sites. Caregivers at the community hospital site completed their baseline questionnaires at an earlier point in the recovery process compared to caregivers at the academic medical center and may have been dealing with more caregiving difficulties earlier in the post-operative period. The sample size in this study may not have detected these differences between groups. The sample had limited racial/ethnic and gender diversity limiting the generalizability of the findings to caregivers who match the demographic and caregiving characteristics of sample. Another limitation of the design was that it was cross-sectional. Future studies need to examine spousal caregivers longitudinally to determine the patterns of change over time in caregiving time and difficulties. Longitudinal studies would also allow investigators to examine whether depressive symptoms manifest later in the caregiving trajectory, after the crisis phase has resolved. Also, the longitudinal design would allow researchers to observe how patients and caregivers begin to integrate what has happened and what it means for their future lives.

Conclusions

In conclusion, differences were examined between CAB surgery caregivers with low versus high caregiving demands in caregiving difficulties, mutuality (open communication, avoiding sad thoughts) and depressive symptoms. It was found that spousal caregivers of CAB surgery patients with high caregiving demands reported more caregiving difficulties and more open communication about the heart surgery compared to spousal caregivers with low caregiving demands. Spousal caregivers of CAB patients with greater caregiving demands may need additional supportive resources to assist them during the first few weeks of the caregiving situation. Future research is needed, particularly in individuals who perceive high caregiving demands, to better understanding their needs and to determine what interventions are needed for this population.

Acknowledgements

This study was supported in part by Phi Delta Gamma, University of Nebraska Chapter, and the Bergstrom Graduate Nursing Fellowship to the first author, and by Grant NR010923 from the National Institute of Nursing Research, National Institute of Health, and by the University of Nebraska Medical Center Clinical Research Center, Research Support Fund to the second author.

Contributor Information

Esther O. Park, Nursing Department, Daegu University, 33 Seongdangro 50gil Namgu, Daegu 705-714, Republic of Korea.

Bernice C. Yates, College of Nursing, University of Nebraska Medical Center, 42nd and Emile, Omaha, NE, 68198, bcyates@unmc.edu.

Jane Meza, College of Public Health, University of Nebraska Medical Center, 984355 Medical Center, Omaha, NE, 68198-4355, jmeza@unmc.edu.

Karl Kosloski, Department of Gerontology, University of Nebraska Omaha, 6001 Dodge St. Omaha, NE, 68182, kosloski@unomaha.edu.

Carol Pullen, College of Nursing, University of Nebraska Medical Center, 42nd and Emile, Omaha, NE, 68198, chpullen@unmc.edu.

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