Review
Older people’s perceived
autonomy in residential care:
An integrative review
Tanja Moilanen and Mari Kangasniemi
University of Turku, Finland
Oili Papinaho
University of Turku, Finland; Oulu University Hospital, Finland
Mari Mynttinen , Helena Siipi and Sakari Suominen
University of Turku, Finland
Riitta Suhonen
University of Turku, Finland; Turku University Hospital, Finland; City of Turku Welfare Division, Finland
Abstract
Autonomy has been recognised as a key principle in healthcare, but we still need to develop a consistent
understanding of older people’s perceived autonomy in residential care. This study aimed to identify,
describe and synthesise previous studies on the perceived autonomy of older people in residential care.
Ethical approval was not required, as this was a review of published literature.We carried out an integrative
review to synthesise previous knowledge published in peer-review journals in English up to September
2019. Electronic and manual searches were conducted using the CINAHL, Philosopher’s Index, PubMed,
SocINDEX, Scopus and Web of Science databases. The data were analysed using the constant comparison
method. The review identified 46 studies. Perceived autonomy referred to the opportunities that older
people had to make their own choices about their daily life in residential care, and achieving autonomy
promoted both health and quality of life. Autonomy was linked to older people’s individual capacities,
including their level of independence, physical and mental competence, personal characteristics, and
whether relatives shared and supported their perceived autonomy. Professionals could facilitate or
hinder older peoples’ autonomy in a number of ways, including providing opportunities for autonomy,
how daily care needs and activities were managed, and controlling older people’s choices. Professionals’
characteristics, such as education and attitudes, and the older people’s living environments were also
associated with their perceived autonomy and included organisational characteristics and physical and
social care facilitators. Older people’s perceived autonomy promoted health and quality of life in
residential care. However, their autonomy was associated with a number of protective and restrictive
individual and environmental factors, which influenced whether autonomy was achieved.
Keywords
Autonomy, care professionals, integrative review, older people, residential care, self-determination
Corresponding author: Tanja Moilanen, Department of Nursing Science, Faculty of Medicine, University of Turku, 20014 Turku,
Finland.
Email: tanja.moilanen@utu.fi
Nursing Ethics
1–21
ª The Author(s) 2020
Article reuse guidelines:
sagepub.com/journals-permissions
10.1177/0969733020948115
journals.sagepub.com/home/nej
Introduction
Organisations that provide residential care for older people should make sure that they enjoy their daily
lives,1 and respecting their autonomy is an important part of that. Autonomy refers to older people’s rights to
make decisions without being influenced by others,2,3 and it is linked to older people’s abilities and oppor-
tunities to govern themselves. Perceived autonomy is older people’s individual perceptions of their abilities
and opportunities related to autonomy. Older people have reported that perceived autonomy increased their
quality of life and satisfaction with daily routines in residential care.4 It has also been associated with
improved health and well-being5 and resulted in organisational benefits, such as increased staff retention.4
It has been recognised that living in residential care can influence how older people perceive their
autonomy.6 Ageing has an impact on an individual’s health status7 and their physical ability to engage in
daily activities.8,9 Autonomous decision-making requires sufficient knowledge, skills and abilities,10
together with resilience, a sense of self-efficacy and material opportunities, such as financial independence.7
Autonomy has been identified as one of the basic ethical principles of healthcare,11 and it is a human right
that is protected by universal declarations and conventions.12,13 Although autonomy is an inherent basic
human right, individuals perceive autonomy differently and its meaning can also vary depending on the time
and context. Perceived autonomy is crucial for older people, because their ability to assert their autonomy can
be reduced by being admitted to residential care6 and having to depend on others.10,14 This puts them in a
vulnerable position.10 Research has shown that older people have suffered from paternalism and a lack of
opportunity to participate in decisions about themselves.9 That is why autonomy is a core value in older
people’s care.15 Professionals need to be aware of what autonomy means and they need to consider how older
people perceive autonomy as part of their everyday practice.12,16 Professionals face wide-ranging respon-
sibilities when it comes to recognising and enabling older people’s perceived autonomy in residential care.
This can be challenging, because previous research has failed to establish a consistent understanding of the
perceived autonomy of older people.
Aim
This study aimed to identify, describe and synthesise previous studies on older people’s perceptions of
autonomy in residential care. We wanted to find out how this had been described in previous studies and
what factors had supported or hindered it.
Method
We employed the integrative review method, as this enabled us to synthesise studies that were produced
using different methods.17
Literature searches
We conducted preliminary searches of existing studies to identify the most eligible search terms and their
combinations. This was done in collaboration with an informatics specialist. Electronic searches were
conducted using the CINAHL, Philosopher’s Index, PubMed, SocINDEX, Scopus and Web of Science
databases. We used Boolean operators and combinations of MeSH terms and free search terms, with their
synonyms, to identify studies that covered older people, autonomy and residential care (Figure 1). Manual
searches were also carried out, by scrutinising the reference lists of the selected papers. The limitations for the
searches were that the article had to be published in English in a peer-reviewed journal and that an abstract
was available. All results up to September 2019 were assessed.
2 Nursing Ethics XX(X)
Search outcomes and retrieval
The selection was based on the inclusion and exclusion criteria established by the Sample, Phenomenon of
Interest, Design, Evaluation, Research tool for synthesising previous evidence (SPIDER)18 (Table 1). We
Search words: 
Aged [Mesh], old people, old patient, old person, old individual, older adult, aged, elderly, senior
AND personal autonomy [Mesh], patient autonomy, autonomy, self-determination, free will
AND housing for the elderly [Mesh], nursing homes [Mesh], residential facilities [Mesh], residential 
care, nursing home, institutional care, institutional home
Limitations
All databases: In English
CINAHL, PhilosophersINDEX, PubMed: Abstract available
Items found (N = 2 927)
CINAHL = 511
PhilosophersINDEX = 9
PubMed = 761
Scopus = 1 018
SocINDEX = 183
Web of Science = 445
Included by title and abstract (n = 177)
CINAHL = 35
PhilosophersINDEX = 1
PubMed = 65
Scopus = 41
SocINDEX = 11
Web of Science = 24
Included for the review (n = 42)
CINAHL = 5
PhilosophersINDEX = 0
PubMed = 29
Scopus = 2
SocINDEX = 3
Web of Science = 3
Excluded 
by title and abstract
(n = 2 750)
Duplicates removed
(n = 74)
Excluded by full text 
(n = 61)
Included from manual searches (n = 4)
Reference lists of the selected original 
articles
Final selected articles
(n = 46)
Figure 1. Flowchart of literature searches.
Moilanen et al. 3
included empirical studies that focussed on the autonomy, self-determination or free will of older people
living in long-term care. Literature reviews, theoretical papers and other papers, such as editorials and
commentaries, were excluded.
The electronic searches yielded 2927 results: 177 original papers were selected based on their title and
abstract and 42 on their full text. The manual searches identified 10 potential papers, based on their title, and 4
were selected for the final review. A total of 46 original papers were independently selected by two authors
(TM and MK) based on the searches. Any potential disagreements about the selected papers were discussed
and the final selection was based on consensus.
Data evaluation
The quality of the selected papers was evaluated using the Mixed Methods Appraisal Tool evaluation
criteria (MMAT).19 The maximum score for the quantitative and qualitative studies was six and it was five
for the mixed methods and randomised controlled trials. The evaluation, which was independently con-
ducted by two researchers (TM and MK), aimed to describe the methodological quality of the original
papers (Table 2). The quality of the selected papers was high. There were some missing values in the
quantitative studies about the response rates and qualitative studies’ considerations of the researchers’
influence.
Data analysis
The analysis began by reading all the selected papers to provide an overview of the content. The methods
used by the papers were tabulated according to the publication, the aim of the study, the methods used and
the study concepts (Table 2). Descriptions of perceived autonomy, such as words, sentences or phrases,
were identified and coded. Then the material that focused on older people’s autonomy was extracted and
analysed by the constant comparison method. This means that the extracted expressions from the individual
papers were grouped based on their similarities and differences. They were also compared to other papers,
and the entire results, at the same time, to ensure that the analysis was representative and not biased.66,67 No
interpretation was carried out and the original text was used for the analysis.
Results
Descriptive information about the studies reviewed
The 46 studies that we reviewed were published between 1985 and 2019. Of these, 24 were quantitative, 21
were qualitative and there was one mixed-method study. All of the studies sought the views of older people:
11 also spoke to professionals20,24,25,31,33,34,36,45,46,56,62 and 11 studies also included feedback from rela-
tives.3031,33,34,46,48,49,51,56,62,65 The studies used concepts such as autonomy (n ¼ 34), self-determination
Table 1. SPIDER18 inclusion and exclusion criteria.
SPIDER Specifications
Sample Older people in residential care
Phenomenon of interest Autonomy
Design Empirical study
Evaluation Reported outcomes/results
Research type Scientific, qualitative, quantitative or mixed-method study
4 Nursing Ethics XX(X)
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m
e
fo
r
se
n
io
r
ci
ti
ze
n
s
(n
¼
1
2
1
)
A
u
to
n
o
m
y
O
ld
er
p
eo
p
le
’s
au
to
n
o
m
y
w
as
af
fe
ct
ed
b
y
so
ci
al
su
p
p
o
rt
,f
u
n
ct
io
n
al
ab
ili
ti
es
,
at
ti
tu
d
es
an
d
th
ei
r
ed
u
ca
ti
o
n
al
le
ve
l.
5
/6
Si
ko
rs
ka
-S
im
m
o
n
s,
2
9
U
n
it
ed
St
at
es
T
o
ex
p
lo
re
h
o
w
o
rg
an
is
at
io
n
al
p
o
lic
ie
s
af
fe
ct
ed
re
si
d
en
ts
’
p
er
ce
p
ti
o
n
s
o
f
au
to
n
o
m
y
in
as
si
st
ed
liv
in
g
Q
u
es
ti
o
n
n
ai
re
s
fo
r
re
si
d
en
ts
in
fa
ci
lit
ie
s
(n
¼
4
1
2
)
A
u
to
n
o
m
y
C
h
o
ic
e-
en
h
an
ci
n
g
p
o
lic
ie
s
im
p
ro
ve
d
o
ld
er
p
eo
p
le
’s
ex
p
er
ie
n
ce
o
f
au
to
n
o
m
y
in
as
si
st
ed
liv
in
g
fa
ci
lit
ie
s.
6
/6
A
n
d
er
ss
o
n
et
al
.,3
0
Sw
ed
en
T
o
d
es
cr
ib
e
o
ld
er
p
eo
p
le
’s
ex
p
er
ie
n
ce
s
o
f
d
ai
ly
lif
e
in
a
ca
re
h
o
m
e
In
te
rv
ie
w
s
w
it
h
re
si
d
en
ts
(n
¼
1
3
),
re
la
ti
ve
s
(n
¼
1
0
)
an
d
co
n
ta
ct
p
er
so
n
s
(n
¼
1
1
)
Se
lf-
d
et
er
m
in
at
io
n
O
ld
er
p
eo
p
le
fe
lt
th
at
th
ei
r
se
lf-
d
et
er
m
in
at
io
n
w
as
u
n
sa
ti
sf
ac
to
ry
in
ca
re
h
o
m
es
.
5
/6
B
o
is
au
b
in
et
al
.,3
1
U
n
it
ed
St
at
es
T
o
ex
p
lo
re
p
er
ce
p
ti
o
n
s
o
f
au
to
n
o
m
y,
d
ig
n
it
y,
q
u
al
it
y
o
fc
ar
e
an
d
d
ec
is
io
n
-
m
ak
in
g
P
ilo
t
st
u
d
y
w
it
h
se
m
i-
st
ru
ct
u
re
d
in
te
rv
ie
w
s
w
it
h
o
ld
er
p
eo
p
le
in
lo
n
g-
te
rm
ca
re
(n
¼
4
),
fa
m
ily
m
em
b
er
s
(n
¼
1
0
)
an
d
h
ea
lt
h
ca
re
p
ro
fe
ss
io
n
al
s
(n
¼
9
)
A
u
to
n
o
m
y
O
ld
er
p
eo
p
le
fe
lt
th
at
th
ey
sh
o
u
ld
ke
ep
th
ei
r
au
th
o
ri
ty
an
d
re
sp
o
n
si
b
ili
ty
fo
r
d
ec
is
io
n
-m
ak
in
g
as
lo
n
g
as
p
o
ss
ib
le
.
W
h
en
th
ey
w
er
e
n
o
lo
n
ge
r
ca
p
ab
le
,
th
en
re
la
ti
ve
s
sh
o
u
ld
m
ak
e
d
ec
is
io
n
s
fo
r
th
em
.
4
/6
H
el
ls
tr
o¨
m
an
d
Sa
rv
im
a¨k
i,3
2
Sw
ed
en
T
o
d
es
cr
ib
e
h
o
w
o
ld
er
p
eo
p
le
in
sh
el
te
re
d
h
o
u
si
n
g
ex
p
er
ie
n
ce
d
se
lf-
d
et
er
m
in
at
io
n
In
te
rv
ie
w
s
w
it
h
re
si
d
en
ts
(n
¼
1
1
)
Se
lf-
d
et
er
m
in
at
io
n
O
ld
er
p
eo
p
le
h
ad
n
eg
at
iv
e
ex
p
er
ie
n
ce
s
ab
o
u
t
h
o
w
th
ei
r
se
lf-
d
et
er
m
in
at
io
n
w
as
ac
kn
o
w
le
d
ge
d
in
th
e
fa
ci
lit
y
an
d
h
o
w
th
e
en
vi
ro
n
m
en
t
d
id
n
o
t
su
p
p
o
rt
th
ei
r
se
lf-
d
et
er
m
in
at
io
n
.
5
/6
C
h
an
an
d
P
an
g,
3
3
C
h
in
a
(H
o
n
g
K
o
n
g)
T
o
ex
am
in
e
p
er
ce
p
ti
o
n
s
ab
o
u
t
in
d
iv
id
u
al
d
ig
n
it
y
an
d
au
to
n
o
m
y,
q
u
al
it
y
o
fc
ar
e
an
d
fin
an
ci
n
g
o
fl
o
n
g-
te
rm
ca
re
In
-d
ep
th
se
m
i-
st
ru
ct
u
re
d
in
te
rv
ie
w
s
w
it
h
o
ld
er
p
eo
p
le
(n
¼
6
),
fa
m
ily
m
em
b
er
s
(n
¼
1
0
),
ad
m
in
is
tr
at
o
rs
(n
¼
6
)
an
d
h
ea
lt
h
ca
re
p
ro
fe
ss
io
n
al
s
(n
¼
7
)
A
u
to
n
o
m
y
O
ld
er
p
eo
p
le
w
er
e
u
n
an
im
o
u
s,
th
at
th
ey
sh
o
u
ld
b
e
al
lo
w
ed
to
m
ak
e
fin
al
d
ec
is
io
n
s.
T
h
ey
w
er
e
co
n
ce
rn
ed
ab
o
u
t
w
h
et
h
er
th
ei
r
w
is
h
es
an
d
n
ee
d
s
w
er
e
ta
ke
n
in
to
ac
co
u
n
t.
O
ld
er
p
eo
p
le
’s
d
ec
is
io
n
s
w
er
e
o
ft
en
co
m
p
ro
m
is
ed
b
y
re
la
ti
ve
s’
o
p
in
io
n
s.
5
/6
Z
h
ai
an
d
Q
iu
,3
4
C
h
in
a
T
o
st
u
d
y
p
er
ce
p
ti
o
n
s
ab
o
u
t
lo
n
g-
te
rm
ca
re
fo
r
o
ld
er
p
eo
p
le
D
es
cr
ip
ti
ve
in
te
rv
ie
w
s
w
it
h
o
ld
er
p
eo
p
le
(n
¼
6
),
re
la
ti
ve
s
(n
¼
1
0
),
as
si
st
an
t
n
u
rs
es
(n
¼
4
),
p
h
ys
ic
ia
n
s
(n
¼
3
)
an
d
m
an
ag
er
s
(n
¼
3
)
A
u
to
n
o
m
y
O
ld
er
p
eo
p
le
fe
lt
th
at
th
ei
r
au
to
n
o
m
y
sh
o
u
ld
b
e
re
sp
ec
te
d
,b
u
t
th
is
d
id
n
o
t
m
ea
n
th
at
th
e
o
ld
er
p
er
so
n
w
as
th
e
o
n
ly
d
ec
is
io
n
-m
ak
er
.
3
/6
(c
on
tin
ue
d)
6
T
a
b
le
2
.
(c
o
n
ti
n
u
ed
)
A
u
th
o
r(
s)
,
co
u
n
tr
y
A
im
M
et
h
o
d
,
d
at
a
an
d
ca
re
fa
ci
lit
y
C
o
n
ce
p
t(
s)
M
ai
n
re
su
lt
s
Q
u
al
it
y
sc
o
re
A
n
d
re
se
n
et
al
.,3
5
D
en
m
ar
k
T
o
ev
al
u
at
e
in
d
iv
id
u
al
ly
ta
ilo
re
d
p
ro
gr
am
m
es
o
n
au
to
n
o
m
y
fo
r
in
st
it
u
ti
o
n
al
is
ed
o
ld
er
p
eo
p
le
B
lin
d
ed
ra
n
d
o
m
is
ed
tr
ia
l
fo
r
o
ld
er
p
eo
p
le
(n
¼
5
0
)
A
u
to
n
o
m
y
In
d
iv
id
u
al
is
ed
su
p
p
o
rt
ca
n
en
ab
le
in
st
it
u
ti
o
n
al
is
ed
o
ld
er
p
eo
p
le
’s
au
to
n
o
m
y.
5
/5
H
aw
ki
n
s
et
al
.,3
6
U
n
it
ed
K
in
gd
o
m
T
o
ex
am
in
e
h
o
w
h
ea
lt
h
ca
re
w
o
rk
er
s
su
p
p
o
rt
ed
re
si
d
en
ts
’
au
to
n
o
m
y
b
y
en
ab
lin
g
th
ei
r
in
d
ep
en
d
en
ce
E
th
n
o
gr
ap
h
ic
ap
p
ro
ac
h
,
w
it
h
q
u
al
it
at
iv
e
o
b
se
rv
at
io
n
s,
se
m
i-
st
ru
ct
u
re
d
in
te
rv
ie
w
s
(1
4
st
af
f
m
em
b
er
s
an
d
8
o
ld
er
re
si
d
en
ts
),
d
o
cu
m
en
ta
ry
an
al
ys
is
A
u
to
n
o
m
y
O
ld
er
p
eo
p
le
’s
au
to
n
o
m
y
w
as
su
p
p
o
rt
ed
b
y
en
ab
lin
g
in
d
ep
en
d
en
ce
.
H
o
w
ev
er
,
co
n
fli
ct
s
b
et
w
ee
n
th
e
st
af
f’s
d
u
ty
to
ca
re
an
d
su
p
p
o
rt
au
to
n
o
m
y
w
as
ac
kn
o
w
le
d
ge
d
.
6
/6
N
ak
re
m
et
al
.,3
7
N
o
rw
ay
T
o
d
es
cr
ib
e
re
si
d
en
ts
’
ex
p
er
ie
n
ce
s
o
f
th
ei
r
n
u
rs
in
g
h
o
m
e
an
d
th
e
q
u
al
it
y
o
f
ca
re
th
ey
re
ce
iv
ed
D
es
cr
ip
ti
ve
,
ex
p
lo
ra
to
ry
d
es
ig
n
,
in
-
d
ep
th
in
te
rv
ie
w
s
w
it
h
o
ld
er
p
eo
p
le
(n
¼
1
5
)
Se
lf-
d
et
er
m
in
at
io
n
O
ld
er
p
eo
p
le
re
co
gn
is
ed
it
w
as
ch
al
le
n
gi
n
g
to
b
al
an
ce
se
lf-
d
et
er
m
in
at
io
n
an
d
d
ep
en
d
en
cy
.
Fe
el
in
gs
o
f
in
d
ig
n
it
y
an
d
d
ep
re
ci
at
io
n
o
f
so
ci
al
st
at
u
s
w
er
e
re
p
o
rt
ed
.
6
/6
C
u
st
er
s
et
al
.,3
8
N
et
h
er
la
n
d
s
T
o
ex
am
in
e
o
ld
er
p
eo
p
le
’s
ex
p
er
ie
n
ce
s
o
f
re
la
te
d
n
es
s,
au
to
n
o
m
y
an
d
co
m
p
et
en
ce
in
th
e
ca
ri
n
g
re
la
ti
o
n
sh
ip
.
T
h
e
so
ci
al
n
at
u
re
o
f
h
u
m
an
b
ei
n
gs
an
d
h
o
w
th
ey
co
n
n
ec
t
Q
u
es
ti
o
n
n
ai
re
(n
¼
7
5
)
an
d
se
m
i-
st
ru
ct
u
re
d
in
te
rv
ie
w
s
w
it
h
o
ld
er
p
eo
p
le
(n
¼
3
5
)
A
u
to
n
o
m
y,
se
lf-
d
et
er
m
in
at
io
n
R
el
at
ed
n
es
s
w
as
p
er
ce
iv
ed
to
b
e
m
o
re
im
p
o
rt
an
t
th
an
au
to
n
o
m
y
an
d
co
m
p
et
en
ce
.
Su
b
je
ct
iv
e
h
ea
lt
h
an
d
co
gn
it
iv
e
fu
n
ct
io
n
in
g
w
er
e
co
rr
el
at
ed
w
it
h
re
la
te
d
n
es
s,
au
to
n
o
m
y
an
d
co
m
p
et
en
ce
.
5
/6
C
an
d
el
a
et
al
.,3
9
It
al
y
T
o
id
en
ti
fy
th
e
lin
ks
b
et
w
ee
n
au
to
n
o
m
y
an
d
d
ai
ly
liv
in
g
ac
ti
vi
ti
es
in
in
st
it
u
ti
o
n
al
is
ed
o
ld
er
p
eo
p
le
Su
rv
ey
o
f
o
ld
er
p
eo
p
le
(n
¼
4
0
)
A
u
to
n
o
m
y
O
ld
er
p
eo
p
le
se
em
ed
to
h
av
e
su
ff
ic
ie
n
t
co
gn
it
iv
e
ab
ili
ti
es
to
m
ai
n
ta
in
th
ei
r
au
to
n
o
m
y.
O
ld
er
p
eo
p
le
w
h
o
h
ad
lo
w
le
ve
ls
o
f
p
er
ce
p
ti
o
n
o
f
th
ei
r
p
h
ys
ic
al
fu
n
ct
io
n
in
g
h
ad
lo
w
le
ve
ls
o
f
au
to
n
o
m
y.
5
/6
R
ie
d
l
et
al
.,4
0
A
u
st
ri
a
T
o
ex
am
in
e
w
h
at
n
u
rs
in
g
h
o
m
e
re
si
d
en
ts
n
ee
d
ed
w
h
en
th
ey
m
o
ve
d
to
n
u
rs
in
g
h
o
m
es
In
te
rv
ie
w
s
w
it
h
o
ld
er
p
eo
p
le
(n
¼
2
0
)
Se
lf-
d
et
er
m
in
at
io
n
O
ld
er
p
eo
p
le
sa
id
th
at
d
ec
is
io
n
s
w
er
e
ta
ke
n
aw
ay
fr
o
m
th
em
an
d
th
at
th
ey
n
ee
d
ed
to
fig
h
t
fo
r
th
ei
r
in
d
ep
en
d
en
ce
.
5
/6
W
u
lff
et
al
.,4
1
G
er
m
an
y
T
o
in
ve
st
ig
at
e
p
er
ce
iv
ed
au
to
n
o
m
y
o
f
n
u
rs
in
g
h
o
m
e
re
si
d
en
ts
Su
rv
ey
o
f
o
ld
er
p
eo
p
le
(n
¼
5
6
0
)
A
u
to
n
o
m
y
O
ld
er
p
eo
p
le
ch
o
se
w
h
en
th
ey
w
an
te
d
to
b
e
ac
ti
ve
in
d
ec
is
io
n
-m
ak
in
g
an
d
w
h
en
th
ey
p
re
fe
rr
ed
to
le
av
e
th
e
d
ec
is
io
n
s
fo
r
o
th
er
s.
T
h
ei
r
h
ea
lt
h
st
at
u
s
re
st
ri
ct
ed
th
ei
r
o
p
p
o
rt
u
n
it
ie
s
fo
r
au
to
n
o
m
o
u
s
d
ec
is
io
n
s.
5
/6
(c
on
tin
ue
d)
7
T
a
b
le
2
.
(c
o
n
ti
n
u
ed
)
A
u
th
o
r(
s)
,
co
u
n
tr
y
A
im
M
et
h
o
d
,
d
at
a
an
d
ca
re
fa
ci
lit
y
C
o
n
ce
p
t(
s)
M
ai
n
re
su
lt
s
Q
u
al
it
y
sc
o
re
C
o
b
o
,4
2
Sp
ai
n
T
o
ex
am
in
e
th
e
in
flu
en
ce
o
f
in
st
it
u
ti
o
n
al
is
at
io
n
o
n
au
to
n
o
m
y
an
d
q
u
al
it
y
o
f
lif
e
Q
u
as
i-
ex
p
er
im
en
ta
l
an
d
lo
n
gi
tu
d
in
al
su
rv
ey
o
f
o
ld
er
p
eo
p
le
(n
¼
1
0
4
),
la
st
in
g
2
0
m
o
n
th
s
A
u
to
n
o
m
y
T
h
e
re
la
ti
o
n
sh
ip
b
et
w
ee
n
o
ld
er
p
eo
p
le
’s
au
to
n
o
m
y
an
d
in
d
ep
en
d
en
ce
w
as
id
en
ti
fie
d
an
d
b
o
th
fa
ct
o
rs
d
et
er
io
ra
te
d
d
u
e
to
in
st
it
u
ti
o
n
al
is
at
io
n
.
5
/6
Fe
rr
an
d
et
al
.,4
3
Fr
an
ce
T
o
ex
am
in
e
o
ld
er
p
eo
p
le
’s
p
sy
ch
o
lo
gi
ca
l
sa
ti
sf
ac
ti
o
n
an
d
th
e
re
la
ti
o
n
sh
ip
b
et
w
ee
n
th
at
an
d
w
el
l-
b
ei
n
g
Su
rv
ey
o
f
o
ld
er
p
eo
p
le
(n
¼
1
0
0
)
Se
lf-
d
et
er
m
in
at
io
n
O
ld
er
p
eo
p
le
’s
au
to
n
o
m
y
w
as
lin
ke
d
to
th
ei
r
sa
ti
sf
ac
ti
o
n
w
it
h
th
ei
r
n
ee
d
fo
r
re
la
te
d
n
es
s
an
d
th
ei
r
p
u
rp
o
se
in
lif
e.
A
u
to
n
o
m
y
an
d
sa
ti
sf
ac
ti
o
n
w
it
h
th
ei
r
n
ee
d
fo
r
re
la
te
d
n
es
s
w
er
e
id
en
ti
fie
d
as
in
d
ic
at
o
rs
o
fw
el
l-
b
ei
n
g.
5
/6
H
ill
co
at
-
N
al
le´
ta
m
b
y,
4
4
U
n
it
ed
K
in
gd
o
m
T
o
ex
am
in
e
o
ld
er
p
eo
p
le
’s
u
n
d
er
st
an
d
in
g
o
fi
n
d
ep
en
d
en
ce
an
d
au
to
n
o
m
y
in
a
re
si
d
en
ti
al
se
tt
in
g
In
te
rv
ie
w
s
w
it
h
o
ld
er
p
eo
p
le
(n
¼
9
1
)
A
u
to
n
o
m
y
O
ld
er
p
eo
p
le
lin
ke
d
in
d
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en
d
en
ce
to
ac
ce
p
ti
n
g
h
el
p
an
d
d
o
in
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th
in
gs
al
o
n
e.
D
el
eg
at
ed
,
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ec
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ti
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al
,
au
th
en
ti
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d
ec
is
io
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al
an
d
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ie
n
t
au
to
n
o
m
y
w
er
e
id
en
ti
fie
d
.
6
/6
T
av
er
n
a
et
al
.,4
5
U
n
it
ed
St
at
es
T
o
ex
am
in
e
th
e
ef
fe
ct
o
fa
u
to
n
o
m
y
o
n
re
si
d
en
ts
’
o
ra
l
h
yg
ie
n
e
M
ix
ed
-m
et
h
o
d
ap
p
ro
ac
h
,
w
it
h
in
d
iv
id
u
al
st
ru
ct
u
re
d
in
te
rv
ie
w
s
an
d
o
p
en
en
d
ed
an
d
Li
ke
rt
-t
yp
e
sc
al
e
q
u
es
ti
o
n
s
fo
r
o
ld
er
p
eo
p
le
(n
¼
1
2
)
an
d
p
ro
fe
ss
io
n
al
s
(n
¼
7
)
A
u
to
n
o
m
y
O
ld
er
p
eo
p
le
’s
au
to
n
o
m
y
w
as
u
se
d
to
re
si
st
p
ro
fe
ss
io
n
al
as
si
st
an
ts
ta
ki
n
g
ch
ar
ge
o
f
th
ei
r
o
ra
l
h
yg
ie
n
e.
4
/5
W
ik
st
ro¨
m
an
d
E
m
ils
so
n
,4
6
Sw
ed
en
T
o
ex
p
lo
re
o
p
p
o
rt
u
n
it
ie
s
fo
r
au
to
n
o
m
y
in
in
st
it
u
ti
o
n
-b
as
ed
h
o
u
si
n
g
Fo
cu
s
gr
o
u
p
in
te
rv
ie
w
s
(n
¼
5
0
),
o
b
se
rv
at
io
n
s
o
n
re
si
d
en
ts
(n
¼
1
7
),
fa
m
ily
m
em
b
er
s
(n
¼
1
0
),
st
af
f
(n
¼
1
2
)
an
d
m
an
ag
er
s
(n
¼
1
1
)
A
u
to
n
o
m
y
O
ld
er
p
eo
p
le
’s
ab
ili
ty
to
m
ai
n
ta
in
co
n
tr
o
l
o
ve
r
th
ei
r
liv
es
w
as
in
flu
en
ce
d
b
y
am
b
iv
al
en
t
m
is
si
o
n
s,
sy
m
b
o
lic
p
o
w
er
an
d
p
ro
fe
ss
io
n
al
s’
ag
ei
st
ap
p
ro
ac
h
es
.
5
/6
C
h
an
g,
4
7
T
ai
w
an
T
o
ex
am
in
e
h
o
w
se
lf-
d
et
er
m
in
at
io
n
an
d
so
ci
al
su
p
p
o
rt
w
it
h
re
ga
rd
to
le
is
u
re
ac
ti
vi
ti
es
w
er
e
re
la
te
d
to
st
re
ss
Fa
ce
-t
o
-f
ac
e
su
rv
ey
s
fo
r
n
u
rs
in
g
h
o
m
e
re
si
d
en
ts
(n
¼
1
4
1
)
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d
o
ld
er
p
eo
p
le
su
p
p
o
rt
ed
in
th
ei
r
o
w
n
h
o
m
es
(n
¼
3
2
2
)
Se
lf-
d
et
er
m
in
at
io
n
O
ld
er
p
eo
p
le
s’
se
lf-
d
et
er
m
in
at
io
n
an
d
so
ci
al
su
p
p
o
rt
w
it
h
re
ga
rd
to
le
is
u
re
ch
o
ic
es
w
er
e
n
eg
at
iv
el
y
lin
ke
d
w
it
h
st
re
ss
.
5
/6
A
ya
lo
n
,4
8
Is
ra
el
T
o
ad
d
re
ss
o
ld
er
ad
u
lt
s’
ex
p
er
ie
n
ce
s
o
f
th
e
tr
an
si
ti
o
n
to
co
n
ti
n
u
in
g
ca
re
in
a
re
ti
re
m
en
t
co
m
m
u
n
it
y
In
te
rv
ie
w
s
w
it
h
o
ld
er
p
eo
p
le
(n
¼
3
2
)
an
d
th
ei
r
re
la
ti
ve
s
(n
¼
1
9
),
o
ld
er
p
eo
p
le
an
d
ad
u
lt
ch
ild
re
n
d
ya
d
s
(n
¼
3
4
)
A
u
to
n
o
m
y
O
ld
er
p
eo
p
le
’s
au
to
n
o
m
y
w
as
d
em
o
n
st
ra
te
d
b
y
th
ei
r
ab
ili
ty
to
ex
er
ci
se
in
d
ep
en
d
en
t
d
ec
is
io
n
s
an
d
a
d
eg
re
e
o
f
ca
p
ac
it
y.
5
/6
B
o
lli
g
et
al
.,4
9
N
o
rw
ay
T
o
st
u
d
y
h
o
w
re
si
d
en
ts
an
d
th
ei
r
re
la
ti
ve
s
p
er
ce
iv
ed
et
h
ic
al
ch
al
le
n
ge
s
in
n
u
rs
in
g
h
o
m
es
In
-d
ep
th
in
te
rv
ie
w
s
w
it
h
o
ld
er
p
eo
p
le
(n
¼
2
5
),
fo
cu
s
gr
o
u
p
s
w
it
h
re
la
ti
ve
s
(n
¼
1
8
)
A
u
to
n
o
m
y.
se
lf-
d
et
er
m
in
at
io
n
O
ld
er
p
eo
p
le
’s
ex
p
er
ie
n
ce
s
o
f
au
to
n
o
m
y
va
ri
ed
b
et
w
ee
n
in
d
iv
id
u
al
s.
So
m
e
o
ld
er
p
eo
p
le
fe
lt
th
at
th
ey
co
u
ld
m
ak
e
th
ei
r
o
w
n
d
ec
is
io
n
s,
w
h
ile
o
th
er
s
fe
lt
th
at
th
ey
d
id
h
av
e
n
o
t
m
u
ch
to
d
ec
id
e.
6
/6
(c
on
tin
ue
d)
8
T
a
b
le
2
.
(c
o
n
ti
n
u
ed
)
A
u
th
o
r(
s)
,
co
u
n
tr
y
A
im
M
et
h
o
d
,
d
at
a
an
d
ca
re
fa
ci
lit
y
C
o
n
ce
p
t(
s)
M
ai
n
re
su
lt
s
Q
u
al
it
y
sc
o
re
D
o
n
n
el
ly
an
d
M
ac
E
n
te
e,
5
0
C
an
ad
a
T
o
ex
p
lo
re
h
o
w
re
si
d
en
ts
ad
ap
te
d
to
ca
re
an
d
fe
lt
ab
o
u
t
it
O
b
se
rv
at
io
n
s
an
d
in
te
rv
ie
w
s
w
it
h
o
ld
er
p
eo
p
le
(n
¼
2
3
)
A
u
to
n
o
m
y
O
ld
er
p
eo
p
le
re
p
o
rt
ed
vi
o
la
ti
o
n
s
o
f
th
ei
r
au
to
n
o
m
y
an
d
id
en
ti
fie
d
p
o
o
r
ca
re
p
ra
ct
ic
es
th
at
th
re
at
en
ed
th
ei
r
d
ig
n
it
y.
5
/6
G
je
rb
er
g
et
al
.,5
1
N
o
rw
ay
T
o
ex
p
lo
re
co
er
ci
o
n
in
a
n
u
rs
in
g
h
o
m
e
fr
o
m
th
e
p
o
in
t
o
f
vi
ew
o
f
o
ld
er
p
at
ie
n
ts
an
d
th
ei
r
fa
m
ily
m
em
b
er
s
In
d
iv
id
u
al
in
te
rv
ie
w
s
w
it
h
o
ld
er
p
eo
p
le
(n
¼
3
5
)
an
d
fo
cu
s
gr
o
u
p
s
fo
r
re
la
ti
ve
s
(n
¼
6
0
)
A
u
to
n
o
m
y
H
al
f
o
f
th
e
re
sp
o
n
d
en
ts
ac
ce
p
te
d
th
e
u
se
o
f
co
er
ci
o
n
an
d
b
el
ie
ve
d
th
at
th
e
p
ro
fe
ss
io
n
al
s
ac
te
d
in
th
e
b
es
t
in
te
re
st
o
f
th
e
p
at
ie
n
t.
4
/6
N
o
rd
,5
2
Sw
ed
en
T
o
ex
am
in
e
fr
ee
ch
o
ic
e
am
o
n
g
o
ld
er
p
eo
p
le
in
re
si
d
en
ti
al
ca
re
In
te
rv
ie
w
s
w
it
h
o
ld
er
p
eo
p
le
(n
¼
1
3
)
Se
lf-
d
et
er
m
in
at
io
n
O
ld
er
p
eo
p
le
’s
n
et
w
o
rk
s
m
ad
e
th
ei
r
ch
o
ic
es
p
o
ss
ib
le
.
O
ld
er
p
eo
p
le
h
ad
h
ig
h
au
to
n
o
m
y
le
ve
ls
ab
o
u
t
d
ec
is
io
n
s
to
m
o
ve
in
re
si
d
en
ti
al
ca
re
.
4
/6
So
u
es
m
e
et
al
.,5
3
Fr
an
ce
T
o
ex
am
in
e
o
ld
er
p
eo
p
le
’s
p
er
ce
p
ti
o
n
s
o
f
su
p
p
o
rt
fo
r
au
to
n
o
m
y
an
d
d
ep
re
ss
iv
e
sy
m
p
to
m
s
Su
rv
ey
s
o
f
o
ld
er
p
eo
p
le
(n
¼
1
0
0
)
A
u
to
n
o
m
y,
Se
lf-
d
et
er
m
in
at
io
n
Lo
w
so
ci
al
su
p
p
o
rt
fo
r
au
to
n
o
m
y
co
rr
el
at
ed
w
it
h
d
ep
re
ss
iv
e
sy
m
p
to
m
s
an
d
ap
at
h
y.
5
/6
T
u
o
m
in
en
et
al
.,5
4
Fi
n
la
n
d
T
o
d
es
cr
ib
e
o
ld
er
p
eo
p
le
’s
ex
p
er
ie
n
ce
s
o
f
fr
ee
w
ill
in
n
u
rs
in
g
h
o
m
es
In
te
rv
ie
w
s
w
it
h
o
ld
er
p
eo
p
le
(n
¼
1
5
)
Fr
ee
w
ill
O
ld
er
p
eo
p
le
sa
w
fr
ee
w
ill
as
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o
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p
o
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y
to
m
ak
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o
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d
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ai
n
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r
ri
gh
ts
.
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w
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as
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ti
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fr
ee
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ei
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ro
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ss
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n
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n
al
ru
le
s.
6
/6
W
al
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r
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d
P
al
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d
el
is
,5
5
A
u
st
ra
lia
T
o
in
ve
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ig
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ld
er
p
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le
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p
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s
o
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in
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in
re
si
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re
In
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ep
th
in
te
rv
ie
w
s
w
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h
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ld
er
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eo
p
le
(n
¼
1
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)
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to
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ld
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-m
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d
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to
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m
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5
/6
B
en
n
et
t
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al
.,5
6
U
n
it
ed
St
at
es
T
o
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p
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o
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h
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in
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si
to
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ct
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si
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en
ts
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au
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o
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y
in
as
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g
E
th
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w
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w
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h
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le
(n
¼
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8
),
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la
ti
ve
s
(n
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7
),
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ro
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ss
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¼
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5
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d
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T
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ru
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s
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m
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si
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m
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r
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5
/6
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h
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.,5
7
So
u
th
K
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o
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ai
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Se
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w
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5
/6
(c
on
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d)
9
T
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M
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8
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el
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St
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5
/6
C
as
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.,5
9
D
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In
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Fr
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p
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6
/6
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6
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e
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at
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so
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p
p
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w
it
h
re
ga
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to
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is
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-f
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(n
¼
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)
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w
it
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ss
.
6
/6
Li
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,6
1
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p
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lo
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re
(n
¼
1
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6
)
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to
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le
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re
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ti
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ti
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.
6
/6
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p
ra
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ifi
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in
lo
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lit
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s
O
b
se
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s
o
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d
in
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w
s
w
it
h
,
o
ld
er
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le
,
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la
ti
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s
an
d
p
ro
fe
ss
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n
al
s
(n
¼
2
8
5
)
A
u
to
n
o
m
y
O
ld
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p
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’s
ab
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to
m
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ve
w
it
h
in
an
d
o
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ts
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e
fa
ci
lit
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s
d
ep
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o
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th
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lo
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d
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Lo
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co
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p
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d
e
se
cu
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ty
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p
le
.
4
/6
B
u
ck
in
x
et
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.,6
3
B
el
gi
u
m
T
o
ev
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at
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m
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n
gt
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le
ve
ls
o
n
au
to
n
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m
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am
o
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g
n
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in
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e
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d
en
ts
Su
rv
ey
o
f
o
ld
er
p
eo
p
le
(n
¼
6
6
2
)
A
u
to
n
o
m
y
B
ei
n
g
u
n
ab
le
to
u
se
kn
ee
an
d
an
kl
e
ex
te
n
so
rs
in
d
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en
tl
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p
re
d
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te
d
lo
ss
o
f
au
to
n
o
m
y.
5
/6
K
lo
o
s
et
al
.,6
4
N
et
h
er
la
n
d
s
T
o
ex
am
in
e
re
la
ti
o
n
sh
ip
s
b
et
w
ee
n
su
b
je
ct
iv
e
w
el
l-
b
ei
n
g
an
d
sa
ti
sf
ac
ti
o
n
w
it
h
au
to
n
o
m
y,
re
la
te
d
n
es
s
an
d
co
m
p
et
en
ce
Q
u
es
ti
o
n
n
ai
re
fo
r
o
ld
er
p
eo
p
le
(n
¼
1
2
8
)
Se
lf-
d
et
er
m
in
at
io
n
O
ld
er
p
eo
p
le
’s
au
to
n
o
m
y
w
as
as
so
ci
at
ed
w
it
h
lif
e
sa
ti
sf
ac
ti
o
n
an
d
lo
ss
o
f
au
to
n
o
m
y
w
as
as
so
ci
at
ed
w
it
h
d
ep
re
ss
iv
e
fe
el
in
gs
.
6
/6
Sc
h
en
el
l
et
al
.,6
5
Sw
ed
en
T
o
ex
am
in
e
p
er
ce
p
ti
o
n
s
o
f
q
u
al
it
y
o
f
ca
re
an
d
se
lf-
d
et
er
m
in
at
io
n
C
ro
ss
-s
ec
ti
o
n
al
st
u
d
y
w
it
h
q
u
es
ti
o
n
n
ai
re
fo
r
o
ld
er
p
eo
p
le
(n
¼
1
1
2
)
an
d
re
la
ti
ve
s
(n
¼
8
3
)
Se
lf-
d
et
er
m
in
at
io
n
O
ld
er
p
eo
p
le
w
an
te
d
to
ke
ep
th
ei
r
d
ec
is
io
n
-m
ak
in
g
p
o
w
er
fo
r
th
em
se
lv
es
an
d
se
ld
o
m
w
an
te
d
to
h
an
d
it
o
ve
r
to
re
la
ti
ve
s
o
r
p
ro
fe
ss
io
n
al
s.
6
/6
10
(n¼ 14), free will (n¼ 1) and freedom (n¼ 1). Most of the studies were conducted in Europe (n¼ 30), with
seven in North America, seven in Asia and one in Australia. One study did not specify the country (Table 2).
This review focused exclusively on the views expressed by older people and did not include feedback from
care professionals and relatives.
Perceived autonomy of older people in residential care
Older people’s autonomy was described as exercising their own free will48,54,56 and their ability to make
independent choices,26,31,44,48,52,56,59 without domination or suppression.54 Their autonomy related to deci-
sions about nutrition,37,46,49,54 rest and sleep,26,54,58,59 outdoor activities40,59 and hygiene,26,37 including
clothing.26,58 Older people wanted to make their own decisions about their own social activities41,58 and
receiving visitors.44,56,58 Perceived autonomy also included how they used their money31 and decorated their
own room.37,44,52
Autonomy was considered as a sign of respect,31 dignity30,33,59 and human value32 and how they were
regarded as an individual.32,34,44 Older people said that their autonomy promoted their well-being,64 subjective
vitality22 and mental health.27 They also felt that it decreased stress levels,21,37,60 depression and
apathy,22,27,53,64 and improved their quality of life and satisfaction.33,43,64 Those who were satisfied with their
autonomy were also more active and satisfied with the activities provided by their residential care home.23 In
contrast, limited autonomy led to feelings of confinement and frustration26,32,57 and increased the overall
mortality rate.22
Factors supporting and hindering perceived autonomy among older people
Older people felt that their autonomy in residential care was associated with their own individual capacity,
how they saw the care practices provided by professionals and the living environment provided by the
residential care home (Table 3).
Older people’s individual capacities
Older people’s competence. Older people felt that expressing their own opinions and maintaining their
rights20 would enhance their autonomy.29,54 They also said that their level of independence allowed them to
make autonomous decisions27,28,44,54,58 and improved their opportunities to demand their rights.54 Indepen-
dence referred to the capacity to act,30,39,44,48,58 with sufficient physical,26,28,63 cognitive26 and psycholo-
gical abilities.39 It also included health status and medical conditions.32,36,38,52,54 The studies reported that
the capacity of older people deteriorated after they were moved to residential care,42,48 while the amount of
help they needed increased.42 Older people who felt they had low competence also perceived low auton-
omy.39 An increased need for care32,37 threatened older people’s autonomy, because of their increasing
dependency on professionals.32,37,59 This increased reliance on others also increased the risk of them being
subjected to paternalistic behaviour. Older people said that their decreased functional abilities hindered their
physical opportunities, but not their inner freedom to think or react.59 They felt that they could keep their
autonomy as long as they have sufficient intellectual skills for decision-making.31 In addition, older people
acknowledged that stress, low energy levels and social isolation hindered their perceived autonomy.58
Personal characteristics. Older people perceived that their autonomy in residential care was influenced by
their educational level and financial abilities: the higher their educational level28 and financial abilities, the
more autonomy they perceived. Having a better economic background gave them more choice,44,48,59 more
control over their life44 and the ability to acquire more help in residential care.32,44 However, age and gender
did not seem to influence older people’s perceived autonomy.32,35,43,44
Moilanen et al. 11
Relatives sharing and supporting autonomy. Older people said that their relatives influenced their autonomy,
but they preferred to make their own decisions,31,33 which they expected their relatives to respect.34 Some
older people involved their relatives in decision-making and shared the burden of decision-making, espe-
cially when their capacity to make own choices declined.31,33,34,44,52 Other older people preferred to leave
any decisions to their relatives,52,65 but they expected them to promote and protect their rights.32,54 When
relatives and friends supported their perceived autonomy, this correlated with positive well-being, vitality,
Table 3. Factors supporting and hindering perceived autonomy among older people.
Main category Supporting and hindering factors
Older people’s individual capacities Older people’s competence
Capacity to act30,39,44,48,58
Increased need of care32,37
Stress, low energy level, social isolation58
Personal characteristics
Education level28
Financial abilities32,44,48,59
Relatives sharing and supporting autonomy
Respect older people’s decisions34
Involvement of relatives31,33,34,44,52
Pressure to make decisions48
Professionals facilitating perceived autonomy Professionals’ activities to create opportunities for perceived autonomy
Support from professionals for perceived autonomy22,28,60
Respect for older people’s autonomy32,34,49,59,66
Recognition of older people’s will33,35,54
Advance directives31,33
Information giving20,24,25,32,46
Professionals’ controlling choices
Professionals make decisions on behalf of older people25–27,32,36,37,50,55
Unethical conduct54 and coercion49
Allowing opportunity to complain32,46,50,54,59
Enabling care practices
Care routines21,26,27,32,36,38,49,59
Availability of assistance32,44,49,54,59
Professionals’ characteristics
Professionals’ education32,45,54
Flexibility,54,63 equality, positivity,54 friendliness38
Arbitrary, manipulative or power-seeking attitude54
Living environment creating opportunities Organisational characteristics
Involvement of older people20,29,54
Group focused rules57
Type and size of facility26,27,32,36,54
Limited resources26,32,45,49,50,54
Physical care facilitators
Easily accessible care environment20,37,40,54,57,59,62
Locked doors49,59,62
Social care facilitators
Privacy20,24,59,62
Other residents46,54
Participation in social activities32,36,46,54,61
Visits from friends and realtives22,23,52,56
12 Nursing Ethics XX(X)
satisfaction with their lives22 and decreased depression.22,53 However, relatives could also hinder older
people’s perceived autonomy, by deciding who could access and visit them56 or putting pressure on older
people to make decisions in line with their own views.48
Professionals facilitating perceived autonomy
Professionals’ activities created opportunities for perceived autonomy. Older people felt they had more auton-
omy if they received support from professionals.22,28,60 They said their autonomy was determined by the
care atmosphere and whether they had the opportunities to influence decisions, express their will20 and
make their own choices.29
Older people said that professionals respected their autonomy,32,34,45,49,59 and supported it,54 although
respect varied among professionals and some showed very little.32,54 Respect for older people included
acknowledging their choices,54 showing good manners, such as knocking on their bedroom door49 and
treating them with dignity. It also included observing the need for privacy while conducting care practices.50
Older people felt that professionals lacked respect when they did not respond to their requests for help32,45
or made them wait unnecessarily.32
Studies showed that older people felt that autonomy was supported by recognising their will,33,35,54
although they wanted more opportunities to discuss what they wanted.32 However, older people acknowl-
edged that respecting their will did not mean that professionals would always respect their wishes.33 Some
older people said that their wishes were ignored,57 but that professionals rarely made decisions that were
totally against their will.29,65 Some of the older people had made advanced directives and care plans to
ensure that their requests were respected.31,33 However, others said that advance directives were useless,
because, at the end of the day, professionals would decide whether they followed them.33
Older people felt that their autonomy could be supported by giving them information, which enabled
them to improve how they controlled their decisions.46 However, the information they received was often
insufficient.20,32,46 Those with higher levels of education said that they had received more information than
those with lower educational levels,24 long-term illnesses, people with no relatives or those who rarely
required nursing interventions.25
Professionals controlling choices. Older people talked about their perceived autonomy in relation to situa-
tions where professionals made decisions on behalf of them.25–27,32,36,37,50,55 These included what clothes to
wear,26,27 the quality of the food they were given,32,54 when they should rest32,50,54 and have showers or
baths, 26,50,54 meeting roommates32 or taking medication.20,24,51,58 Some older people said that the profes-
sionals should decide, because they knew what was best for them,37,51 even if they acted against their will.51
Some older people felt they were incapable of making their own decisions26 and some felt that professionals
were responsible for their well-being30 and they trusted them to evaluate situations.51
However, some older people felt that their autonomy was constrained by the unethical conduct54 and
coercion49 of professionals and that they had no choice. Older people’s views varied from accepting
coercion to opposing it to some extent. Coercion was accepted in some cases, when older people felt that
they did not know what was best for them, they were in danger of harming themselves or others or they
needed help to protect their self-image and dignity. The respondents did say that if coercion was used, it
should be carried out gently.51
Older people perceived that their opportunity to complain in care homes improved their autonomy. If
older people were afraid of the potential consequences of any complaints,49,54 or did not want to appear
troublesome,32,46,54 they felt they lost their autonomy.59 Other older people said they believed that com-
plaining to professionals would change nothing, because they dismissed their opinions.32,50 Older people
said that they promoted their perceived autonomy by getting along with professionals, following their
requests and being polite.54
Moilanen et al. 13
Enabling care practices. Older people said that care routines in residential care risked their autonomy.26,32,49
Strict daily routines decreased their control over their own lives and their ability to make deci-
sions.21,26,27,36,59 For example, they were expected to attend some social activities, and had no chance to
refuse,26 or they faced restrictions with regard to eating or washing.38 In contrast, others described how care
routines encouraged them to do things by themselves38 and that steps had been taken to decrease the obvious
safety risks.26
Older people felt that their autonomy was linked to the availability of assistance44,49 from relatives, friends
or care professionals.44 They felt that insufficient32,49 or delayed help hindered their autonomy.54,59 These
could partly result from older people refusing to ask for help32,40,54 or finding it difficult to ask for it.44,46,50
Professionals’ characteristics. Well-educated professionals enhanced older people’s perceived auton-
omy.32,45,54 In addition, professionals who were flexible in their working methods38,54 and had equal,
positive54 and friendly attitudes towards older people supported their autonomy.38 Older people said it was
important that professionals knew them and their needs.59 Their autonomy was hindered if professionals did
not take the initiative to help them and if they felt that professionals displayed arbitrary, manipulative or
power-seeking attitudes against older people.54
Living environments create opportunities for perceived autonomy
Organisational characteristics. The residential care environment they lived in was linked to older people’s
autonomy.56,57 Their autonomy was greater if care homes involved older people in their individual care
plans, let them decorate their own rooms and listened to their feedback on menus.20 People who had more
influence on the organisation of their care home also had more positive perceptions of their autonomy.29 In
contrast, older people felt that their autonomy was lower if they were restricted by group focused rules57 and
had no chance to influence organisational matters.54
Older people felt that the type and size of the care facility influenced their autonomy. Older people’s
autonomy was better recognised in residential care homes than in nursing homes26 or homes run by private
organisations.26,27 In addition, older people living in smaller homes had more opportunities to make their
own choices than those who lived in bigger units.36 Older people also said that political decisions that
reduced residential care funding hindered their opportunities for perceived autonomy and their ability to
receive the help they needed.32,54
Older people reported that limited resources in residential care homes risked their autonomy. Insufficient
staffing and time constraints during sifts26,32,45,49,50,54 meant they had fewer opportunities to talk to care
professionals and this resulted in limited autonomy.32 Insufficient staffing meant that older people went to
bed earlier,49 had to wait for help when they needed to go to the toilet32,54 and faced restrictions on going
outside.32 Organisational staff limitations meant that older people had fewer choices.26 Older people said that
constantly changing care professionals and no opportunity to choose their caregivers risked their autonomy.59
Physical care facilitators. Older people felt that their autonomy was enhanced if they lived in an easily
accessible care environment. They felt they had greater autonomy when they were able to move about freely
if they needed a wheelchair and if doors were easy to open.20,37,40,54,57,59,62 Locked doors made older people
feel that their autonomy was restricted,59 but they realised that such measures protected the safety of some
residents and enabled others to have privacy.49,59,62
Social care facilitators. Privacy played a crucial role in older people’s perceived autonomy,62 although it
was described as rare. This was due to limited access to private rooms, lack of privacy when they were
making phone calls and no secure place for personal belongings.20 Older people who had their own room
had more opportunities for privacy and to make their own choices than if they lived with others.26 Sharing a
room with others could prevent older people from making own decisions about their treatment,24 when they
14 Nursing Ethics XX(X)
had the lights on or off, and whether they could open windows for fresh air.59 Other residents could exhibit
disturbing behaviour that hindered older people’s perceived autonomy.54 For example, during meal times,
the loudest residents were served first, while others had to wait.46
Older people said that taking part in social activities had an impact on their perceived auton-
omy32,36,46,54,61 and the sense of control they had over their own lives.61 Social activities referred to parties
and social gatherings,36 such as bingo, using a gym and other group activities,46 which were generally
controlled by care professionals.36,46 Older people had limited chances to influence the content of the
activities and choose which ones they took part in.32,46
The more visits from friends and relatives older people had, the more autonomy they felt they had.22,23
Even short visits could be seen as difficult or unacceptable, as they got in the way of the routines in the care
homes. In addition, some professionals discouraged visitors that they felt were a burden.56 Some older
people were forbidden to live with their partner, due to residential care rules, which meant that their spouse
had to live in another care home.52
Discussion
Autonomy is a basic value for older people. Our review found that they reported individual experiences with
regard to perceived autonomy that was associated with many different outcomes. Their autonomy was
influenced by different healthcare activities, circumstances and situations and how professional carers
responded to their daily needs.
This review revealed many factors that supported or hindered perceived autonomy, including those
related to older people’s capacity, the professionals who cared for them and the environment they lived
in. Factors related to perceived autonomy can be viewed in a continuum, as the presence or absence of those
factors, such as care that was provided or neglected, supported or hindered older people’s autonomy. The
studies that we reviewed provided multilevel and many-faceted descriptions of these factors.
Older people’s contextual autonomy in residential care
Older people’s perceived autonomy was based on dignity and referred to their ability to make their own
choices and act in accordance with their own will in relation to daily activities in residential care. Inter-
estingly, their perceived autonomy focused mainly on daily activities, but neglected the big, but rare,
decisions about end-of-life treatment or lifestyle choices.11 However, professionals may consider such
daily ethical issues as secondary to big decisions,11 even though older people feel that their daily life is
very important. In future, older people’s autonomy should be studied further and this should include
decisions that they rarely need to make.
Older people recognised that the greatest threat to their perceived autonomy was their increased depen-
dency on care professionals for their daily physical needs.68 It is worth noting that being dependent on
others in this way did not stop older people’s inner freedom and ability to think.59 In addition to their
increased need for care, other individual factors supported or hindered older people’s perceived autonomy.
Some of these were stable and unchangeable, such as educational level, while others compensable, such as
decreased physical abilities.
Perceived autonomy could be related to relationships, such relatives being involved in the older person’s
care and the ethical conduct of the care professionals. This could vary depending on how able the older person
was to make decisions at certain times and in certain situations. In some situations, older people preferred to
make their own decisions, while at other times they welcome shared decision-making with others. Older people
have also been reported to willingly delegate decision-making to relatives or professionals, as acknowledged
in our results. Thus, professionals need to be sensitive and recognise that older people can behave differently
Moilanen et al. 15
when it comes to specific decision-making situations.69 They also need to be aware of how relatives influence
how older people perceive their autonomy. Relatives can help older people to be autonomous in a number of
ways, such as helping them to make their wishes heard. They can also make demands that go against the older
people’s views. However, it is worth noting that different generations can have varying perceptions about what
is needed and how to express and experience autonomy. This generation gap can create misunderstandings and
conflicts in families, not to mention criticism in relation to care practices.
Professionals’ care practices and preventing violations of autonomy
The role that professionals play in older people’s perceptions of autonomy is highlighted by this review. We
found that older people’s perceived autonomy could be hindered by strict care practices or ideologies that
meant they were treated as subjects by care professionals. Care practices that meant that older people had to
ask for help could also hinder perceived autonomy. This was because older people felt that it made them
look weak70 or they didn’t want to be an extra burden to others. This sometimes led to some older people
adopting a passive client role as they waited for the professionals to take care of them.68 In order to maintain
their perceived autonomy and capacity for independence, older people may require assistance or need other
people to advocate on their behalf so that their existing capacities are not reduced.
Perceived autonomy can be restricted in residential care due to safety issues that inhibit older people’s
decision-making, such as whether they are allowed to get out of bed68 or move freely around the facility.
These restrictions can be understandable when older people’s well-being or dignity is in danger. In these
situations, care professionals should discuss these issues with older people and, or, their relatives so that
they can come up with the best solutions to protect the older person’s autonomy, safety and well-being.
However, it is common for older people to experience mistreatment and violation of their autonomy and
studies have shown that these are partly the result of professional practice.71,72 Mistreatment includes
psychological abuse by restricting decision-making,73 ignoring older people’s preferences and coercing
them into following instructions from professionals.74 The psychological abuse of older people was
reflected in our results. There is limited research evidence to support the development of best practice,75
and further studies are needed to identify how to prevent violating older people’s autonomy. For example,
intervention studies could help to identify professional practices that support older people’s autonomy. It is
evident that organisational ethics and leadership, as well as professionals’ ethical competence and decision-
making skills, need to be considered further.
Strengths and limitations
This review had some strengths and limitations. The search phrases were formulated in collaboration with the
library information specialist and research group to ensure their validity and to increase methodological
rigour. The research group consisted of researchers with expertise in healthcare and ethics. The literature
searches were conducted following a systematic search protocol. A limited number of databases were used,
but they were the most suitable76 for the area covered by this review on how older people perceived their
autonomy when living in residential care. A number of the papers we reviewed also included the views of
professionals and relatives on older people’s autonomy, but these were not included as they lay outside the
scope of this review. However, these views do warrant further investigation. Manual searches were also used
to eliminate any search bias that may have resulted from the electronic searches, with regard to indexing,
inconsistency in search terminology and variations in the term residential care. This additional search also
maximised the number of relevant papers.17 We did not set any time limits on the start of the search, which
was carried out in September 2019, and we identified papers going back to 1985. However, we did limit the
search to peer-review journals published in English. The studies were independently selected by two
16 Nursing Ethics XX(X)
researchers to support the validity of the papers that we included. Decisions about the inclusion criteria were
based on the SPIDER tool, and the quality of the selected studies was evaluated using the MMAT. These were
both designed to review both qualitative and quantitative studies.18,19,77
Conclusion
This review provided new, synthesised knowledge on the perceived autonomy of older people living in
residential care. Autonomy is a fundamental value in healthcare. In residential care, autonomy focused on
older people’s decisions about their daily activities, but it included their dignity and human rights. Our
review found that older people’s perceived autonomy was closely intertwined with their social relation-
ships with relatives, professionals’ care practices and residential care environments. It is noteworthy that
older people felt that autonomy promoted their health and quality of life, but that healthcare professionals
also played a crucial role in facilitating and enabling their autonomy. Factors that supported and inhibited
older people’s perceived autonomy in residential care had already been well identified by a number of
studies. The practical implications of the study findings are that older people’s perceived autonomy needs
to be acknowledged throughout everyday life and these can range from small daily issues to rare deci-
sions. In addition, older people need to be supported so that they can exercise their autonomy and they
should receive individual support that respects their wishes and needs. The knowledge that this review
provides can be used to plan, implement and evaluate care in residential facilities. In future, more
attention needs to be focused on how older people’s perceived autonomy in residential care is affected
by professionals’ ethical competencies, leadership and care practices and the environment that older
people live in.
Conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or
publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship and/or
publication of this article: This study was funded by The Foundation for Municipal Development in Finland.
ORCID iDs
Tanja Moilanen https://orcid.org/0000-0003-1657-1791
Mari Kangasniemi https://orcid.org/0000-0003-0690-1865
Oili Papinaho https://orcid.org/0000-0002-5133-2801
Mari Mynttinen https://orcid.org/0000-0003-0007-4141
Riitta Suhonen https://orcid.org/0000-0002-4315-5550
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