The impact of relationships, motivations, and meanings on dementia caregiving outcomes.

Abstract

ABSTRACT Background: Numerous theoretical models have been developed to explore how caregiving can impact on caregiving outcomes. However, limited attention has been given to the effects of caregivers' motivations for providing care, the meaning they find in caregiving, and the nature of their relationship with the care-recipient. The current study explored the associations between intrinsic and extrinsic motivations, ability to find meaning in caregiving, and pre-caregiving and current relationship quality, and the way in which these variables interact to influence caregiving outcomes. Methods: This was a cross-sectional questionnaire study, in which the respondents were 447 caregivers of people with dementia who were in receipt of a specialist nursing service. Results: The results showed that intrinsic motivations, meaning, and pre-caregiving and current relationship quality were significantly related to each other, while extrinsic motivations were only related to intrinsic motivations and meaning. All these factors were significantly related to caregiving outcomes as measured by caregiver burden, role captivity, and competence. Conclusions: Based on these findings, it is recommended that interventions aimed at reducing caregiving stress should take into account the impact of the quality of the relationship and the caregivers' motivations for providing care. More longitudinal research is needed to explore how meanings, motivations, and relationship quality change over the caregiving career.

Full text

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International Psychogeriatrics: page 1 of 11 C ?International Psychogeriatric Association 2012
doi:10.1017/S1041610212000889
The impact of relationships, motivations, and meanings on
dementia caregiving outcomes
.........................................................................................................................................................................................................................................................................................................................................................................
Catherine Quinn,1Linda Clare,1Ted McGuinness2and Robert T. Woods3
1School of Psychology, Bangor University, Bangor, Gwynedd, UK
2Hulton Hospital, Bolton, UK
3Dementia Services Development Centre, Bangor University, Bangor, Gwynedd, UK
ABSTRACT
Background: Numerous theoretical models have been developed to explore how caregiving can impact on
caregiving outcomes. However, limited attention has been given to the effects of caregivers’ motivations for
providing care, the meaning they find in caregiving, and the nature of their relationship with the care-recipient.
Thecurrentstudyexploredtheassociationsbetweenintrinsicandextrinsicmotivations,abilitytofindmeaning
in caregiving, and pre-caregiving and current relationship quality, and the way in which these variables interact
to influence caregiving outcomes.
Methods: This was a cross-sectional questionnaire study, in which the respondents were 447 caregivers of
people with dementia who were in receipt of a specialist nursing service.
Results: The results showed that intrinsic motivations, meaning, and pre-caregiving and current relationship
quality were significantly related to each other, while extrinsic motivations were only related to intrinsic
motivations and meaning. All these factors were significantly related to caregiving outcomes as measured by
caregiver burden, role captivity, and competence.
Conclusions: Based on these findings, it is recommended that interventions aimed at reducing caregiving stress
should take into account the impact of the quality of the relationship and the caregivers’ motivations for
providing care. More longitudinal research is needed to explore how meanings, motivations, and relationship
quality change over the caregiving career.
Key words: cross-sectional, quantitative methods, positive aspects of care, informal caregiving
Introduction
The majority of people with dementia are cared
for at home by informal caregivers, normally
someone who knew the care-recipient beforehand.
The influences on the caregiver’s decision to take
on the caregiving role, and the changing nature
of the relationship with the care-recipient may
affect the outcomes of caregiving. In addition,
caregivers’ ability to find meaning in caregiving,
to identify positive aspects, could reinforce their
desire to provide care. In this study, we aim to
investigatehowthesethreefactorsofmotivationsfor
caregiving, the relationship between the caregiver
and care-recipient, and the meanings attributed to
caregiving impact on the caregiving experience. In
the current study, we will examine whether and in
Correspondence should be addressed to: Dr. Catherine Quinn, School of Psy-
chology, Bangor University, Bangor, Gwynedd LL57 2AS, UK. Phone: +44
1248 388359; Fax: +44 1248 382599. Email: catherine.quinn@bangor.ac.uk.
Received 24 Feb 2012; revision requested 18 Mar 2012; revised version
received 19 Apr 2012; accepted 23 Apr 2012.
what way these factors are related to each other and
exploretheindividualandcombinedimpactofthese
factors on caregiving outcomes.
There have been numerous theoretical models
developed to explain the process of caregiving
(e.g. Pearlin et al., 1990). One major commonality
between these models is that the outcomes of
this process concern the impact of caregiving
upon caregivers’ wellbeing. Traditionally, there
has been a tendency for research to focus on
the negative impact of caregiving on caregivers’
health and wellbeing; however, some caregivers
may be able to derive something positive out of
providing care. One way in which caregivers can
positively appraise the caregiving situation is to find
meaning in the caregiving role. There have been
different conceptualizations of meaning and the
term has primarily been used to describe coping-
related phenomena (Folkman, 1997). Folkman
(1997)proposedthat“meaningiscreatedbyfinding
a redeeming value in loss” (p. 1215). During
stressful circumstances, such as providing care,

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C. Quinn et al.
a person may search for meaning as a way to
cope with this stress. For instance, a caregiver
may positively reappraise the situation in order to
identify benefits or positive changes. Meaning has
beenviewedasbeingmultidimensional,withseveral
components. Reker and Wong (1988) propose that
meaning has a cognitive component, as it is a
way of making sense of one’s experiences, and an
emotional component, as it is linked to feelings
of satisfaction and fulfillment. Meaning also has
a motivational component, since finding meaning
may help motivate the person to sustain coping.
Despite its relevance in understanding adaptation
to stressful events, there has been little research
exploring the role of finding meaning in dementia
caregiving. A systematic review identified only a
limited number of studies, but the results indicated
that finding meaning can have a positive impact on
dementia caregivers’ wellbeing (Quinn et al., 2010).
Some caregivers may be able to derive meaning
through the relational aspects of providing care.
Caregiving can affect the quality of the relationship
for both the caregiver and care-recipient; however,
relationship quality has tended to be neglected in
models of stress and coping. Some models, such
as the Stress Process Model (Pearlin et al., 1990),
have viewed the relationship between the caregiver
and care-recipient as just a background factor,
yet this relationship will gradually alter throughout
the caregiving process. This transformation in the
relationship is likely to impact on the experiences
of the caregiver and care-recipient. A better
quality of relationship has been linked to higher
wellbeing in caregivers and care-recipients (e.g.
Clare et al., 2012), and a slower decline in the
care-recipient’s cognitive and functional abilities
(Norton et al., 2009). A systematic review on
relationship quality (Quinn et al., 2009) found
that studies exploring the differences in ratings of
pre-caregiving and current relationship quality had
inconsistent findings. Therefore, in this review it
was recommended that more research is needed
to explore the impact of both pre-caregiving and
currentrelationshipqualityoncaregivingoutcomes.
While it has been argued that the relationship
between the caregiver and care-recipient can
influence the caregiving experience, this relation-
ship will also have an important role in the
commencement of caregiving. It is often the
relational connection or history that prompts
relatives or friends to begin caregiving; for instance,
research by Kolmer et al. (2008) indicated that
caregivers were primarily motivated to care because
of their relationship with the care-recipient. There
has been limited research into dementia caregivers’
motivations to provide care and the way in which
these motivations influence caregiving outcomes.
However, some studies have explored the role of
cultural motivations, such as familism, in caregiving
(e.g. Knight and Sayegh, 2010; Romero-Moreno
et al., 2011). It has been argued that, since effective
caregiving requires the caregiver to be motivated
to accept the responsibility and effort required in
providing care, inadequate motivation on the part
of the caregiver may result in provision of ineffective
or low levels of support (Feeney and Collins, 2003).
A systematic review indicated that motivations
to provide care can indeed impact on wellbeing
(Quinn et al., 2010). Yet, the studies reviewed did
not conceptualize motivations within a theoretical
framework.Therearedifferenttypesofmotivations;
intrinsic motivations relate to internal desires to
provide care, while extrinsic motivations relate
to extrinsic pressures to provide care. Utilizing
appropriate conceptual frameworks can further
illuminate how different motivations can influence
caregiving outcomes.
The available evidence suggests that relationship
quality, motivations, and meaning can impact on
dementia caregiving. However, there has been
no quantitative exploration of the way in which
motivations for caregiving, the meanings attributed
to caregiving, and the evolving nature of the
relationship between the caregiver and care-
recipient are potentially related to and influence
each other. In a previous study, exploring the
predictors of finding meaning we found that both
relationshipqualityandcaregivingmotivationswere
correlated with finding meaning (Quinn et al.,
2012). In the current study, we will explore the
relationship between these three factors and the
way in which they influence caregiving outcomes.
Developing a greater understanding of the factors
that can influence the caregiving experience will
aid the development of better interventions for
caregivers.
Research aims
1 To
motivations, meaning, and pre-caregiving and
currentrelationshipqualityarerelatedtoeachother,
and if so in what way.
2 Toexamine whether
motivations, meaning, and pre-caregiving and
current relationship quality are related to caregiving
outcomes.
explore whetherintrinsic and extrinsic
intrinsic andextrinsic
Methods
Design
This was a large-scale cross-sectional postal ques-
tionnaire survey exploring the relationship between
meanings, motivations, relationship quality, and

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Relationships, motivations, and meanings
3
caregiving outcomes. The respondents were in
receipt of a specialist nursing service, provided by
Admiral Nurses.
Ethical issues
Ethical approval for this study was obtained from
the relevant National Health Service Multi-Centre
Research Ethics Committee. In order to ensure
participant confidentiality, selected Admiral Nurses
acted as local collaborators on this project, and they
alone had access to the participants’ contact details.
Participants
The participants in this study were informal
caregiversof people
caregivers were identified from the caseloads of 12
Admiral Nurse teams across England. The Admiral
NurseserviceisaUK-basedspecialistmentalhealth
nursing service, supported by the charity Dementia
UK, which aims to improve the quality of life of
all people affected by dementia with a focus on the
needs of caregivers. Admiral Nurses work with the
caregiver/care-recipient dyad to identify dementia
care services appropriate to their needs. They
also provide practical advice, emotional support,
and information about dementia. Caregivers were
included in this study if, at the time of the study,
they were currently in receipt of the Admiral
Nurse Service or had been discharged from the
Service within the past six months. Caregivers were
excluded from the study if the care-recipient had
died.
withdementia.These
Measures
DEMOGRAPHIC CHARACTERISTICS
The caregivers were asked to complete basic
demographic information about themselves, the
care-recipient, and the caregiving situation, and to
rate their health on a 5-point scale ranging from 1
(Poor) to 5 (Excellent).
MEANING
Meaning was measured using the 12-item Meaning
inCaregivingScale(NoonanandTennstedt,1997).
This explores the positive aspects of care and ways
in which caregivers can find meaning through the
caregiving experience, for example “I’ve learned
a lot about myself as a result of caring.” The
questions were rated on a 5-point scale ranging
from 1 (Strongly disagree) to 5 (Strongly agree).
Possible scores ranged from 12 to 60, with a higher
score indicating a greater sense of finding meaning
in caregiving. The Cronbach’s α coefficient for this
measure was 0.88.
MOTIVATIONS TO PROVIDE CARE
The caregivers’ motivations to provide care were
measured by the Motivations in Elder Care Scale
(Lyonette and Yardley, 2003), which is comprised
of two subscales: Extrinsic Motivations to Care
(EXMECS) and Intrinsic Motivations to Care
(INMECS). As the measure was designed for
caregivers of older adults, the wording of the
questions was slightly altered to be appropriate
for caregivers of people with dementia. The
INMECS subscale measured intrinsic motivations,
for example “it is part of my nature to provide care
forothers.”Thesubscaleconsistsofsevenquestions
which were rated on a 5-point scale ranging from 1
(Strongly disagree) to 5 (Strongly agree). Possible
scores ranged from 7 to 35, with a higher score
indicating greater intrinsic motivations to provide
care. The Cronbach’s α coefficient for this measure
was 0.81.
The EXMECS subscale measured extrinsic
reasons for providing care, for example “the person
I care for expected me to care for him/her.”
The subscale consists of six questions which
caregivers rated on a 5-point scale ranging from 1
(Strongly disagree) to 5 (Strongly agree). Possible
scores ranged from 6 to 30, with a higher
score indicating greater extrinsic motivations to
provide care. Analysis of the reliability of the scale
using the present dataset found that one question
(“person was gradually becoming more dependent
on me”) correlated poorly with the other items.
Pallant (2005) recommends that items which have
correlations below 0.3 should be removed from the
scale. Thus, this item was removed prior to further
analysis, increasing the Cronbach’s α coefficient
from 0.76 to 0.78.
RELATIONSHIP QUALITY
Current and pre-caregiving relationship quality was
measured using the Positive Affect Index (Bengtson
and Schrader, 1982). The measure consists of
five items which assess the closeness of the
relationship, communication, similarity in views,
getting along, and shared activities. The phrasing
of these questions was amended to assess both pre-
caregiving and current relationship quality. In each
case,responseswereratedona6-pointscaleranging
from 1 to 6. Possible scores ranged from 1 to 30,
with higher scores indicating greater relationship
quality. The Cronbach’s α coefficient for pre-
caregiving relationship quality was 0.88, and for
current relationship quality was 0.76.
BURDEN
Burden was measured using the short version of the
Zarit Burden Interview (Bédard et al., 2001). The

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C. Quinn et al.
scale measures caregivers’ appraisal of the impact
caregiving has had on their lives. The measure
consists of 12 questions rated on a 5-point scale
ranging from 0 (Never) to 4 (Nearly always).
Possible scores ranged from 0 to 48, with higher
scores indicating greater burden. The Cronbach’s
α coefficient for this measure was 0.87.
ROLE CAPTIVITY
Role captivity was measured using a 3-item scale
(Pearlinetal.,1990).Thecaregiversratedtheextent
to which they felt trapped in their role on a 5-
point scale ranging from 1 (Strongly disagree) to
5 (Strongly agree). Possible scores ranged from 3 to
15,withhigherscoresindicatingmorerolecaptivity.
The Cronbach’s α coefficient for this measure was
0.84.
COMPETENCE
Competence was measured using the 3-item Care-
giving Competence scale reported by Robertson
et al. (2007). The caregivers evaluated the adequacy
of their role as a caregiver on a 5-point scale
ranging from 1 (Strongly disagree) to 5 (Strongly
agree). Possible scores ranged from 3 to 15, with
higher scores indicating greater competence. The
Cronbach’s α coefficient for this measure was 0.86.
Procedure
Acting as local collaborators, the Admiral Nurses
accessed the Admiral Nurse client database and
utilizedtheinclusioncriteriatoidentifyparticipants.
Participants’ names and addresses were collected
and the questionnaires were posted out to the
participants. The participants were provided with a
freepost envelope in which to return the completed
anonymous questionnaire to the researcher. Upon
receipt, the researcher numbered the questionnaires
and entered the data into an SPSS (Statistical
Package for the Social Sciences) database version
16 for Windows Vista.
Planned statistical analysis
Prior to analysis, the data were examined for
normality of distribution and the presence of
outliers. Examination of histograms, plots of
normality, and box plots indicated that some
of the measures were skewed and so the most
appropriate method of transformation was chosen
for each measure. Competence, pre-caregiving
relationship quality, INMECS, and EXMECS were
all negatively skewed. Competence was reflected
and then a square root transformation was applied.
Pre-caregiving relationship quality, EXMECS, and
INMECS were reflected and then logarithmically
transformed. As these transformations reversed
the direction of the variable, the variables were
subsequently re-reflected to return them back
to their original direction (Munro, 2005). Since
rolecaptivity waspositively
transformed using a square-root transformation.
These transformations were effective in reducing
the skew in these measures. In preparation for the
hierarchical regressions, the data were checked for
linearity, multicollinearity, and homoscedasticity.
No changes were made to the data.
A Wilcoxon signed-rank test was performed
to determine whether there was a significant
difference between scores of pre-caregiving and
current relationship quality. Correlational analyses
were conducted to indicate whether and in what
way there was a relationship between INMECS,
EXMECS, meaning, and current relationship
quality and pre-caregiving relationship quality.
Correlational analyses were also performed to
explore the relationship between these factors,
selected demographic factors, and the measures
of caregiving outcomes. Hierarchical regression
analysis was employed to determine how much
of the variance in caregiving outcomes scores
could be explained by meaning, intrinsic and
extrinsicmotivations, and
current relationship quality, beyond that accounted
for by demographic factors. For each of these
analyses, demographic characteristics were entered
in the first step, followed by pre-caregiving and
current relationship quality, meaning, INMECS,
and EXMECS in the next step.
skewed,itwas
pre-caregivingand
Results
In total, 1,228 questionnaires were sent out to
caregivers, and 460 completed questionnaires were
returned, a response rate of 37.5%. Of these
questionnaires, 13 were not included in the analysis
as they came from caregivers where the care-
recipient had died. Therefore, data from 447
questionnaires were included in the analysis.
Sample characteristics
The characteristics of the caregivers and care-
recipients are described in Table 1. The mean age
of the care-recipients was 78.6 (range 25–95) and
54% were female. The mean age of the caregivers
was 67.8 (range 25–95), 66.9% were female, and
68.3% were spouses. The majority of the caregivers
were White British and were married. The length
of caregiving varied, with 22% reporting that they
have been providing care for between 2 and 3 years
and 18.9% providing care for 5–10 years. Sixty-four
percentofthecaregiversreportedthattheyprovided
care for over 50 hours per week.

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Relationships, motivations, and meanings
5
Table 1.
recipients, and caregiving situation
Characteristics of the caregivers, care-
VARIABLE
.......................................................................................................................................................
Care-recipient
Age (M, SD)
Gender (female)
Caregiver
Age (M, SD)
Gender (female)
Marital status (married)
Relationship to care-recipient
Spouse
Other
Ethnicity
White British
White European
White other
Asian Bangladeshi
Asian Indian
Asian other
Black African
Black Caribbean
Other
Length of caregiving
Less than 1 year
1–2 years
2–3 years
3–4 years
4–5 years
5–10 years
10–15 years
15+ years
Hours of care per week
Less than 50
Over 50
N
%
78.6 (8.71)
24154
67.8 (12.52)
299
374
66.9
84
304
141
68.3
31.7
405
11
91.2
2.5
1.4
0.5
1.1
0.5
0.5
1.6
0.9
6
2
5
2
2
7
4
16
59
97
65
78
83
25
17
3.6
13.4
22.0
14.8
17.7
18.9
5.7
3.9
148
272
35.3
64.8
Information on the caregivers’ scores on the
measures is provided in Table 2. Ratings of
pre-caregiving relationship quality (M=23.09,
SD=5.42) were higher than those for current re-
lationship quality (M=17.86, SD=5.13). Analysis
using a Wilcoxon signed-ranks test shows that this
difference was significant, T=95.30, p<0.001,
r=–0.52.
Relationships between variables and
caregiver characteristics
Theintercorrelationsbetweenintrinsicmotivations,
extrinsic motivations, meaning, pre-caregiving and
current relationship quality, caregiver characterist-
ics, and type of relationship to the care-recipient
are shown in Table 3. Gender was associated
with both pre-caregiving and current relationship
quality, such that being a male caregiver was
associated with higher pre-caregiving and current
relationship quality. Spousal caregivers reported
higher pre-caregiving relationship quality, intrinsic
and extrinsic motivations, and meaning.
Associations between motivations, meaning,
and relationship quality
Table 3 contains the intercorrelations between
these variables. There was a medium positive
association between pre-caregiving and current
relationship quality. There were small positive
associations between the quality of the relationship,
both pre-caregiving and current, and meaning.
There was a medium positive association between
pre-caregiving relationship quality and intrinsic
motivations, and a small positive association
between current relationship quality and intrinsic
motivations.Thus, higher
current relationship quality were related to higher
meaning and higher intrinsic motivations. There
was a medium positive correlation between intrinsic
motivations and meaning, with higher intrinsic
motivationsassociated
Extrinsic motivations were significantly related only
to intrinsic motivations and meaning. There was a
medium positive correlation between extrinsic and
intrinsicmotivationsandasmallpositivecorrelation
between extrinsic motivations and meaning. Higher
pre-caregivingand
withhigher meaning.
Table 2. Mean scores on all the measures
VARIABLE
.........................................................................................................................................................................................................................................................................
Pre-caregiving RQ443 23.095.42
Current RQ 437 17.86 5.13
Meaning431 43.617.57
INMECS 433 30.613.48
EXMECS435 20.313.64
Burden 43122.52 8.58
Role captivity431 7.74 3.09
Competence432 11.882.09
NM SD RANGE (ACTUAL)
RANGE (POSSIBLE)
5–30
5–30
20–60
16–35
5–25
0–44
3–15
3–15
5–30
5–30
12–60
5–35
5–25
0–48
3–15
3–15
Note: RQ=Relationship Quality, INMECS=Intrinsic Motivations, EXMECS=Extrinsic Motivations.

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C. Quinn et al.
Table 3. Intercorrelations between study variables
VARIABLE
1
2
3
4
6
7
8
9
10
11
12
13
14
..................................................................................................................................................................................................................................................................................................................................................................................................................................................
1. Gender- cg (0=male)
–
2. Age- cg
−0.26∗∗
–
3. Relationship (0=spouse)
0.18∗∗
−0.70∗∗
–
4. Hours of care (0=>50)
−0.16∗∗
0.22∗∗
−0.41∗∗
–
6. Health- cg
0.00
−0.18∗∗
0.10∗
−0.07
–
7. Pre-caregiving RQ
−0.18∗∗
0.14∗∗
−0.28∗∗
0.23∗∗
0.07
–
8. Current RQ
−0.24∗∗
0.08
−0.08
0.04
0.13∗∗
0.49∗∗
–
9. INMECS
−0.07
0.10∗
−0.12∗
0.17∗∗
−0.08
0.37∗∗
0.23∗∗
–
10. EXMECS
−0.03
0.10∗
−0.17∗∗
0.02
−0.08
0.09
−0.03
0.44∗∗
–
11. Meaning
−0.09
0.08
−0.17∗∗
0.11∗
0.10∗
0.29∗∗
0.25∗∗
0.45∗∗
0.24∗∗
–
12. Burden
0.29∗∗
−0.19∗∗
0.14∗∗
0.07
−0.30∗∗
−0.25∗∗
−0.42∗∗
−0.11∗
0.13∗∗
−0.28∗∗
–
13. Role captivity
0.27∗∗
−0.16∗∗
0.15∗∗
0.01
−0.17∗∗
−0.34∗∗
−0.46∗∗
−0.23∗∗
0.08
−0.36∗∗
0.72∗∗
–
14. Competence
−0.08
0.02
−0.09
0.13∗
0.06
0.16∗∗
0.20∗∗
0.39∗∗
0.21∗∗
0.46∗∗
−0.30∗∗
−0.21∗∗
–
Note: RQ=Relationship Quality, INMECS=Intrinsic Motivations, EXMECS=Extrinsic Motivations, cg=caregiver.
∗p<0.05,∗∗p<0.001.
extrinsic motivations were associated with higher
meaning and higher intrinsic motivations.
Relationships between motivations, meaning,
relationship quality, and caregiving outcomes
Table 3 contains the intercorrelations between
these variables. Meaning had a small negative
correlation with burden, a medium negative
correlation with role captivity, and a medium
positive correlation with competence. Thus, higher
meaning was associated with lower burden and
role captivity, and with higher competence. Pre-
caregiving relationship quality had a small negative
correlation with burden, a medium negative
correlation with role captivity, and a small positive
correlation with competence. Current relationship
quality had medium negative correlations with
burden and role captivity, and a small positive
correlation with competence. Thus, both a better
pre-caregiving relationship and a better current
relationship were associated with lower burden and
role captivity, and higher competence. Extrinsic
motivations had small positive correlations with
burden and competence. Intrinsic motivations had
small negative correlations with burden and role
captivity, and a medium positive correlation with
competence. Thus, higher intrinsic motivations
were associated with lower burden and role
captivity, and higher competence, while higher
extrinsic motivations were associated with higher
burden and competence.
Hierarchical regressions
BURDEN
Table 4 indicates the percentage variance in
burden accounted for by the independent variables.
In the first step of the model, demographic
characteristics explained 18% of the variance in
burden (Adjusted R2= 0.18, F(4, 372)=21.77,
p<0.001). All the variables made a significant
contribution: gender, relationship, health status,
and hours of care. Thus, being a female or a
non-spousal caregiver, having poor health, and
providing long hours of care predicted higher
levels of burden. The inclusion of pre-caregiving
and current relationship quality, meaning, intrinsic
motivations, and extrinsic motivations uniquely
explained an additional 18% of the variance
in burden, significantly increasing the variance
explained to 36% (Adjusted R2= 0.36, F change
(5, 367)=21.72, p<0.001). Current relationship
quality, meaning, and extrinsic motivations were
all significant predictors of variance in burden.
Thus, a poorer current relationship, lower meaning,
and higher extrinsic motivations were significant
predictors of greater burden.

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Relationships, motivations, and meanings
7
Table 4. Hierarchical multiple regressions predicting burden, role captivity, and competence
BURDEN ROLE CAPTIVITY COMPETENCE
STEP VARIABLE
.......................................................................................................................................................................................................................................................................................................................................................................................................................................................
Step 1 0.18
Gender5.37 0.850.30∗∗
0.340.06
Relationship3.170.960.17∗
0.180.07
Health rating
−2.00
Hours of care2.250.930.13∗
0.100.07
Step 20.36
Gender3.78 0.780.21∗∗
0.200.05
Relationship2.79 0.900.15∗
0.120.06
Health rating
−1.53
Hours of care2.850.84 0.16∗∗
0.16 0.06
Current RQ
−0.40
Pre-caregiving RQ
−1.00
Meaning
−0.26
INMECS
−1.52
EXMECS 6.151.22 0.24∗∗
0.400.08
BSE BBETAADJUSTED R2
BSE BBETA ADJUSTED R2
B SE B
BETA ADJUSTED R2
0.120.02
0.28∗∗
0.14∗
−0.16∗
0.08
–0.05
–0.07
0.05
0.12
0.06
0.07
0.03
0.06
–0.05
–0.06
0.10∗
0.11∗
0.40
−0.24∗∗
−0.09 0.03
0.370.26
0.17∗∗
0.10∗
−0.09
0.13∗
−0.26∗∗
−0.09
−0.26∗∗
−0.11∗
0.23∗∗
−0.01
0.01
0.03
0.09
0.01
−0.12
0.03
0.31
0.10
0.05
0.06
0.02
0.06
0.01
0.08
0.00
0.09
0.08
−0.01
0.01
0.05
0.08
0.10
−0.09
0.36∗∗
0.21∗∗
0.06
0.36
−0.18∗∗
−0.05 0.02
0.09
1.19
0.05
1.29
−0.24∗∗
−0.05
−0.23∗∗
−0.06
−0.03
−0.14
−0.02
−0.19
0.01
0.08
0.00
0.09
Note: RQ=Relationship Quality, INMECS=Intrinsic Motivations, EXMECS=Extrinsic Motivations.
∗p<0.05,∗∗p<0.001.

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8
C. Quinn et al.
ROLE CAPTIVITY
Table 4 provides the percentage variance in
role captivity accounted for by the independent
variables.Inthefirststepofthemodel,demographic
characteristics explained 12% of the variance in role
captivity (Adjusted R2=0.12, F(4, 372)=13.37,
p<0.001). Gender, relationship, and health ratings
made significant contributions to the variance. This
indicates that being a female or a non-spousal
caregiver and having poor health accounted for
higherrolecaptivity.Theinclusionofpre-caregiving
and current relationship quality, meaning, intrinsic
motivations, and extrinsic motivations uniquely
explained an additional 25% in variance, increasing
the total variance explained to 37% (Adjusted
R2=0.37, F change (5, 367)=30.21, p<0.001).
Current relationship quality, meaning, and intrinsic
and extrinsic motivations all significantly explained
variance inrolecaptivity.
current relationship, lower meaning, lower intrinsic
motivations, and higher extrinsic motivations were
significant predictors of greater role captivity.
Thus,apoorer
COMPETENCE
Table 4 provides the percentage variance accounted
for in competence by the independent variables.
In the first step of the model, demographic
characteristics explained only 2% of the variance
in competence, with hours of care alone making
a significant contribution (Adjusted R2=0.02,
F(4, 371)=2.98, p<0.05). This indicates that
providing greater hours of care was associated with
higher competence. The inclusion of pre-caregiving
and current relationship quality, meaning, and
intrinsic and extrinsic motivations uniquely ex-
plained an additional 24% in variance, significantly
increasing the total variance explained to 26%
(Adjusted R2=0.26, F change (5, 366)=24.65,
p<0.001). Only intrinsic motivations and meaning
were significant predictors. Thus, higher intrinsic
motivations and higher meaning were significant
predictors of greater competence.
Discussion
In the current study, we aimed to explore the
linkages between relationship quality, motivations
to provide care, and the meaning caregivers find
in caregiving. The findings indicate that intrinsic
motivations, meaning, and pre-caregiving and cur-
rent relationship quality were significantly positively
related to each other. Extrinsic motivations were
only positively related to intrinsic motivations and
meaning. Both higher pre-caregiving and current
relationship quality were associated with greater
ability to find meaning. Some studies have found
that relationship quality can be linked to positive
aspects of providing care; for instance, a good
pre-caregiving relationship has been linked to
higher caregiving satisfaction (e.g. López et al.,
2005). Similarly, Lyonette and Yardley (2003)
found that, for caregivers of older people, a better
relationship and greater intrinsic motivations were
linked to higher caregiving satisfaction. However,
the measure of relationship quality used in that
study contained a mixture of questions on both
pre-caregiving and current relationship quality. In
the current study, both high pre-caregiving and
high current relationship quality were associated
with high intrinsic motivations. Given that these
intrinsic motivations emerge from internal desires
for providing care, then it is likely that affection
for the care-recipient would be linked to these
motives. Lyonette and Yardley (2003) also found
an association between high relationship quality
and low extrinsic motivations. However, in the
current study there was no significant relationship
between extrinsic motivations and pre-caregiving
or current relationship quality. Both intrinsic and
extrinsic motivations were linked to higher ability to
find meaning; however, intrinsic motivations had a
stronger relationship with meaning. It was expected
that, given the links to better wellbeing, intrinsic
motivations would be linked to meaning. The
unexpected finding of the link between extrinsic
motivations and meaning indicates that perhaps
it is the caregivers’ awareness of their reasons for
providing care that helps them find meaning in their
role.Levineetal.(1984)arguedthatcaregiversneed
to find meaning in the choices they have made, for
instance, commencing and continuing caregiving.
The findings from correlational analyses indicate
that intrinsic and extrinsic motivations, meaning,
and pre-caregiving and current relationship quality
were individually related to the measures of
caregiving outcomes. Both a better pre-caregiving
and current relationship were linked to better
outcomes.Thissupportstheviewthathavingagood
pre-caregiving relationship with the care-recipient
is beneficial for the caregiver. Other studies have
found that a good pre-caregiving relationship was
related to lower burden (Steadman et al., 2007).
The findings of the current study also indicate that a
goodrelationshipislinkedtofeelingsofcompetence
in caregiving. A study with adult-child caregivers
of older adults found that greater closeness in the
current relationship was related to greater feelings
of subjective effectiveness (Townsend and Franks,
1995). In addition, it is possible that feelings of
competency in providing care can help caregivers to
feel more positive about their relationship with the
care-recipient. In the current study, higher meaning
was associated with better outcomes, and other

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Relationships, motivations, and meanings
9
studies have found higher meaning is associated
with lower role strain and burden (e.g. McLennon
et al., 2011; Quinn et al., 2010). The link between
meaning and competence indicates that finding
meaning may have a positive influence on the
way in which caregivers appraise their role. The
findings of the current study suggest that intrinsic
and extrinsic motivations can have differential
impacts on caregiving outcomes. Higher intrinsic
motivations were associated with lower burden, role
captivity, and higher competence, whereas higher
extrinsic motivations were associated with higher
burden. Thus, intrinsic motivations were associated
withbetteroutcomesandextrinsicmotivationswere
linked to poorer outcomes. Studies have found
this effect with other types of motivations. In a
study with adult-child caregivers of older adults,
Cicirelli (1993) reported that feelings of obligation
to provide care were linked to greater burden, and
motivations to provide care based on feelings of
attachment to the care-recipient were related to
lower burden. In the current study, higher extrinsic
motivations were also linked to higher competence.
It is possible that the caregivers being aware of the
reasons why they were providing care contributed
to them feeling competent in their role.
This study also sought to examine the combined
impact of meanings, motivations, and relationship
quality on caregiving outcomes. When combined,
these factors significantly explained 18% of the vari-
anceinburden,25%ofthevarianceinrolecaptivity,
and 24% of the variance in competence. Overall,
pre-caregiving and current relationship quality,
meaning, and intrinsic and extrinsic motivations
made a significant contribution to the caregiving
outcomemeasures,even
characteristics were controlled. Meaning was the
most consistent predictor of these variables. Pre-
caregiving relationship quality did not significantly
predict scores on any of the outcome measures.
It is possible that there is some shared variance
between pre-caregiving and current relationship
quality which resulted in only current relationship
quality being a significant predictor of burden and
role captivity. The selected predictor variables only
explained a proportion of variance in caregiving
outcomes and there are other variables could ex-
plain the rest. For instance, Pinquart and Sörensen
(2003) conducted a meta-analysis of studies on
caregiving stressors. They identified that caregiving
burden and depression were linked to the physical
and cognitive impairment of the care-recipient, and
the number of caregiving tasks. Harwood et al.
(2000) reported that both caregiving burden and
satisfaction were predicted by social support.
The findings of the current study indicate
that theoretical models exploring predictors of
when demographic
caregiving outcomes should incorporate meanings,
motivations, and relationship quality. Some models
have begun to include these factors; for instance,
the theoretical model proposed by Sörensen et al.
(2006) included both relationship quality and
meaning. The present findings also indicate that
both positive and negative aspects of providing
care can influence caregiving outcomes. Meaning
significantlyexplainedvarianceinbothnegativeand
positive outcomes. It is important for models of
caregiving to recognize that positive aspects of care
can influence both positive and negative affect, as
with the Folkman (1997) revised model of coping,
which indicates that meaning-based coping can
influence both positive emotions and distress.
Given the link between motivations, meanings,
relationship quality, and caregiving outcomes,
interventions aimed at reducing caregiving stress
and promoting feelings of caregiving competence
should take into account the impact of these factors.
Although interventions may not be able to directly
affect motivations for caregiving, understanding the
influence of motivations on caregiving outcomes
would aid the provision of more effective support.
For instance, caregivers who have higher extrinsic
thanintrinsicmotivationsmayrequiremoresupport
to help them cope with caregiving. Interventions
that address caregivers’ perceptions of relationship
quality, for instance through counseling, and that
aim to help caregivers cope with their changing
relationship with the care-recipient, are likely to
be helpful. Given the implications of a good pre-
caregiving relationship for caregiving outcomes,
caregivers with a poor pre-caregiving relationship
withthecare-recipient
support. Finally, although finding meaning is an
individual process, interventions could aim to help
caregivers to identify positive aspects of providing
care. Psychoeducational interventions have been
used to enhance caregivers’ feelings of self-efficacy
and satisfaction (e.g. Ducharme et al., 2011).
In considering the findings, it is important to
take into account the limitations of the present
study. The caregivers were recruited through
the Admiral Nurse Service and thus may not be
representative of the caregivers who do not
have access to this kind of specialist service. There
are only a limited number of Admiral Nurses within
the UK and so not all caregivers will have access
to this service. In this study, as 91.2% of the
caregivers were White British it was not possible
to include the caregivers’ ethnicity as a variable in
the analyses. Some studies have found that ethnicity
can have an impact on caregiving motives and the
meaning caregivers find in caregiving (Quinn et al.,
2010). The pre-caregiving relationship quality was
examined retrospectively and it is possible that the
mayneedadditional

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10
C. Quinn et al.
caregivers’ current mood may have had an impact
on the ratings of this relationship. It is recognized
that caregiving is not a static process and that there
is a dynamic relationship between stressors and
resources (Zarit and Edwards, 2008). Longitudinal
studies would make it possible to explore how
meanings, motivations, and relationship quality
change over the caregiving career, and how they
continue to influence or be influenced by caregiving
outcomes. Longitudinal studies would also be able
to explore how these factors influence nursing home
placement; for instance, Wright (1998) found that
caregivers who had lower affection for the care-
recipient were subsequently more likely to place
the care-recipient in a nursing home. Camden et al.
(2011) reported that caregivers who had a more
“negative” reason for providing care were more
likely to place the care-recipient into full-time care.
Inconclusion,the
demonstrate that there were significant associations
between meanings, motivations, and relationship
quality, and these factors could influence caregiving
outcomes.Itisrecognizedthatlongitudinalresearch
is needed to discover how meanings, motivations,
and relationship quality change over the caregiving
career. However, the findings of the present study
indicate that these factors play an important role in
shaping the caregiver’s experience of caregiving.
findings ofthisstudy
Conflict of interest
None.
Description of authors’ roles
CQ designed the study and the questionnaire,
was responsible for data entry and analysis, and
had primary responsibility for writing the paper.
LC contributed to the design of the study, the
interpretation of the findings, and assisted in
the revising of the paper. TM contributed to the
design of the study, supervised the recruitment of
participants, and commented on the paper. RW
contributed to the design of the study and assisted
in the revising of the paper.
Acknowledgments
This work was supported by an ESRC-CASE
PhD Studentship in conjunction with the charity
“Dementia UK.” The authors would like to
thank the Admiral Nurses who assisted with the
identificationofparticipantsandtoallthecaregivers
who took the time to complete the questionnaire.
The authors would like to thank Chris Whittaker for
his assistance with the formulation of the statistical
analysis plan.
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